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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Vicodin Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ female with HIV on HAART, COPD, HCV cirrhosis complicated by ascites and hepatic encephalopathy who initially presented to the ED yesterday with hypotension after a paracentesis. The patient has had accelerated decompensation of her cirrhosis recently with worsening ascites, and she is maintained on twice weekly paracentesis. She was at her regular session yesterday when she had hypotension to SBP ___ and felt lightheadedness. Per the patient, that's when her memory started to get fuzzy. She does not have much recollection of what happened since then. Her outpatient hepatologist saw her and recommended that she go to the ED. In the ED, she was evaluated and deemed to have stable blood pressure. She was discharged home. At home, she had worsening mental status with her daughter getting concerned, and she returned to the ED. In the ED, initial vitals were 98.7 77 96/50 16 98% RA. The patient was only oriented to person. Her labs were notable for Na 126, K 6.7, Cr 0.7 (baseline 0.4), ALT 153, AST 275, TBili 1.9, Lip 66, INR 1.5. Initial EKG showed sinus rhythm with peaked T waves. Her head CT was negative for any acute processes. She received ceftriaxone 2gm x1, regular insulin 10U, calcium gluconate 1g, lactulose 30 mL x2, and 25g 5% albumin. On transfer, vitals were 99.0 93 84/40 16 95% NC. On arrival to the MICU, patient was more alert and conversant. She has no abdominal pain, nausea, vomiting, chest pain, or difficulty breathing. She has a chronic cough that is not much changed. She has not had any fever or chills. She reports taking all of her medications except for lactulose, which she thinks taste disgusting. Past Medical History: - HCV Cirrhosis: genotype 3a - HIV: on HAART, ___ CD4 count 173, ___ HIV viral load undetectable - COPD: ___ PFT showed FVC 1.95 (65%), FEV1 0.88 (37%), FEFmax 2.00 (33%) - Bipolar Affective Disorder - PTSD - Hx of cocaine and heroin abuse - Hx of skin cancer per patient report Social History: ___ Family History: She a total of five siblings, but she is not talking to most of them. She only has one brother that she is in touch with and lives in ___. She is not aware of any known GI or liver disease in her family. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals T: 98.7 BP: 84/48 P: 91 R: 24 O2: 98% NC on 2L GENERAL: Alert, oriented, no acute distress LUNGS: Decreased air movement on both sides, scattered expiratory wheezes CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, distended, flank dullness bilaterally, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no cyanosis or edema DISCHARGE PHYSICAL EXAM: Vitals- Tm 99.5, Tc 98.7, ___ 79-96/43-58 20 95% on 3L NC, 7BM. General- Cachectic-appearing woman, alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear, poor dentition with partial dentures 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- Mildly distended and firm, non-tender, bowel sounds present, no rebound tenderness or guarding GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- AOx3, No asterixis. Pertinent Results: ADMISSION LABS: ================= ___ 06:39AM BLOOD WBC-6.9 RBC-3.98* Hgb-14.1 Hct-41.1 MCV-103* MCH-35.4* MCHC-34.3 RDW-15.8* Plt ___ ___ 06:39AM BLOOD Neuts-72.7* Lymphs-14.7* Monos-9.8 Eos-2.5 Baso-0.3 ___ 06:39AM BLOOD ___ PTT-32.4 ___ ___ 06:39AM BLOOD Glucose-102* UreaN-49* Creat-0.7 Na-126* K-6.7* Cl-95* HCO3-25 AnGap-13 ___ 06:39AM BLOOD ALT-153* AST-275* AlkPhos-114* TotBili-1.9* ___ 06:39AM BLOOD Albumin-3.6 IMAGING/STUDIES: ================ ___ CT HEAD: No evidence of acute intracranial process. The left zygomatic arch deformity is probably chronic as there is no associated soft tissue swelling. ___ CXR: No acute intrathoracic process. DISCHARGE LABS: =============== ___ 04:45AM BLOOD WBC-4.8 RBC-3.15* Hgb-11.2* Hct-32.1* MCV-102* MCH-35.4* MCHC-34.8 RDW-15.8* Plt Ct-95* ___ 04:45AM BLOOD ___ PTT-37.6* ___ ___ 04:45AM BLOOD Glucose-121* UreaN-35* Creat-0.4 Na-130* K-5.2* Cl-97 HCO3-27 AnGap-11 ___ 04:45AM BLOOD ALT-96* AST-168* AlkPhos-69 TotBili-1.7* ___ 04:45AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.___ w/ HIV on HAART, COPD on 3L home O2, HCV cirrhosis decompensated (ascites requiring biweekly therapeutic paracenteses, hepatic encephalopathy; not on transplant list ___ comorbidities) w/ AMS, hypotension, ___, and hyperkalemia. Altered mental status improved with lactulose. Hypotension was felt to be due to fluid shifts from paracentesis on the day prior to admission as well as low PO intake in the setting of AMS. Hypotension and ___ resolved with IV albumin. Hyperkalemia resolved with insulin and kayexalate. # Hypotension: Patient presented with SBP in ___ and improved with albumin in the ED to ___. It was felt to be due to fluid shifts from paracentesis on ___, as well as likely hypovolemia given AMS and decreased PO intake. No concern for bleeding or sepsis with baseline CBC and lack of fever. She continued to received IV albumin during her hospital course, with which her SBP improved to ___ and patient remained asymptomatic. # Hyperkalemia: Patient presented with K 6.7 with EKG changes. Given low Na, likely the result of low effective arterial volume leading to poor K excretion, with likely exacerbation from ___. AM cortisol was normal. K improved with insulin and kayexalate and K was 5.2 on day of discharge. Bactrim was held during hospital course. # ___: Patient presented with Cr 0.7 from baseline Cr is 0.3-0.4. It was felt to be likely due to volume shift from her paracentesis on the day prior to admission as well as now low effective arterial volume, likely ___ poor PO intake ___ AMS. Cr improved to 0.4 with albumin administration. Furosemide and Bactrim were held during hospital course. #GOC: The ___ son (HCP) met with Dr. ___ outpatient hepatologist) during ___ hospital course. They discussed that the patient is not a transplant candidate givenevere underlying lung disease (FEV1 ~0.8), hypoxia, RV dilation and very low BMI. A more conservative approach was recommended and the patient was transitioned to DNR/DNI. The patient agreed with this plan. She was treated with the goal of treating any any correctable issues. Social work met with the patient prior to discharge. The patient was interested in following up with palliative care, for which an outpatient referral was made. # Altered Mental Status: Patient presented with confusion that was most likely secondary to hepatic encephalopathy. Based on outpatient records, patient has had steady decline in decompensated cirrhosis and mental status. No signs of infection and head CT was negative as well. Mental status improved with lactulose in the ED and patient reports that she has not been taking lactulose regularly at home. Patient was also continued on rifaximin. # HCV Cirrhosis: Genotype 3a. Patient is decompensated with increasing ascites and worsening hepatic encephalopathy. She is dependent on twice weekly paracentesis. Spironolactone was recently stopped due to hyperkalemia. Patient is not a transplant candidate given her comorbidities COPD per outpatient hepatologist. The patient would like to continue biweekly paracenteses as an outpatient. # HIV: Most recent CD4 count 173 on ___. HIV viral load on ___ was undetectable. She was continued on her home regimen of raltegravir, emtricitabine, and tenofovir. Bactrim prophylaxis was held during admission because of hyperkalemia. # COPD: Patient on 3L NC at home. She was continued on her home regimen. TRANSITIONAL ISSUES: -Follow up with Palliative Care as outpatient -Bactrim prophylaxis (HIV+) was held during hospital course due to ___. Consider restarting as outpatient. -Furosemide was held due to ___, consider restarting as outpatient -Follow up with hepatology -Continue biweekly therapeurtic paracenteses -Code status: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 15 mL PO TID 2. Tiotropium Bromide 1 CAP IH DAILY 3. Raltegravir 400 mg PO BID 4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 5. Furosemide 40 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q8H:PRN Pain 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. Calcium Carbonate 500 mg PO BID 9. Rifaximin 550 mg PO BID 10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO BID 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Fluticasone Propionate 110mcg 1 PUFF IH BID 4. Lactulose 30 mL PO TID 5. Raltegravir 400 mg PO BID 6. Rifaximin 550 mg PO BID 7. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain 8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 9. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension Hyperkalemia Acute Kidney Injury Secondary: HIV Cirrhosis COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because of confusion, low blood pressure, and a high potassium value. Your confusion improved with lactulose. Your blood pressure improved with extra fluids and your potassium improved as well. You also had small degree of kidney injury when you came to the hospital, and this also improved with fluids. While you were here, you discussed changing your goals of care to focusing on symptom management and treatment of reversible processes, such as an infection. While you were in the hospital, you were seen by one of our social workers. You will also follow up with Palliative Care in their clinic and will continue to have therapeutic paracenteses. It has been a pleasure taking care of you and we wish you all the best, Your ___ Care team Followup Instructions: ___

{'altered mental status': ['Chronic hepatitis C with hepatic coma'], 'hypotension': ['Other iatrogenic hypotension'], 'hyperkalemia': ['Hyperpotassemia'], 'hepatic encephalopathy': ['Chronic hepatitis C with hepatic coma'], 'ascites': ['Other ascites'], 'COPD': ['Chronic airway obstruction, not elsewhere classified'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'cirrhosis': ['Cirrhosis of liver without mention of alcohol']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: omeprazole Attending: ___. Chief Complaint: dysphagia Major Surgical or Invasive Procedure: Upper endoscopy ___ History of Present Illness: ___ w/ anxiety and several years of dysphagia who p/w worsened foreign body sensation. She describes feeling as though food gets stuck in her neck when she eats. She put herself on a pureed diet to address this over the last 10 days. When she has food stuck in the throat, she almost feels as though she cannot breath, but she denies trouble breathing at any other time. She does not have any history of food allergies or skin rashes. In the ED, initial vitals: 97.6 81 148/83 16 100% RA Imaging showed: CXR showed a prominent esophagus Consults: GI was consulted. Pt underwent EGD which showed a normal appearing esophagus. Biopsies were taken. Currently, she endorses anxiety about eating. She would like to try eating here prior to leaving the hospital. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: ___ Family History: + HTN - father + Dementia - father Physical Exam: ================= ADMISSION/DISCHARGE EXAM ================= VS: 97.9 PO 109 / 71 70 16 97 ra GEN: Thin anxious woman, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI NECK: Supple without LAD, no JVD PULM: CTABL no w/c/r COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, +BS, no HSM EXTREM: Warm, well-perfused, no ___ edema NEURO: CN II-XII grossly intact, motor function grossly normal, sensation grossly intact Pertinent Results: ============= ADMISSION LABS ============= ___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 MCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___ ___ 08:27AM BLOOD ___ PTT-28.6 ___ ___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 Cl-104 HCO3-22 AnGap-20 ___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 TotBili-1.0 ___ 08:27AM BLOOD Albumin-4.8 ============= IMAGING ============= CXR ___: IMPRESSION: Prominent esophagus on lateral view, without air-fluid level. Given the patient's history and radiographic appearance, barium swallow is indicated either now or electively. NECK X-ray ___: IMPRESSION: Within the limitation of plain radiography, no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD: ___ Impression: Hiatal hernia Angioectasia in the stomach Angioectasia in the duodenum (biopsy, biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - no obvious anatomic cause for the patient's symptoms - follow-up biopsy results to rule out eosinophilic esophagitis - follow-up with Dr. ___ if biopsies show eosinophilic esophagitis Brief Hospital Course: Ms. ___ is a ___ with history of GERD who presents with subacute worsening of dysphagia and foreign body sensation. This had worsened to the point where she placed herself on a pureed diet for the last 10 days. She underwent CXR which showed a prominent esophagus but was otherwise normal. She was evaluated by Gastroenterology and underwent an upper endoscopy on ___. This showed a normal appearing esophagus. Biopsies were taken. TRANSITIONAL ISSUES: -f/u biopsies from EGD -if results show eosinophilic esophagitis, follow-up with Dr. ___. ___ for management -pt should undergo barium swallow as an outpatient for further workup of her dysphagia -f/u with ENT as planned #Code: Full (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications: 1. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: -dysphagia and foreign body sensation SECONDARY DIAGNOSIS: -GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___. You came in due to difficulty swallowing. You had an endoscopy to look for any abnormalities in the esophagus. Thankfully, this was normal. They took biopsies, and you will be called with the results. You should have a test called a barium swallow as an outpatient. We wish you all the best! -Your ___ Team Followup Instructions: ___

{'dysphagia': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'foreign body sensation': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'anxiety': ['Anxiety disorder', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: omeprazole / Iodine and Iodide Containing Products / hallucinogens Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Status post left CRPP ___, ___ History of Present Illness: REASON FOR CONSULT: Femur fracture HPI: ___ female presents with the above fracture s/p mechanical fall. This morning, pt was walking ___, when dog pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners. Denies numbness or weakness in the extremities. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: ___ Family History: + HTN - father + Dementia - father Physical Exam: General: Well-appearing female in no acute distress. Left Lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left closed reduction and percutaneous pinning of hip, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactaid (lactase) 3,000 unit oral DAILY:PRN 2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp #*30 Syringe Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 8. Lactaid (lactase) 3,000 unit oral DAILY:PRN 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left valgus impacted femoral neck fracture Discharge Condition: AVSS NAD, A&Ox3 LLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks Followup Instructions: ___

{'Left hip pain': ['Unspecified intracapsular fracture of left femur'], 'Femur fracture': ['Unspecified intracapsular fracture of left femur'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Hypercholesterolemia': ['Pure hypercholesterolemia'], 'Kidney stones': ['Personal history of urinary calculi'], 'Mitral valve prolapse': ['Nonrheumatic mitral (valve) prolapse'], 'Migraine headaches': ['Migraine', 'unspecified', 'not intractable', 'without status migrainosus'], 'Osteoporosis': ['Age-related osteoporosis without current pathological fracture']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: renal mass Major Surgical or Invasive Procedure: right laparascopic radical nephrectomy- Dr. ___, Dr. ___ ___ History of Present Illness: ___ y/o healthy female with incidental finding of right renal mass suspicious for RCC following MRI on ___. Past Medical History: PMH: nonspecific right axis deviation PSH- cesarean section ALL-NKDA Social History: ___ Family History: no history of RCC Pertinent Results: ___ 07:15AM BLOOD WBC-7.6 RBC-3.82* Hgb-11.9* Hct-33.8* MCV-89 MCH-31.2 MCHC-35.2* RDW-12.8 Plt ___ ___ 07:15AM BLOOD Glucose-150* UreaN-10 Creat-0.9 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 Brief Hospital Course: Patient was admitted to Urology after undergoing laparoscopic right radical nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once. On POD1,foley was removed without difficulty, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with ___ in 3 weeks. Medications on Admission: none Discharge Medications: 1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for break through pain only (score >4) . Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: renal cell carcinoma Discharge Condition: stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for ___ weeks, drink plenty of fluids -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be used as your first line pain medication. If your pain is not well controlled on Tylenol you have been prescribed a narcotic pain medication. Use in place of Tylenol. Do not exceed 4 gms of Tylenol in total daily -Do not drive or drink alcohol while taking narcotics -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofen) until you see your urologist in follow-up -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Call Dr. ___ to set up follow-up appointment and if you have any urological questions. ___ Followup Instructions: ___

{'renal mass': ['Malignant neoplasm of kidney', 'except pelvis'], 'right axis deviation': [], 'cesarean section': [], 'nonspecific': []}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tramadol Attending: ___. Chief Complaint: Abdominal distention, back pain, fever; leukocytosis. Major Surgical or Invasive Procedure: Paracentesis x 3. History of Present Illness: This is a ___ woman with a history of ETOH abuse who presents with abdominal distention, back pain, fever, and elevated white count from Liver Clinic. Ms. ___ was recently admitted to this hospital about 1 week ago for treatment of ascites and work-up of alcoholic hepatitis. At that time she had a diagnostic and therapeutic paracentesis and was treated for a UTI. She was discharged home and instructed to follow-up in Liver Clinic in 1 week. On day of presentation to liver clinic, patient complained of worsening abdominal pain and low-grade fevers at home. Her labwork was also significant for an elevated white count. As such, Ms. ___ was admitted for work-up of fever and white count, and for treatment of recurrent ascites. Past Medical History: --Alcohol abuse --Chronic back pain Social History: ___ Family History: Breast cancer in mother age ___, No IBD, liver failure. Multiple relatives with alcoholism. Physical Exam: VS: 97.9, 103/73, 86, 18, 96% RA GEN: A/Ox3, pleasant, appropriate, well appearing HEENT: No temporal wasting, JVD not elevated, neck veins fill from above. CV: RRR, No MRG PULM: CTAB but decreased BS in R base. ABD: Distended and tight, diffusely tender to palpation, BS+, + passing flatulence. LIMBS: 2+ edema of the LEs to knee bilaterally ___ pulses 2+ bilaterally NEURO: No asterixis, very mild general tremor. Pertinent Results: Labs at Admission: ___ 09:47AM BLOOD WBC-26.2*# RBC-3.86* Hgb-13.0 Hct-43.3 MCV-112* MCH-33.7* MCHC-30.0* RDW-12.7 Plt ___ ___ 09:47AM BLOOD Neuts-88* Bands-1 Lymphs-2* Monos-7 Eos-1 Baso-1 ___ Myelos-0 ___ 09:20PM BLOOD ___ ___ 09:47AM BLOOD UreaN-8 Creat-0.5 Na-133 K-5.1 Cl-92* HCO3-26 AnGap-20 ___ 09:47AM BLOOD ALT-45* AST-165* LD(LDH)-345* AlkPhos-200* TotBili-2.0* ___ 09:47AM BLOOD Albumin-2.9* Calcium-8.1* Phos-4.0 Mg-2.2 ___ 09:20PM BLOOD Ethanol-NEG Bnzodzp-NEG Labs at Discharge: ___ 07:20AM BLOOD WBC-20.7* RBC-3.03* Hgb-10.3* Hct-32.0* MCV-106* MCH-33.9* MCHC-32.1 RDW-13.7 Plt ___ ___ 07:20AM BLOOD ___ PTT-42.0* ___ ___ 07:20AM BLOOD Glucose-96 UreaN-7 Creat-0.4 Na-125* K-4.4 Cl-90* HCO3-30 AnGap-9 ___ 07:20AM BLOOD ALT-35 AST-131* LD(___)-265* AlkPhos-184* TotBili-1.9* ___ 07:20AM BLOOD Albumin-2.5* Calcium-7.2* Phos-2.6* Mg-2.0 Micro Data: ___ PERITONEAL FLUID GRAM STAIN- negative; FLUID CULTURE-PENDING; ANAEROBIC CULTURE- negative ___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative ___ URINE URINE CULTURE- negative ___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS- negative ___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative ___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles- negative ___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE- negative ___ BLOOD CULTURE Blood Culture, Routine- negative ___ BLOOD CULTURE Blood Culture, Routine-negative ___ URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA} INPATIENT ___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES negative Imaging Results: CTA (___): 1. No evidence of pulmonary embolism. 2. Stable atelectasis at the right lung base. 3. Moderate right and small left pleural effusions, unchanged. CTAP (___): 1. Hepatomegaly and large ascites consistent with stated history of liver disease. No evidence of portal venous thrombosis suggesting that the findings on the prior ultrasound may have resulted from extremely slow / undetectable flow. 2. Moderate right and small left pleural effusions, increased on the right with right basilar atelectasis. 3. Replaced right hepatic artery arising from the SMA, otherwise conventional arterial and venous anatomy. Brief Hospital Course: This is a ___ woman with likely alcoholic hepatitis and recurrent ascites who is admitted with low-grade fevers, high white count, and abdominal pain. # ASCITES/ALC HEPATITIS/LEUKOCYTOSIS: Patient with fatty liver and ascites in setting of extensive drinking history and AST/ALT elevation >2. Discriminant function on admission was ~30. Patient had a paracentesis on ___ and 4L was removed; peritoneal fluid was negative for SBP. Diuretics were initially held in the setting of hyponatremia. She was treated supportively with nutrition, brief antibiotics for urinary tract infection (3-days of ceftriaxone), and therapeutic paracenteses x3. Her symptoms, white cell count, and total bilirubin were improving at time of discharge. She will follow-up with Dr. ___ in liver clinic and with her primary care provider, Dr. ___, in two weeks. # HYPONATREMIA: Likely hypovolemic hyponatremia with some component of euvolemic hyponatremia from liver disease. Her spironlactone was held and can be restarted at the discretion of her outpatient liver team, if necessary. Sodium at time of discharge was 125. She has been advised to continue a low sodium diet and free water restriction to ___ liters daily. # ALCOHOLISM: Patient has been trying to cut back recently, but reports daily heavy alcohol intake for the past ___ years; she has had withdrawal symptoms before but no seizures. Shakes and hallucinations. Reports sobriety since prior admission. She will continue outpatient rehab. # URINARY TRACT INFECTION: she was treated with a three-day course of empiric ceftriaxone for concern of UTI. # BACK PAIN/ABDOMINAL PAIN: this was treated in house with lidocaine patches as needed and oxycodone as needed. She has been provided with a short course of Tramadol to take as needed until follow-up with her primary care provider. She understands that this is only a temporary medication and will be discontinued when her acute hepatitis resolves. # Prophylaxis: -DVT ppx with SC heparin -Bowel regimen with lactulose, no PPI -Pain management with oxycodone and lidocaine patch # Communication: Patient # Code: presumed full Medications on Admission: Multivitamin, thiamine, folate, spironolactone 25mg daily, lidocaine patch prn, nicotine patch. Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Alcoholic hepatitis. 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 for alcoholic hepatitis. This is a condition in which your liver becomes inflamed due to excessive alcohol intake. You were also noted to have an elevated white cell count which can sometimes indicate infection. You were treated with a brief course of antibiotics for a urinary tract infection. Otherwise your blood and peritoneal fluid cultures remain negative. We made the following changes to your medications: We stopped your spironolactone because your blood sodium levels were too low. We added Tramadol to take as needed for back pain. Followup Instructions: ___

{'Abdominal distention': ['Acute alcoholic hepatitis', 'Other ascites'], 'Back pain': ['Acute alcoholic hepatitis', 'Unspecified pleural effusion'], 'Fever': ['Acute alcoholic hepatitis', 'Sepsis', 'Urinary tract infection'], 'Leukocytosis': ['Acute alcoholic hepatitis', 'Sepsis', 'Urinary tract infection']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Abdominal distention/pain and fever Major Surgical or Invasive Procedure: Paracentesis ___ (diagnostic) and ___ (therapeutic) History of Present Illness: ___ with recently diagnosed alcoholic hepatitis, persistent ascites, and persistent fevers and leukocytosis which have been atributed to her hepatitis who presented to ___ today with worsening abdominal distention, pain, and persistent fever. She denies chills but did have sweats the night prior to admission. She has tried to be strictly compliant with her low socium diet and fluid restriction, and denies any increased fluid or sodium intake. She reports sobriety from alcohol since ___. At ___ she was febrile and tender to palpation, so she was referred to the ED. . In the ED initial vital signs were 99.0 113/72 132 16 99% on RA. Her temp increased to 100.4 and her pulse came down to the 100s with Ativan. She received morphine 4mg IV x 4 for pain, tylenol ___ PO x1 for fever, ondansetron 4mg IV x2 for nausea, and lorazeman 0.5mg IV x1 for anxiety. She underwent a diagnostic paracentesis but the samples were initially lost. She was treated with ceftriaxone 2g IV x1 for possible SBP. She was admitted to Medicine for further management. Fortunately, her samples were found after she arrived on the floor. . On the floor her mood is labile. She is at times tearful and at times pleasant. She does seem uncomfortable. She is not confused or obviously encephalopathic. She denies cough, dysuria, diarrhea, or rash. She does endorse decreased UOP for the past few days. . Review of Systems: (+) Per HPI (-) Denies chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Alcohol abuse - Alcoholic hepatitis, with persistent fever and leukocytosis - Ascites - Chronic back pain Social History: ___ Family History: - Mother: ___ cancer, age ___ - No family history of liver disease - Multiple relatives with alcoholism Physical Exam: Physical Exam on Admission: GEN: NAD, labile affect between pleasant and tearful VS: 101.0 104/69 125 18 95% on RA HEENT: Dry MM, no OP lesions, mild scleral icterus CV: RR, tachy, no MRG PULM: Bibasilar crackles R > L ABD: BS+, soft, distended, diffusely tender with mild rebound, obvious collateral veins, some mild angiomata LIMBS: Trace ___ edema, no tremors or asterixis SKIN: No rashes or skin breakdown, scattered ecchymoses at puncture sites NEURO: A and O x 3, no pronator drift, reflexes are 1+ of the upper and lower extremities Pertinent Results: LABS: Blood ___: WBC-17.9* RBC-3.25* HGB-11.0* HCT-34.1* MCV-105* MCH-33.9* MCHC-32.3 RDW-14.0 PLT COUNT-198 ___ PTT-39.3* ___ ALBUMIN-2.7* ALT(SGPT)-33 AST(SGOT)-124* ALK PHOS-186* TOT BILI-2.4 Ascitic Fluid ___: WBC-52* RBC-98* POLYS-13* LYMPHS-20* MONOS-0 EOS-1* MESOTHELI-16* MACROPHAG-50* TOT PROT-1.1 LD(LDH)-42 ALBUMIN-<1.0 Ascitic Fluid ___: WBC-104* RBB-290* POLYS-14* LYMPHS-17* MONOS-3* EOS-21* MESOTHELI-45* Blood ___: WBC-11.1 HCT 30.7 RADIOLOGY: Lumbo-sacral XR: Normal, no evidence of osteomyelitis/vertebral compression fracture. Brief Hospital Course: #Abdominal distention/pain: She was treated empirically due to concern for spontaneous bacterial peritonitis with ceftriaxone 2g x 1. A diagnostic paracentesis was performed in the ED. Ascitic fluid analysis was performed. Spontaneous bacterial peritonitis was ruled out given that the fluid cell count showed only 52 WBC; antibiotics were discontinued in this setting. Subsequently, a large volume paracentesis was performed on ___ with 4.5L of fluids removed. After the procedure, her abdomen was less distended and less painful. Fluid analysis again did not reveal SBP. . #Alcoholic hepatitis: Patient's liver synthetic function was monitored while hospitalized. She was maintained on her home regimen of lactulose. She also had 24-hr urine collection for copper to evaluate for ___ disease. . #Leukocytosis and mild fever: She had a temparature of 101 upon presentation in the ED. She had no signs or symptoms of any infection. Urine culture showed only GU flora, consistent with contamination. After arrival to the floor her temperature was stable, ranging from 99 to 101. Her WBC trended down throughout the hospitalization and was 11 at the time of discharge. . #Tachycardia: Her heart rate was elevated in the 100-120s throughout the hospitalization. She had good oxygenation and had no complaints of SOB, dyspnea, chest pain, palpitations. The most likely etiology of this is pain, anxiety, and her low intravascular volume. She was tachycardic in the 100s upon discharge. . #Back pain: Lumbosacral spine film revealed no skeletal abnormalities (vertebral compression fracture and osteomyelitis). Her pain was present but well-controlled throughout the hospitalization with oxycodone ___ Q6H PRN pain. Recommended follow up with her primary care provider to address management of her chronic pain. . #Diet: Low sodium (2g/day), fluid restriction (1500mL/day) . #Code: Full Medications on Admission: - AMITRIPTYLINE - 10 mg PO HS - OXYCODONE - 5 mg PO Q8H PRN pain - Thiamine 100mg PO daily - Folic acid 1mg PO daily - MVI PO daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: Ascites Portal hypertension Alcoholic hepatitis . Secondary: Chronic back pain Discharge Condition: Alert and Oriented. Ambulating without help. Hemodynamically stable, afebrile, tachycardic. Discharge Instructions: You were seen in the ___ Associates with complaints of increasing abdominal distention and pain. In the clinic, you also had a mild fever, fast heart rate, and increased white blood count. You were sent to the emergency department and admitted to the hospital for further workup. During the hospitalization your ascitic fluid was tapped and analyzed. The result showed that you did not have an infection of the ascitic fluid. Subsequently, fluid was removed from your abdomen via paracentesis. We also started a 24-hr urine collection for copper to work up for other potential causes of your liver disease. The liver clinic will follow up with you regarding the results of these tests. . Your back pain persisted during your hospitalization. You underwent x-rays which showed no evidence of fracture or bone infection. Please continue your home pain regimen and readdress with your primary care provider. . No changes were made to your home medications. You should continue to use lactulose for constipation while using pain medications. . Please stop using all herbal or tonic remedies until your liver function has recovered. Some of these therapies may interact with your current medications or make it difficult to interpret your laboratory results. Followup Instructions: ___

{'Abdominal distention/pain': ['Portal hypertension', 'Other ascites', 'Alcoholic cirrhosis of liver'], 'Fever': ['Acute alcoholic hepatitis'], 'Leukocytosis': ['Acute alcoholic hepatitis'], 'Tachycardia': ['Portal hypertension', 'Other ascites', 'Alcoholic cirrhosis of liver'], 'Back pain': ['Lumbago', 'Other chronic pain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfonamides / Codeine / Bactrim Attending: ___. Chief Complaint: abdominal pain and vomiting Major Surgical or Invasive Procedure: ___ Exploratory laparotomy, lysis of adhesions, small bowel resection with enteroenterostomy. History of Present Illness: The patient is a ___ year old woman s/p hysterectomy for uterine fibroids and s/p R lung resection for carcinoid tumor who is seen in surgical consultation for abdominal pain, nausea, and vomiting. The patient was feeling well until early this morning at approximately 1:00am, when she developed cramping abdominal pain associated with nausea and bilious emesis without blood. She vomited approximately ___ times which prompted her presentation to the ED. At the time of her emesis, she had diarrhea and moved her bowels > 3 times. She has never had this or similar pain in the past, and she states that she has never before had a small bowel obstruction. She has never had a colonoscopy. Past Medical History: PMH: carcinoid tumor as above Vitamin B12 deficiency depression hyperlipidemia PSH: s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: non contributory Physical Exam: Temp 96.9 HR 105 BP 108/92 100%RA NAD, appears non-toxic but uncomfortable heart tachycardic but regular, no murmurs appreciated lungs clear to auscultation; decreased breath sounds on R; well-healed R thoracotomy scar present abdomen soft, very obese, minimally distended, somewhat tender to palpation diffusely across abdomen; no guarding; no rebound tenderness, low midline abdominal wound c/d/i, no drainage, no erythema Pertinent Results: ___ 04:40AM WBC-12.5*# RBC-4.46 HGB-13.6 HCT-39.7 MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 ___ 04:40AM NEUTS-91.1* LYMPHS-7.4* MONOS-0.8* EOS-0.3 BASOS-0.2 ___ 04:40AM PLT COUNT-329 ___ 04:40AM GLUCOSE-151* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 ___ 04:40AM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-180 ALK PHOS-62 ___ CT of abdomen and pelvis :1. Slightly dilated loops of small bowel with fecalization of small bowel contents and distal collapsed loops, together indicating early complete or partial small-bowel obstruction. 2. Post-surgical changes noted at the right ribs as detailed above. ___ CT of abdoman and pelvis : 1. Interval worsening of small bowel obstruction. Transition point in the left mid abdomen. (The patient went to the OR on the evening of the study). 2. Trace free fluid in the pelvis is likely physiologic. ___ 10:57PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 10:57PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 10:57PM URINE RBC->50 ___ BACTERIA-MOD YEAST-NONE EPI-0 ___ 10:57PM URINE MUCOUS-OCC ___ 04:40AM GLUCOSE-151* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 ___ 04:40AM estGFR-Using this ___ 04:40AM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-180 ALK PHOS-62 TOT BILI-0.2 ___ 04:40AM LIPASE-17 ___ 04:40AM WBC-12.5*# RBC-4.46 HGB-13.6 HCT-39.7 MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 ___ 04:40AM NEUTS-91.1* LYMPHS-7.4* MONOS-0.8* EOS-0.3 BASOS-0.2 ___ 04:40AM PLT COUNT-329 Brief Hospital Course: This ___ year old female was admitted to the hospital and was made NPO, IV fluids were started and she had a nasogastric tube placed. She was pan cultured for a temperature of 101 and was followed with serial KUB's and physical exam. Her nasogastric tube was clamped on hospital day 2 and she soon developed increased abdominal pain prompting repeat CT of abdomen and pelvis. This demonstrated an increase in the degree of obstruction and she was subsequently taken to the operating room for the aforementioned procedure. She tolerated the procedure well, remained NPO with nasogastric tube in place and treated with IV fluids. Her pain was initially controlled with a morphine PCA . Her nasogastric tube was removed on post op day #2 and she began a clear liquid diet which she tolerated well. This was gradually advanced over 36 hours to a regular diet and was tolerated well. She was having bowel movements and tolerated oral pain medication. Her incision was healing well and staples were intact. After an uncomplicated course she was discharged home on ___ Medications on Admission: Albuteral MDI prn wheezes Flovent inhaler prn wheezes Srtraline 200 mg oral daily Simvastatin 20 mg oral daily Trazadone 100 mg oral daily at bedtime Wellbutrin 75 mg oral twice a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing, shortness of breath. 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: High grade small bowel obstruction Discharge Condition: Henodynamically stable, tolerating a regular diet, having bowel movements, adequate pain control Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody Followup Instructions: ___

{'abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'nausea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'vomiting': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'diarrhea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'cramping abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'bilious emesis': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'small bowel obstruction': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'tachycardic': ['Depressive disorder', 'not elsewhere classified'], 'regular but no murmurs appreciated': ['Depressive disorder', 'not elsewhere classified'], 'soft abdomen': ['Depressive disorder', 'not elsewhere classified'], 'minimally distended': ['Depressive disorder', 'not elsewhere classified'], 'somewhat tender': ['Depressive disorder', 'not elsewhere classified'], 'low midline abdominal wound': ['Surgical operation with anastomosis', 'bypass', 'or graft'], 'well-healed R thoracotomy scar': ['Personal history of malignant neoplasm of bronchus and lung'], 'decreased breath sounds on R': ['Personal history of malignant neoplasm of bronchus and lung'], 'Vitamin B12 deficiency': ['Other B-complex deficiencies'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo woman with h/o hypertension, hyperlipidemia, diabetes mellitus on insulin therapy, h/o cerebellar-medullary stroke in ___, CKD stage III-IV presenting with fatigue and dyspnea on exertion (DOE) for a few weeks, markedly worse this morning. Over the past few weeks, the patient noted DOE and shortness of breath (SOB) even at rest. She has also felt more tired than usual. She notes no respiratory issues like this before. She cannot walk up stair due to DOE, and feels SOB after only a short distance. She is unsure how long the episodes last, but states that her breathing improves with albuterol which she gets from her husband. She had a bad cough around a month ago, but denies any recent fevers, chills, or night sweats. No chest pain, nausea, or dizziness. Past Medical History: 1. CAD RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: MI in ___ 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Diabetes mellitus on insulin therapy h/o cerebellar-medullary stroke in ___ CKD stage III-IV PVD Social History: ___ Family History: Denies cardiac family history. Family hx of DM and HTN; otherwise non-contributory. Physical Exam: Admission exam: GENERAL- Oriented x3. Mood, affect appropriate. VS- T= 98.1 BP= 200/103 HR= 65 RR= 26 O2 sat= 100% on RA HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- JVD to angle of mandible CARDIAC- RR, normal S1, S2. No murmurs, rubs or gallops. No thrills, lifts. LUNGS- Kyphosis. Resp were labored, mild exp wheezes bilaterally. ABDOMEN- Soft, non-tender, not distended. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES- No clubbing, cyanosis or edema. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. NEURO- CNII-XII grossly intact. Strength ___ in LEs and UEs. Diminished sensation along lateral aspect of left leg to light touch Discharge exam: Lungs: CTAB Otherwise unchanged Pertinent Results: Admission Labs ___ 01:18PM BLOOD WBC-6.4# RBC-3.15* Hgb-9.5* Hct-30.1* MCV-96 MCH-30.1 MCHC-31.5 RDW-14.1 Plt ___ ___ 01:18PM BLOOD Glucose-150* UreaN-33* Creat-1.6* Na-144 K-4.8 Cl-111* HCO3-18* AnGap-20 ___ 01:18PM BLOOD CK(CPK)-245* ___ 01:18PM BLOOD cTropnT-0.05* ___ 01:18PM BLOOD CK-MB-6 proBNP-4571* ___ 03:56AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.0 Cholest-230* Pertinent Labs ___ 06:09AM BLOOD WBC-4.3 RBC-3.27* Hgb-9.9* Hct-31.4* MCV-96 MCH-30.4 MCHC-31.6 RDW-14.5 Plt ___ ___ 06:09AM BLOOD Glucose-138* UreaN-31* Creat-1.4* Na-144 K-4.3 Cl-107 HCO3-26 AnGap-15 ___ 06:09AM BLOOD ALT-20 AST-17 ___ 03:56AM BLOOD Triglyc-97 HDL-65 CHOL/HD-3.5 LDLcalc-146* ___ 03:56AM BLOOD %HbA1c-8.1* eAG-186* ___ 01:18PM BLOOD CK(CPK)-245* CK-MB-6 cTropnT-0.05* ___ 08:43PM BLOOD CK(CPK)-198 CK-MB-5 cTropnT-0.03* ___ 03:56AM BLOOD CK(CPK)-173 CK-MB-5 cTropnT-0.04* ___ 06:09AM BLOOD cTropnT-0.01 ___ 01:18PM proBNP-4571* ECG ___ 7:56:06 ___ Baseline artifact. Sinus rhythm. The Q-T interval is 400 milliseconds. Q waves in leads V1-V2 with ST-T wave abnormalities extending to lead V6. Consider prior anterior myocardial infarction. Since the previous tracing of ___ atrial premature beats are not seen. The Q-T interval is shorter. ST-T wave abnormalities are less prominent. CXR ___: PA and lateral views of the chest demonstrate low lung volumes. Tiny bilateral pleural effusions are new since ___. No signs of pneumonia or pulmonary vascular congestion. Heart is top normal in size though this is stable. Aorta is markedly tortuous, unchanged. Aortic arch calcifications are seen. There is no pneumothorax. No focal consolidation. Partially imaged upper abdomen is unremarkable. IMPRESSION: Tiny pleural effusions, new. Otherwise unremarkable. ECHO ___: The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, anteriorly directed jet of mild to moderate (___) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, the severity of mitral and tricuspid regurgitation are increased and moderate PA hypertension is now identified. Brief Hospital Course: ___ woman with h/o hypertension, hypelipidemia, diabetes mellitus on insulin, cerebellar-medullary stroke in ___, stage ___ CKD followed by Dr ___ presenting with fatigue and DOE for a few weeks, markedly worse the morning of admission. The patient has known diastolic dysfunction. Of note, she has been noncompliant with her medications at home. On arrival to the floor, she required hydralazine 20 mg to bring down her BP. She has likely had elevated BPs at home for a while, which is contributing to her SOB, CHF exacerbation, and secondary demand myonecrosis (hypertensive urgency) with mildly elevated troponin. # CAD: Although she did not have a classic anginal presentation, patient has several risk factors for acute coronary syndrome. Her only symptom was SOB in the setting of elevated BPs attributed to medication noncompliance at home. Her troponin fell from 0.05 at admission to 0.01 at discharge in the setting of renal dysfunction, but there was not a clear rise and fall to suggest an acute infarction from plaque rupture and thrombosis. She was scheduled for an outpatient stress test to evaluate for evidence of ischemia from flow-limiting CAD. We decreased ASA to 81 mg from 325 mg daily to decrease the risk of bleeding. Her LDL was found to be 146. We wanted to change her from simvastatin to the more potent atorvastatin (and avoid issues with drug-drug interactions), but her insurance would not cover atorvastatin. She was therefore switched to pravastatin 80 mg at discharge. From a cardiac standpoint, we did not feel that Plavix was necessary for CAD, but her neurologist was contacted and wanted Plavix continued. We had to stop metoprolol due to HR in the ___ during admission even off metoprolol. # Pump: Last echo in ___ showed low normal LVEF. Her current presentation was consistent with CHF exacerbation with bilateral pleural effusions, dyspnea, and elevated NT-Pro-BNP. Her TTE showed mild-moderate mitral and moderate tricuspid regurgitation, LVEF 50-55%, and pulmonary hypertension. We changed her HCTZ to Lasix 40 mg PO at discharge. This medication can be uptitrated as needed. # Hypertension: The patient's nephrologist, Dr. ___, agreed with our proposed medication adjustments, but recommended staying away from clonidine. There has been a H/O medication non-adherence. Social work was involved in discharge planning, and ___ will be assisting the patient at home. We added lisinopril 20 mg daily, Lasix 40 mg daily and continued nifedipine 120 mg daily. Her atenolol was stopped due to her renal dysfunction, but her metoprolol had to be stopped due to bradycardia. She should continue on once a day medication dosing to help with compliance. # ? COPD: The patient may have a component of COPD as she was wheezing on admission and responded to albuterol. She was given a prescription for albuterol prn. Transitional Issues: - She will be scheduled for outpt stress stress test - She has follow-up appointments with Dr. ___ and Dr. ___ and both can work on uptitrating her BP meds as needed. - ___ will need to work with patient on medication compliance. Medications on Admission: ATENOLOL - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on shoulder once a week CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once a day generic is available preferable, please call Dr ___ an appointment FENOFIBRATE MICRONIZED - 134 mg Capsule - 1 Capsule(s) by mouth once a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day NIFEDIPINE [NIFEDIAC CC] - 60 mg Tablet Extended Release - 2 Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually sl as needed for prn chest pain may use 3 doses, 5 minutes apart; if no relief, ED visit RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - 325 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL (70-30) Suspension - 30 units at dinner at dinner MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: may take up to 3 over 15 minutes. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*2* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Thirty (30) units Subcutaneous at dinner. Disp:*900 units* Refills:*2* 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Hypertension with hypertensive urgency -Myocardial infarction attributed to demand myonecrosis -Acute on chronic left ventricular diastolic heart failure -Chronic kidney disease, stage ___ -Chronic obstructive pulmonary disease -Prior cerebellar-medullary stroke -Hyperlipidemia -Diabetes mellitus requiring insulin therapy -Medication non-adherence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted for shortness of breath. You were found to have elevated blood pressure on admission in the setting of not taking all of your medications regularly. We obtained an echocargiogram of your heart which showed some strain on your heart possibly related to your elevated blood pressures. You will be contacted about an outpatient stress test. This will be completed within the next month. You will be prescribed several new medications as shown below. A visiting nurse ___ come to your home to help with managing your medications. You should dispose of all your home medications and only take the medications shown on this discharge paperwork. Medications: STOP Hydrochlorothiazide STOP Simvastatin STOP Clonidine STOP Atenolol due to low heart rate CHANGE 325mg to 81mg once daily START Lisinopril 20mg once daily START Lasix 40mg once daily START Pravastin 80mg once daily If you experience any chest pain, excessive shortness of breath, or any other symptoms concerning to you, please call or come into the emergency department for further evaluation. Thank you for allowing us at the ___ to participate in your care. Followup Instructions: ___

{'shortness of breath': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'fatigue': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'dyspnea on exertion': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'elevated blood pressure': ['Hypertensive chronic kidney disease', 'unspecified', 'with chronic kidney disease stage I through stage IV', 'or unspecified'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'diabetes mellitus': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled', 'Long-term (current) use of insulin'], 'history of cerebellar-medullary stroke': ['Personal history of transient ischemic attack (TIA)', 'and cerebral infarction without residual deficits'], 'chronic obstructive pulmonary disease': ['Chronic airway obstruction', 'not elsewhere classified'], 'chronic kidney disease': ['Chronic kidney disease', 'Stage III (moderate)'], 'congestive heart failure': ['Congestive heart failure', 'unspecified'], 'noncompliance with medication': ['Personal history of noncompliance with medical treatment', 'presenting hazards to health']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Worsening ABD distension and pain Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: ___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, bioplar, PTSD, presented from OSH ED with worsening abd distension over past week. Pt reports self-discontinuing lasix and spirnolactone ___ weeks ago, because she feels like "they don't do anything" and that she "doesn't want to put more chemicals in her." She does not follow Na-restricted diets. In the past week, she notes that she has been having worsening abd distension and discomfort. She denies ___ edema, or SOB, or orthopnea. She denies f/c/n/v, d/c, dysuria. She had food poisoning a week ago from eating stale cake (n/v 20 min after food ingestion), which resolved the same day. She denies other recent illness or sick contacts. She notes that she has been noticing gum bleeding while brushing her teeth in recent weeks. she denies easy bruising, melena, BRBPR, hemetesis, hemoptysis, or hematuria. Because of her abd pain, she went to OSH ED and was transferred to ___ for further care. Per ED report, pt has brief period of confusion - she did not recall the ultrasound or bloodwork at osh. She denies recent drug use or alcohol use. She denies feeling confused, but reports that she is forgetful at times. In the ED, initial vitals were 98.4 70 106/63 16 97%RA Labs notable for ALT/AST/AP ___ ___: ___, Tbili1.6, WBC 5K, platelet 77, INR 1.6 Past Medical History: 1. HCV Cirrhosis 2. No history of abnormal Pap smears. 3. She had calcification in her breast, which was removed previously and per patient not, it was benign. 4. For HIV disease, she is being followed by Dr. ___ Dr. ___. 5. COPD 6. Past history of smoking. 7. She also had a skin lesion, which was biopsied and showed skin cancer per patient report and is scheduled for a complete removal of the skin lesion in ___ of this year. 8. She also had another lesion in her forehead with purple discoloration. It was biopsied to exclude the possibility of ___'s sarcoma, the results is pending. 9. A 15 mm hypoechoic lesion on her ultrasound on ___ and is being monitored by an MRI. 10. History of dysplasia of anus in ___. 11. Bipolar affective disorder, currently manic, mild, and PTSD. 12. History of cocaine and heroin use. Social History: ___ Family History: She a total of five siblings, but she is not talking to most of them. She only has one brother that she is in touch with and lives in ___. She is not aware of any known GI or liver disease in her family. Her last alcohol consumption was one drink two months ago. No regular alcohol consumption. Last drug use ___ years ago. She quit smoking a couple of years ago. Physical Exam: VS: 98.1 107/61 78 18 97RA General: in NAD HEENT: CTAB, anicteric sclera, OP clear Neck: supple, no LAD CV: RRR,S1S2, no m/r/g Lungs: CTAb, prolonged expiratory phase, no w/r/r Abdomen: distended, mild diffuse tenderness, +flank dullness, cannot percuss liver/spleen edge ___ distension GU: no foley Ext: wwp, no c/e/e, + clubbing Neuro: AAO3, converse normally, able to recall 3 times after 5 minutes, CN II-XII intact Discharge: PHYSICAL EXAMINATION: VS: 98 105/70 95 General: in NAD HEENT: anicteric sclera, OP clear Neck: supple, no LAD CV: RRR,S1S2, no m/r/g Lungs: CTAb, prolonged expiratory phase, no w/r/r Abdomen: distended but improved, TTP in RUQ, GU: no foley Ext: wwp, no c/e/e, + clubbing Neuro: AAO3, CN II-XII intact Pertinent Results: ___ 10:25PM GLUCOSE-109* UREA N-25* CREAT-0.3* SODIUM-138 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9 ___ 10:25PM estGFR-Using this ___ 10:25PM ALT(SGPT)-100* AST(SGOT)-114* ALK PHOS-114* TOT BILI-1.6* ___ 10:25PM LIPASE-77* ___ 10:25PM ALBUMIN-3.3* ___ 10:25PM WBC-5.0# RBC-4.29 HGB-14.3 HCT-42.6 MCV-99* MCH-33.3* MCHC-33.5 RDW-15.7* ___ 10:25PM NEUTS-70.3* LYMPHS-16.5* MONOS-8.1 EOS-4.2* BASOS-0.8 ___ 10:25PM PLT COUNT-71* ___ 10:25PM ___ PTT-30.9 ___ ___ 10:25PM ___ . CXR: No acute cardiopulmonary process. U/S: 1. Nodular appearance of the liver compatible with cirrhosis. Signs of portal hypertension including small amount of ascites and splenomegaly. 2. Cholelithiasis. 3. Patent portal veins with normal hepatopetal flow. Diagnostic para attempted in the ED, unsuccessful. On the floor, pt c/o abd distension and discomfort. Brief Hospital Course: ___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, bioplar, PTSD, presented from OSH ED with worsening abd distension over past week and confusion. # Ascites - p/w worsening abd distension and discomfort for last week. likely ___ portal HTN given underlying liver disease, though no ascitic fluid available on night of admission. No signs of heart failure noted on exam. This was ___ to med non-compliance and lack of diet restriction. SBP negative diuretics: > Furosemide 40 mg PO DAILY > Spironolactone 50 mg PO DAILY, chosen over the usual 100mg dose d/t K+ of 4.5. CXR was wnl, UA negative, Urine culture blood culture negative. Pt was losing excess fluid appropriately with stable lytes on the above regimen. Pt was scheduled with current PCP for ___ check upon discharge. Pt was scheduled for new PCP with Dr. ___ at ___ and follow up in Liver clinic to schedule outpatient screening EGD and ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Spironolactone 50 mg PO DAILY 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 4. Raltegravir 400 mg PO BID 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. Nicotine Patch 14 mg TD DAILY 7. Ipratropium Bromide Neb 1 NEB IH Q6H SOB Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 4. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 5. Nicotine Patch 14 mg TD DAILY 6. Raltegravir 400 mg PO BID 7. Spironolactone 50 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Ascites from Portal HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you! You came to us with stomach pain and worsening distension. While you were here we did a paracentesis to remove 1.5L of fluid from your belly. We also placed you on you 40 mg of Lasix and 50 mg of Aldactone to help you urinate the excess fluid still in your belly. As we discussed, everyone has a different dose of lasix required to make them urinate and it's likely that you weren't taking a high enough dose. Please take these medications daily to keep excess fluid off and eat a low salt diet. You will follow up with Dr. ___ in liver clinic and from there have your colonoscopy and EGD scheduled. Of course, we are always here if you need us. We wish you all the best! Your ___ Team. Followup Instructions: ___

{'worsening abd distension': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'abd pain': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'gum bleeding': ['Unspecified viral hepatitis C without hepatic coma'], 'forgetfulness': ['Bipolar disorder', 'unspecified', 'Posttraumatic stress disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ with history of AAA s/p repair complicated by MI, hypertension, and hyperlipidemia who presents upon transfer from outside hospital with nasal fractures and epistaxis secondary to fall. The patient reports that he was at the ___ earlier this afternoon. While coughing, he tripped on the curb and suffered trauma to his face. He had no loss of consciousness. However, he had a persistent nosebleed and appeared to have some trauma to his face, thus was transferred to ___ for further care. There, a CT scan of the head, neck, and face were remarkable for a nasal bone and septal fracture. Given persistent epistaxis, bilateral RhinoRockets were placed. He had a small abrasion to the bridge of his nose which was not closed. Bleeding was well controlled. While in the OSH ED, he had an episode of nausea and coughed up some blood. At that time, he began to feel lightheaded and was noted to be hypotensive and bradycardic. Per report, he had a brief loss of consciousness, though quickly returned to his baseline. His family noted that his eyes rolled back into his head. The patient recalls the event and denies post-event confusion. He had no further episodes of syncope or hemodynamic changes. Given the syncopal event and epistaxis, the patient was transferred for further care. In the ED, initial vital signs 98.9 92 140/77 18 100%/RA. Labs were notable for WBC 11.3 (91%N), H/H 14.1/40.2, plt 147, BUN/Cr 36/1.5. HCTs were repeated which were stable. A urinalysis was negative. A CXR demonstrated a focal consolidation at the left lung base, possibly representing aspiration or developing pneumonia. The patient was given Tdap, amoxicillin-clavulanate for antibiotic prophylaxis, ondansetron, 500cc NS, and metoprolol tartrate 50mg. Clopidogrel was held. Past Medical History: MI after AAA repair when he was ___ y/o HTN Hypercholesterolemia Social History: ___ Family History: Patient is unaware of a family history of bleeding diathesis. Physical Exam: ADMISSION: VS: 98.5 142/65 95 18 98RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under both eyes, swollen nose with mild tenderness, RhinoRockets in place NECK: Supple, without LAD RESP: Generally CTA bilaterally CV: RRR, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended GU: Deferred EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: No excoriations or rash. DISCHARGE: VS: 98.4 125/55 73 18 94RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under both eyes, swollen nose with mild tenderness, RhinoRockets in place NECK: Supple, without LAD RESP: Generally CTA bilaterally CV: RRR, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended GU: Deferred EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: No excoriations or rash. Pertinent Results: ADMISSION: ___ 08:15PM BLOOD WBC-11.3* RBC-4.30* Hgb-14.1 Hct-40.2 MCV-93 MCH-32.8* MCHC-35.1* RDW-12.8 Plt ___ ___ 08:15PM BLOOD Neuts-91.1* Lymphs-4.7* Monos-3.8 Eos-0.3 Baso-0.1 ___ 08:15PM BLOOD ___ PTT-26.8 ___ ___ 08:15PM BLOOD Glucose-159* UreaN-36* Creat-1.5* Na-141 K-4.1 Cl-106 HCO3-21* AnGap-18 ___ 06:03AM BLOOD CK(CPK)-594* CARDIAC MARKER TREND: ___ 07:45AM BLOOD cTropnT-0.04* ___ 06:03AM BLOOD CK-MB-36* MB Indx-6.1* cTropnT-0.57* ___ 03:03PM BLOOD CK-MB-23* MB Indx-4.2 cTropnT-0.89* ___ 05:59AM BLOOD CK-MB-8 cTropnT-1.28* ___ 01:16PM BLOOD CK-MB-5 cTropnT-1.29* ___ 06:10AM BLOOD CK-MB-4 cTropnT-1.48* ___ 07:28AM BLOOD CK-MB-2 cTropnT-1.50* DISCHARGE LABS: ___ 07:28AM BLOOD WBC-4.2 RBC-3.85* Hgb-12.5* Hct-36.0* MCV-94 MCH-32.5* MCHC-34.7 RDW-12.9 Plt ___ ___ 07:28AM BLOOD Glucose-104* UreaN-30* Creat-1.6* Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 IMAGING: ___ CXR PA and lateral views of the chest provided. The lungs are adequately aerated. There is a focal consolidation at the left lung base adjacent to the lateral hemidiaphragm. There is mild vascular engorgement. There is bilateral apical pleural thickening. The cardiomediastinal silhouette is remarkable for aortic arch calcifications. The heart is top normal in size. ___ ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal apical hypokinesis. The remaining segments contract normally (LVEF = 55 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. There is mild aortic valve stenosis (valve area 1.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction most c/w CAD (distal LAD distribution). Mild aortic valve stenosis. Mild aortic regurgitation. Brief Hospital Course: Mr. ___ is an ___ with history of AAA s/p repair complicated by MI, hypertension, and hyperlipidemia who presented with nasal fractures and epistaxis after mechanical fall with hospital course complicated by NSTEMI. #Epistaxis, nasal fractures Patient presenting after mechanical fall with Rhinorockets placed at outside hospital for ongoing epistaxis. CT scan from that hospital demonstrated nasal bone and septal fractures. The Rhinorockets were maintained while inpatient and discontinued prior to discharge. He was encouraged to use oxymetolazone nasal spray and hold pressure should bleeding reoccur. #NSTEMI Patient found to have mild elevation of troponin in the ED. This was trended and eventually rose to 1.5, though MB component downtrended during course of admission. The patient was without chest pain or other cardiac symptoms. Cardiology was consulted who thought that this was most likely secondary to demand ischemia (type II MI) secondary to his fall. An echocardiogram demonstrated aortic stenosis and likely distal LAD disease based on wall motion abnormalities. The patient's metoprolol was uptitrated, his pravastatin was converted to atorvastatin, his clopidogrel was maintained, and he was started on aspirin. #Hypoxemia/L basilar consolidation Patient reported to be mildly hypoxic in the ED, though he maintained normal oxygen saturations on room air. He denied shortness of breath or cough, fevers, or other infectious symptoms and had no leukocytosis. A CXR revealed consolidation in left lung, thought to be possibly related to aspirated blood. -monitor O2 saturation, temperature, trend WBC. He was convered with antibiotics while inpatient as he required prophylaxis for the Rhinorockets, but this was discontinued upon discharge. #Acute kidney injury Patient presented with creatinine of 1.5 with last creatinine at PCP 1.8. Patient was unaware of a history of kidney disease. The patient was discharged with a stable creatinine. #Peripheral vascular disease Patient had a history of AAA repair in ___ without history of MI per PCP. Patient denied history of CABG or cardiac/peripheral stents. A cardiac regimen was continued, as above. TRANSITIONAL ISSUES -Outpatient stress echo for futher evaluation distal LAD disease (possibly a large myocardial territory at risk). -Repeat echocardiogram in ___ years to monitor mild AS/AR. -If epistaxis returns, can use oxymetolazone nasal spray. -Repeat chest x-ray in ___ weeks to ensure resolution of the LLL infiltrative process. -Consider follow-up with ENT or Plastic Surgery for later evaluation of nasal fractures. -Repeat CBC in one week to ensure stability of HCT and platelets. -Consider conversion of metoprolol tartrate to succinate for ease-of-administration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO TID 3. Pravastatin 80 mg PO QPM Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Acetaminophen 650 mg PO Q8H:PRN pain Please avoid NSAID medications like ibuprofen given your bleeding. 3. Aspirin 81 mg PO DAILY Duration: 30 Days 4. Metoprolol Tartrate 75 mg PO TID RX *metoprolol tartrate 25 mg 3 tablet(s) by mouth three times daily Disp #*270 Tablet Refills:*0 5. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth every evening Disp #*30 Tablet Refills:*0 6. Oxymetazoline 1 SPRY NU BID:PRN nosebleed This can be purchased over-the-counter, the brand name is ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Nasal fracture Epistaxis NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted after you fell and broke your nose. You had nose bleeds that were difficult to control, thus plugs were placed in your nose to stop the bleeding. During your hospital course, you were found to have high troponins, a blood test for the heart. A ultrasound of your heart was performed. You should follow-up with your PCP to discuss stress test. It was a pleasure participating in your care, thank you for choosing ___. Followup Instructions: ___

{'Epistaxis': ['Epistaxis'], 'NSTEMI': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'Hypoxemia/L basilar consolidation': ['Hypoxemia'], 'Acute kidney injury': ['Acute kidney failure'], 'Peripheral vascular disease': ['Peripheral vascular disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim Attending: ___ Chief Complaint: nausea, vomiting, cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ female, with past medical history significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, back pain, carcinoid, cervical DJD, depression, hyperlipidemia, osteoarthritis, and history of Exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy for a high grade SBO ___ who presents with nausea, vomiting, weakness x 2 weeks. She has been uable to tolerate PO liquids, and solids. Had similar presentation ___ for high grade SBO. Denies passing flatus today. However reports having last normal bowel movement this AM, without hematochezia, melena. Also reporting subjective fever (100.0), non productive cough. Denies HA, myalgias. Takes NSAIDS sparingly. Denies alcohol use. Denies sick contacs/ travel or recent consumption of raw foods. Has never had a colonoscopy. . In ED VS were 97.8 120 121/77 20 98% RA Labs were remarkable for lactate 2.8, alk phos 293, HCT 33, WBC 13.9 Imaging: CT abdomen showed mult masses in the liver, consistent with malignancy. CXR also showed multiple nodules EKG: sinus, 112, NA, NI, TWI in III, but largely unchanged from prior Interventions: zofran, tylenol, 2L NS, GI was contacted and they are planning on upper / lower endoscopy for cancer work-up. . Vitals on transfer were 99.2 113 119/47 26 98% Past Medical History: PMH: # high grade SBO ___ s/p exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy # carcinoid # hyperlipidemia # vitamin B12 deficiency # cervical DJD # osteoarthritis PSH: s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: non contributory Physical Exam: On admission VS: 98.9 137/95 117 20 100 RA GENERAL: AOx3, NAD HEENT: MMM. no JVD. neck supple. HEART: Regular tachycardic, S1/S2 heard. no murmurs/gallops/rubs. LUNGS: CTAB, non labored ABDOMEN: soft, tender to palpation in epigastrium. EXT: wwp, no edema. DPs, PTs 2+. SKIN: dry, no rash NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L extremities grossly intact. gait not assessed. On Discharge: VS: 98.7 118/78 97 20 99RA GENERAL: Patient is sitting in a chair, appears comfortable, A+Ox3, cooperative. HEENT: EOMI, PERRLA, No Pallor or Jaundice, MMM, no JVD, neck supple. HEART: RRR, no m/r/g. LUNGS: CTAB ABDOMEN: obese, soft, mild tenderness on mid +right epigastrium w/o peritoneal signs, no shifting dullness, difficult to appreciate organomegaly. EXT: wwp, no edema, no signs of DVT SKIN: no rash, normal turgor NEURO: no gross deficits PSYCH: appropriate affect, no preceptual disturbances, no SI, normal judgment. Pertinent Results: ___ 03:14PM ___ ___ 12:50PM URINE HOURS-RANDOM ___ 12:50PM URINE UHOLD-HOLD ___ 12:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 12:50PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-2 ___ 09:54AM LACTATE-2.8* ___ 09:45AM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 ___ 09:45AM estGFR-Using this ___ 09:45AM ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-293* TOT BILI-0.5 ___ 09:45AM LIPASE-14 ___ 09:45AM ALBUMIN-3.0* ___ 09:45AM ___ AFP-1.7 ___ 09:45AM WBC-13.9* RBC-3.94* HGB-9.8* HCT-33.0* MCV-84# MCH-25.0*# MCHC-29.9* RDW-16.1* ___ 09:45AM NEUTS-75.2* LYMPHS-17.9* MONOS-5.9 EOS-0.7 BASOS-0.3 ___ 09:45AM PLT COUNT-657*# CT abdomen/pelvis 1. Innumerable hepatic and pulmonary metastases. No obvious primary malignancy is identified on this study. 2. No evidence of small bowel obstruction, ischemic colitis, fluid collection, or perforation. CXR: New nodular opacities within both upper lobes, left greater than right. Findings are compatible with metastases, as was noted in the lung bases on the subsequent CT of the abdomen and pelvis performed later the same day. Brief Hospital Course: ___ Female with PMH significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, OA, carcinoid, cervical DJD, depression, SBO who presented with nausea, vomiting, weakness x 2 weeks and was found to have multiple liver and lung masses per CT consistent with metastatic cancer of unknown primary. Patient was treated with IV fluids overnight for dehydration. She refused to stay in the hospital for any further work-up or treatment and stated she would rather go home to to think and see to her affairs over the weekend and consider pursuing further work-up as an outpatient. She tolerated oral fluids well w/o vomiting. She remained hemodynamically stable and afebrile throughout her stay. Of note patient has psychiatric history of depressive symptoms and isolation tendencies. She denied any SI/SA or any risk to herself. She has little social supports but does have a good relationship with her driver and friend who came in and was updated by the medical team on the morning of discharge and will be taking her home. She sees a mental health provider at ___ once a month and has a good relationship with her primary care physician. Patient was dischaerged home at her request. Home medications were continued to which we added some symptomatic treatment for her cough with benzonatate and Guaifenesin. We held off on anti-emetics for now as she did not want to stay inhouse to make sure these would be well tolerated (would need to monitor for drug interactions given multiple QTc prolonging and serotonergic medications on her home meds). She was instructed to maintain good hydration and try a soft diet at home if she can not tolerate regular diet. The patient met with SW who provided her with resources for community councelling. Outpatient appointments with oncology, GI and her PCP were set up and her PCP and mental health provider were updated. Her PCP ___ also ___ with her later today by telephone. Medications on Admission: The Preadmission Medication list is accurate and complete 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Ibuprofen 800 mg PO Q8H:PRN pain 5. Sertraline 200 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 8. traZODONE 100 mg PO HS:PRN sleep 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Sertraline 200 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 7. traZODONE 100 mg PO HS:PRN sleep 8. Ibuprofen 800 mg PO Q8H:PRN pain 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 10. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN cough Disp #*60 Capsule Refills:*0 11. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6H:PRN cough Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Liver and Lung Mets of unkown primary Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were seen in the ED for ongoing cough, nausea and vomiting and had imaging studies which unfortunately showed spots in your liver and lungs which are likely due to wide-spread cancer. ___ were admitted for further work-up and treatment of your symptoms. ___ chose to not have any more work-up in the hospital and wanted to be discharged home as soon as possible. Please make sure ___ keep well hydrated by taking water sips throughout the day. I also prescribed some symptomatic treatment for your nausea and cough. I updated your PCP and ___ and have set up ___ appointments as below. Followup Instructions: ___

{'nausea': ['Nausea with vomiting'], 'vomiting': ['Nausea with vomiting'], 'weakness': ['Nausea with vomiting'], 'cough': ['Cough'], 'fever': ['Fever'], 'leukocytosis': ['Leukocytosis'], 'dehydration': ['Dehydration'], 'cardiac dysrhythmias': ['Other specified cardiac dysrhythmias'], 'radiological findings': ['Nonspecific (abnormal) findings on radiological and other examination of abdominal area', 'Other nonspecific abnormal finding of lung field'], 'depressive disorder': ['Depressive disorder', 'not elsewhere classified'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'B-complex deficiencies': ['Other B-complex deficiencies'], 'cervical spondylosis': ['Cervical spondylosis without myelopathy'], 'osteoarthrosis': ['Osteoarthrosis', 'unspecified whether generalized or localized', 'site unspecified'], 'tobacco use': ['Personal history of tobacco use'], 'NSAID use': ['Long-term (current) use of non-steroidal anti-inflammatories (NSAID)'], 'intestinal bypass': ['Intestinal bypass or anastomosis status']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: Exposed hardware Major Surgical or Invasive Procedure: Exposed hardware removal History of Present Illness: The is a ___ year old female who had prior surgery for a possible right parietal anaplastic astrocytoma with craniotomy for resection on ___ by Dr. ___ in ___ followed by involved-field irradiation to 6,120 cGy ___ in ___, 3 cycles of Temodar ended ___ and a second craniotomy for tumor recurrence on ___ by Dr. ___ at ___ with PCV(comb chemo) ___ - ___. In ___ she presented with exposed hardware to the office and she needed admission an complex revision for a plate that had eroded through the skin; Plastics and I reconstructed the scalp at that time. The patient presents today again with some history of pruritus on the top of her head and newly diagnosed exposed hardware. She reports that she had her husband look at the top of her head " a few ago" and saw that metal hardware from her prior surgery was present. Past Medical History: right parietal anaplastic astrocytoma, Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ wound revision and removal of the exposed craniotx hardware, Accutane for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: AF VSS obese Gen: WD/WN, comfortable, NAD. HEENT: ___ bilat EOMs: intact Neck: Supple. no LNN RRR no SOB obese Extrem: Warm and well-perfused, Neuro: Mental status: Awake and alert, cooperative with exam, normal affect but VERY simple construct. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements W: there is an area over the R hemiconvexity that shows a chronic skin defect where the underlying harware has eroded through the skin. Different from previous repaired portion and represents piece of the implanted miniplates; No discharge; no reythemal no swelling; surprisingly benign aspect. PHYSICAL EXAM PRIOR TO DISCHARGE: AF VSS obese Gen: WD/WN, comfortable, NAD. HEENT: ___ bilat EOMs: intact Neck: Supple. Incision: clean, dry, intact. No redness, swelling, erythema or discharge. Sutures in place. Pertinent Results: ___: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:25 4.8 3.49* 11.2* 34.4* 98 31.9 32.5 16.3* 245 BASIC COAGULATION ___, PTT, PLT, INR) Plt Ct ___ 06:25 245 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:25 ___ 142 3.4 110* 23 12 Brief Hospital Course: The patient presented to the ___ neurosurgical service on ___ for treatment of exposed hardware from a previous surgery on her head. She went to the OR on ___, where a was performed removal of exposed hardware by Dr. ___. Postoperatively, the patient was stable. Infectious disease consulted the patient and recommended fluconazole 200 mg PO for 5 days for yeast infection and Keflex ___ mg PO BID for 7 days. For DVT prophylaxis, the patient received subcutaneous heparin and SCD's during her stay. At the time of discharge, the patient was able to tolerate PO, was ambulatoryand able to void independently. She was able to verbalize agreement and understanding of the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ALPRAZolam 0.5 mg PO TID 2. Azathioprine 100 mg PO BID 3. DiCYCLOmine 10 mg PO Q6H:PRN abdominal pain 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN pain 6. Infliximab 100 mg IV Q6 WEEKS 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Mesalamine 500 mg PO QID 9. Omeprazole 20 mg PO DAILY 10. Promethazine 25 mg PO Q6H:PRN n/v 11. Topiramate (Topamax) 200 mg PO BID 12. Venlafaxine XR 150 mg PO DAILY 13. Zolpidem Tartrate 15 mg PO HS Discharge Medications: 1. ALPRAZolam 0.5 mg PO TID 2. Azathioprine 100 mg PO BID 3. DiCYCLOmine 10 mg PO Q6H:PRN abdominal pain 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Mesalamine 500 mg PO QID 6. Omeprazole 20 mg PO DAILY 7. Topiramate (Topamax) 200 mg PO BID 8. Venlafaxine XR 150 mg PO DAILY 9. Zolpidem Tartrate 15 mg PO HS 10. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN pain 11. Acetaminophen 325-650 mg PO Q6H:PRN temperature; pain 12. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 100 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 13. Fluconazole 200 mg PO Q24H Duration: 4 Days RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN for moderate pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 15. Cephalexin 500 mg PO Q12H Duration: 7 Days RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hardware removal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: • Please take Fluconazole 200mg once daily for 4 days. Please take Keflex for 7 days for wound infection. 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 •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: increasing redness, increased swelling, increased tenderness, or drainage. •Fever greater than or equal to 101.5° F. Followup Instructions: ___

{'pruritus': ['Disruption of external operation (surgical) wound'], 'exposed hardware': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'chronic skin defect': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'eroded through the skin': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'hardware has eroded': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'wound revision': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'tubal ligation': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'tonsillectomy': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'bronchitis': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'seizures': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'depression': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: exposed craniotomy hardware Major Surgical or Invasive Procedure: Right scalp flap with split thickness skin graft and wound VAC placement History of Present Illness: ___ year old female with multiple prior surgeries for right parietal anaplastic astrocytoma diagnosed in ___. She has also undergone chemo and radiation. She presented to ___ in ___ with ___ month history of pruritus on the top of her head. She reports that she had her husband look at the top of her head and her found her metal hardware from her prior surgery was present. On ___ Dr. ___ metal hardware (removal of harware but not the bone flap). She presented today for a rotational flap and skin graft for proper coverage of wound. Past Medical History: right parietal anaplastic astrocytoma,Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ wound revision and removal of the exposed craniotx hardware, Accutane for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: Afebrile. vital signs stable. Right scalp incision clean, dry and intact with xeroform dressing in place. Right STSG site with bolstered xeroform dressing in place. No drainage or bleeding. Pertinent Results: None this admission. Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had a flap and skin graft to your scalp defect. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received vicodin with good pain relief noted. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cefadroxil for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Her scalp graft site was clean and pink and she had xeroform dressing intact. Her right thing graft donor site had original xeroform dressing in place to left open to air to dry out. Medications on Admission: ___: azathioprine, Pentasa, topiramate, alprazolam, omeprazole, zolpidem, venlafaxine hcl er 30, popylthiouracil, promethazine, keflex Discharge Medications: 1. azathioprine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for abdominal pain. 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO QID (4 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical BID (2 times a day). Disp:*1 tube* Refills:*2* 10. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* 11. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain: Max 8/day. . Disp:*40 Tablet(s)* Refills:*0* 12. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: exposed craniotomy wound Status post hardware removal, split thickness skin graft application to scalp, donor site from leg Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -The hemovac drain should always be collapsed so as to apply constant suction to the wound. Does not need to be emptied unless not collapsed and does not have suction. -Your skin graft site on your scalp should be covered with a Xeroform dressing and you should apply bacitracin ointment with Qtips UNDER the xeroform dressing twice a day. WARNING: do NOT change the xeroform that is sewn/sutured in place already...leave that in place. -Please keep your skin graft site free of any pressure or extreme temperatures (cover with loose hat that does not sit on your graft site). -You may shower 48 hours after surgery but do not let water run on your head/scalp area. You may shower from the neck down only. -your thigh 'donor site' should be left 'open to air' and left to dry out. The old xeroform dressing will peel back/fall off on its own. When you shower you must cover your thigh 'donor site' with Plastic wrap to keep it free of water while you shower. You may remove plastic wrap when you are done and leave the donor site open to air again to dry out. . Diet/Activity: 1. You may resume your regular diet. 2. DO NOT bend over, avoid heavy lifting and do not engage in strenuous activity until instructed by Dr. ___. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. 8. do not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen etc . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___

{'pruritus': ['Regional enteritis of unspecified site', 'Depressive disorder', 'Epilepsy unspecified without mention of intractable epilepsy'], 'exposed craniotomy hardware': ['Encounter for planned post-operative wound closure', 'Personal history of irradiation', 'Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: exposed craniotomy hardware Major Surgical or Invasive Procedure: wound revision and hardware removal History of Present Illness: This is a ___ year old female with prior surgery which includes right parietal anaplastic astrocytoma with Craniotomy for resection on ___ by Dr. ___ in ___ followed by involved-field irradiation to 6,120 cGy ___ in ___, 3 cycles of Temodar ended ___ and a second craniotomy for tumor recurrence on ___ by Dr. ___ at ___ with PCV(comb chemo) ___ - ___. The patient presents today with ___ month history of pruritus on the top of her head. She reports that she had her husband look at the top of her head ___ days ago and saw that metal hardware from her prior surgery was present. The patient and her husband presented to their local Emergency and was told to follow up here. The patient denies fever, chills, nausea vomiting, nuchal rigidity, numbness or tingling sensation, vision or hearing changes, bowel or bladder incontinence. She denies new onset weakness. She reports baseline tremors in arms due to her hyperthyroid disease and baseline left sided weakness since her initial surgery. She does not ambulate with a walker Past Medical History: right parietal anaplastic astrocytoma,Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: O: T:96.7 BP: 139/73 HR:114 R:20 O2Sats: 100% ra Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3-2mm bilat EOMs: intact Neck: Supple. Extrem: Warm and well-perfused, arms hands tremulous- (patient states this is her baseline due to hyperthyroid disease) Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ on right 4+/5 on left. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT Head 1. No evidence of abscess formation. 2. Stable appearance of postoperative changes related to right frontal mass resection with residual encephalomalacia and edema in a similar distribution as ___ MR exam. Brief Hospital Course: patient presented to the ED at ___ on ___ with complaints of itchy head and exposed hardware. She was admitted to the floor for observation and pre-operative planning. On 3.5 she was taken to the OR for wound revision and removal of the exposed hardware. She tolerated the procedure well and was transferred to the ___ post-operatively. She was transferred to the floor for further management and remained stable. On the morning of ___ she was deemed fit for discharge and was given instructions for close follow-up of her incision. Medications on Admission: azathioprine, Pentasa, topiramate, alprazolam, omeprazole, zolpidem, venlafaxine hcl er 30, popylthiouracil, promethazine- patient does not have doses at the time of the exam. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. alprazolam 1 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for anxiety. 4. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 13 days. Disp:*52 Capsule(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for for sleep. 9. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO QID (4 times a day). 10. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 12. propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 14. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 15. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours) as needed for back pain. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: exposure of craniotomy hardware and infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge 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. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. •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. Followup Instructions: ___

{'pruritus': ['Disruption of external operation (surgical) wound'], 'tremors': ['Personal history of malignant neoplasm of brain'], 'exposed hardware': ['Disruption of external operation (surgical) wound'], 'fever': [], 'chills': [], 'nausea vomiting': [], 'nuchal rigidity': [], 'numbness or tingling sensation': [], 'vision or hearing changes': [], 'bowel or bladder incontinence': [], 'new onset weakness': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Wound Infection Major Surgical or Invasive Procedure: Right Craniotomy and Evacuation of Abscess on ___ History of Present Illness: Ms. ___ is a ___ y/o woman with a past medical history of MS, and a right parietal brain abscess which was discovered approxiamtely one month ago, when she presented with left arm and face numbness. The abscess was drained in the OR on ___, and she was initially started on broad spectrum antibiotics until culture data returned with S. anginosus and fusobacterium, she was then transitioned to Ceftriaxone 2g IV q12h, and flagyl 500mg TID, which she has been on since through her PICC line. On ___, she was seen in ___ clinic and a repeat MRI was performed which revealed increased edema with persistent ring enhancing abnormality at the right parietal surgical site, concerning for ongoing abscess. She was therefore scheduled for repeat drainage on ___. She was seen as an outpatient in the infectious disease office today, ___, and it was recommended that she be admitted to the hospital one day early for broadening of her antibiotic regimen prior to drainage. She states that over the past month, her symptoms, including left upper extremity weakness and numbness, have come and gone, although she thinks that overall they have worsened slightly. She denies any fevers/chills, or headaches. No changes in vision, leg weakness or trouble with coordination or balance. She denies shortness of breath, chest pain, abdominal pain. Past Medical History: Multiple sclerosis Social History: ___ Family History: Mother with pancreatic cancer, brother-lung cancer, two sisters with brain cancer. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: General Physical Exam: General - Appears comfortable HEENT - MMM, no scleral icterus, no proptosis, sclera and conjunctiva with no edema/injection. Neck is supple. CV - RRR, no murmurs, rubs, or gallops. No carotid bruits Pulm - CTA b/l Abd - soft, non-tender, normal bowel sounds Extremities - no cyanosis, no edema Skin - warm and pink with no rashes Neurologic Exam: MENTAL STATUS: Awake and alert, oriented x 3, responds to multi-step commands which cross the midline. Knows recent and distant events. No hemisensory or visual neglect. PHYSICAL EXAMINATION ON DISCHARGE: XXXXXX Pertinent Results: MRI Brain for Operative Planning: ___ Decrease in size of known right frontal vertex rim-enhancing lesion, but unchanged vasogenic edema and mass effect. Non-Contrast Head CT: ___ POST-OP SCAN IMPRESSION: Status post redo right parietal vertex craniotomy with no evidence of hemorrhage. Stable vasogenic edema extending in the right frontal and parietal lobes. Brief Hospital Course: Ms. ___ is a ___ y/o F who was admitted to the neurosurgery service on the day of admission, ___ from the Infectious Disease Clinic in anticipation for evacuation of the brain abscess. She underwent a MRI prior surgery for operative planning. She underwent a right craniotomy and evacuation of abscess on ___. She tolerated the procedure well and was extubated in the operating room. She was then transferred to the ICU for recovery. She underwent a post-operative non-contrasat head CT which revealed normal post operative changes and no new hemorrahge. On ___, she was sitting in the chair, hemodynamically and neurologically intact. She transfered to the floor in stable conditions. Mrs. ___ was followed by Infectious Disease. They recommended that the patient be started on vancomycin and meropenem until culture data from her head wound was obtained. On ___, cultures revealed no growth. The patient was continued on Vancomycin, meropenem was changed to ertapenum. The patient continued to progress well, although she had some residual left-sided weakness. She also complained of some left-handed numbness and pain. On ___, the patient had a MR head with and without contrast including DWI, which showed slight improvement. She was discharged home on ___ with appropriate follow-up, and all questions were answered before discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CeftriaXONE 1 gm IV Q12H 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 4. Acetaminophen 325-650 mg PO Q6H:PRN pain 5. LeVETiracetam 1000 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brain Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: •Your staples should stay clean and dry until they are removed. •Have a friend or family member check the wound for signs of infection such as redness or drainage daily. •Take your pain medicine as prescribed if needed. You do not need to take it if you do not have pain. •Exercise should be limited to walking; no lifting >10lbs, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •DO not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. •You have been discharged on Keppra (Levetiracetam) for anti-seizure medicine; you will not require blood work monitoring. •Do not drive until your follow up appointment. Followup Instructions: ___

{'left arm and face numbness': ['Intracranial abscess', 'Multiple sclerosis'], 'wound infection': ['Intracranial abscess', 'Streptococcus infection in conditions classified elsewhere and of unspecified site', 'Other specified bacterial infections in conditions classified elsewhere and of unspecified site'], 'increased edema with persistent ring enhancing abnormality': ['Intracranial abscess', 'Cerebral edema'], 'left upper extremity weakness': ['Intracranial abscess', 'Multiple sclerosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: IV Dye, Iodine Containing Attending: ___. Chief Complaint: nausea, vomiting x 1 day Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p sigmoid colectomy for recurrent diverticulitis on ___ discharged home on ___ after tolerating a low residue diet and po antibiotics for a wound infection. She returned one week after discharge with 1 day of intense nausea and emesis (non-bloody, non-biliary). The nausea is associated with a slight increase in epigastric abdominal pain without any significant tenderness on exam. Past Medical History: diverticulitis s/p lap sigmoid colectomy c/b wound infection Migraines Left finger cellulitis Social History: ___ Family History: father with h/o colitis Physical Exam: afebrile, vital signs within normal limits NAD, talkative EOM full, PERRL, anicteric sclera Chest clear RRR, no murmurs Abdomen soft, round, non-tender, non-distended with 6cm of open transverse incision through the subcutis with intact deep fascia; no erythema or induration; minimal serous output. ___ without edema, 2+ DP pulses Pertinent Results: CT ABDOMEN W/O CONTRAST ___ 6:___BDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: r/o abscess-NO IV contrast, PO only Field of view: 40 UNDERLYING MEDICAL CONDITION: ___ year old woman with h/o divertic s/p colectomy here with elevated WBC and nausea REASON FOR THIS EXAMINATION: r/o abscess-NO IV contrast, PO only CONTRAINDICATIONS for IV CONTRAST: RF INDICATION: ___ woman with elevated white blood cell count and nausea, history of recent colectomy for recurrent diverticulitis. COMPARISON: CT abdomen and pelvis of ___. TECHNIQUE: MDCT acquired axial images were obtained through the abdomen and pelvis after the administration of oral contrast. No intravenous contrast was administered. Multiplanar reformatted images were also obtained. FINDINGS: The lung bases are clear. A 4-mm calcified granuloma in the right lung base is unchanged. Limited images of the heart are unremarkable. There is no pericardial effusion. In the abdomen, the liver, gallbladder, spleen, kidneys, adrenal glands, pancreas, stomach, and intra-abdominal loops of small and large bowel are unremarkable. There is no mesenteric lymphadenopathy. There is no free fluid or free air in the abdomen. Immediately adjacent to the left common iliac artery, is a linear focus of hyper-attenuating material, with the appearance of suture material, largely unchanged from the prior examination. In the pelvis, suture material is seen in the distal sigmoid colon, unchanged in appearance from prior examination and consistent with colonic anastomosis. There is no evidence of stricture or obstruction at this site. There is no local fluid collection to indicate abscess. There are no signs of inflammation. The intrapelvic loops of small and large bowel are unremarkable, containing air and stool in a normal pattern without bowel dilatation. The appendix is visualized and is normal. The urinary bladder, uterus, and adnexa are unremarkable. There are no abnormally enlarged lymph nodes in the pelvis. A fat-containing left inguinal hernia is unchanged. Examination of soft tissues reveals stranding and subcutaneous air of the soft tissues along the midline lower anterior abdominal wall, slightly larger in size than on the prior examination of approximately 2 weeks ago. Additionally, a small focus of fluid attenuating material now extends from the abdominal wall musculature through the subcutaneous tissues, and appears to drain into an external collecting device. No discrete fluid collection is identified to indicate abscess formation, or that would be amenable to drainage. However, this appearance suggests continued cellulitis. Examination of osseous structures reveals mild degenerative disease at L5-S1 and are otherwise unremarkable. IMPRESSION: 1. Stable appearance of sigmoid colon anastomosis without obstruction or abscess formation. 2. Stranding and subcutaneous air along the lower abdominal wall in the midline, indicating cellulitis, but without discrete or drainable fluid collection The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___. ___: SUN ___ 9:36 AM ____________________________________________ ___ 03:45AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:20AM GLUCOSE-124* UREA N-20 CREAT-1.4* SODIUM-138 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-30 ANION GAP-15 ___ 02:20AM estGFR-Using this ___ 02:20AM ALT(SGPT)-38 AST(SGOT)-20 ALK PHOS-107 TOT BILI-0.6 ___ 02:20AM LIPASE-62* ___ 02:20AM WBC-15.4*# RBC-3.17* HGB-9.4* HCT-28.2* MCV-89 MCH-29.7 MCHC-33.4 RDW-13.7 ___ 02:20AM NEUTS-85.8* LYMPHS-10.0* MONOS-2.5 EOS-1.2 BASOS-0.5 ___ 02:20AM PLT COUNT-730*# Brief Hospital Course: GI: Admitted in early morning on ___ the pt was made NPO with IVF resuscitation. A abdominal/pelvic CT was done and demonstrated a stable sigmoid anastomosis without any fluid collections or free air. Over the first night her urine output increased and a foley was not placed. Due to her constant loose stools, toxin screens of C.diff were sent and returned negative. By HD2, the nausea persisted an a GI consult was obtained. The GI service believed the nausea to be related to baseline reflux exacerbated by her postop course, including a wound infection. Per their recommendations, she was started on an antacid and upon discharge she will follow up with a gastroenterologist to determine her H.pylori status. Prior to discharge, she was tolerating a low residue diet and able to hydrate herself. Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*0 * Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: nausea and vomiting Discharge Condition: Followup Instructions: ___

{'nausea': ['Esophageal reflux', ' Diverticulosis of colon (without mention of hemorrhage)'], 'vomiting': ['Esophageal reflux', ' Diverticulosis of colon (without mention of hemorrhage)'], 'epigastric abdominal pain': [' Diverticulosis of colon (without mention of hemorrhage)'], 'wound infection': ['Other specified aftercare following surgery']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bladder cancer Major Surgical or Invasive Procedure: robotic anterior exenteration and open ileal conduit History of Present Illness: ___ with invasive bladder cancer, pelvic MRI concerning for invasion into anterior vaginal wall, now s/p robotic anterior exent (Dr ___ and open ileal conduit (Dr ___. Past Medical History: Hypertension, laparoscopic cholecystectomy six months ago, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. Social History: ___ Family History: Negative for bladder CA. Physical Exam: A&Ox3 Breathing comfortably on RA WWP Abd S/ND/appropriate postsurgical tenderness to palpation Urostomy pink, viable Pertinent Results: ___ 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5* MCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136 K-4.4 Cl-104 HCO3-23 AnGap-13 ___ 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0 Brief Hospital Course: Ms. ___ was admitted to the Urology service after undergoing [robotic anterior exenteration with ileal conduit]. No concerning intrao-perative events occurred; please see dictated operative note for details. Patient received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. The post-operative course was notable for several episodes of emesis prompting NGT placement on ___. Pt self removed the NGT on ___, but nausea/emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue. With advacement of diet, patient was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. Her drain was removed. The ostomy was perfused and patent, and one ureteral stent had fallen out spontaneously. ___ was consulted and recommended disposition to rehab. Post-operative follow up appointments were arranged/discussed and the patient was discharged to rehab for further recovery. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Heparin 5000 UNIT SC ONCE Start: in O.R. Holding Area 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Levothyroxine Sodium 175 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID take while taking narcotic pain meds RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe Refills:*0 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY take while ureteral stents are in place RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet Refills:*0 6. Atorvastatin 10 mg PO QPM 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bladder cancer Discharge Condition: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I (steris) Stoma is well perfused; Urine color is yellow Ureteral stent noted via stoma JP drain has been removed Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. No edema or pitting Discharge Instructions: -Please also refer to the handout of instructions provided to you by your Urologist -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -You will be sent home with Visiting Nurse ___ services to facilitate your transition to home care of your urostomy -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -___ you have been prescribed IBUPROFEN, please note that you may take this in addition to the prescribed NARCOTIC pain medications and/or tylenol. FIRST, alternate Tylenol (acetaminophen) and Ibuprofen for pain control. -REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol (examples include brand names ___, Tylenol #3 w/ codeine and their generic equivalents). ALWAYS discuss your medications (especially when using narcotics or new medications) use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break-through pain that is >4 on the pain scale. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from ALL sources) PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol (acetaminophen) so this needs to be considered when monitoring your daily dose and maximum. -If you are taking Ibuprofen (Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger -Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks -If you had a drain or skin clips (staples) removed from your abdomen; bandage strips called “steristrips” have been applied to close the wound OR the site was covered with a gauze dressing. Allow any steristrips/bandage strips to fall off on their own ___ days). PLEASE REMOVE any "gauze" dressings within two days of discharge. Steristrips may get wet. -No heavy lifting for 4 weeks (no more than 10 pounds). Do "not" be sedentary. Walk frequently. Light household chores (cooking, folding laundry, washing dishes) are generally “ok” but AGAIN, avoid straining, pulling, twisting (do NOT vacuum). Followup Instructions: ___

{'Bladder cancer': ['Malignant neoplasm of bladder neck'], 'Hypertension': ['Essential (primary) hypertension'], 'Laparoscopic cholecystectomy': [], 'Left knee replacement': [], 'Laminectomy of L5-S1': [], 'Two vaginal deliveries': [], 'Invasion into anterior vaginal wall': ['Malignant neoplasm of bladder neck'], 'Emesis': [], 'Nausea': [], 'Pain': ['Malignant neoplasm of bladder neck'], 'Constipation': []}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) / Penicillins Attending: ___ Chief Complaint: Facial weakness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ RHF w/ hx GERD, mild depression, and prior migraines, presents now with episode of facial numbness. She had been lying on her left face, watching TV, and noticed when she got up that her left face was numb as if she were injected with novacaine, in a distribution that she traces along mid-V2 down to her jaw line. She initially thought it was ___ the way she was lying, but became concerned when it persisted. She endorsed a mild diffuse dull HA that is not unusual for her. She states in some ways, it felt as though a migraine were coming on, though the HA she had was not typical of her past migraines. The numbness lasted 90 minutes, and has now resolved completely. There was no associated weakness, no sensory changes outside of her face, no VC, vertigo, or language impairment. She cannot recall something like this happening before, and states that her day was otherwise routine. On ROS, she notes that about 2 weeks ago she had diarrhea for 1 week which resolved spontaneously. She also endorses feeling "achey" 4 days ago, otherwise, her health has been normal. Past Medical History: GERD mild depression migraines (throbing HA's assoc with visual flashes of light), last ___ years ago bunions Social History: ___ Family History: Father with HD, sustained a stroke after a cardiac cath. Later in life father developed a meningioma and subsequent seizures. Physical Exam: 98.4F 69 134/79 15 100%RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says ___ backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Reading intact. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Retinas with sharp disc margins B/L. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3 to both LT and PP. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift Del Tri Bi WF WE FE FF IP H Q DF PF TE TF R ___ ___ ___ ___ 5 5 L ___ ___ ___ ___ 5 5 Sensation: Intact to light touch, pinprick, and proprioception throughout. Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, heel to shin normal, FT and RAMs normal. Gait: Narrow based, steady. Able to tandem walk without difficulty Romberg: Negative Pertinent Results: ___ 06:10AM BLOOD WBC-5.3 RBC-4.38 Hgb-11.5* Hct-36.1 MCV-82 MCH-26.2* MCHC-31.8 RDW-13.3 Plt ___ ___ 11:14PM BLOOD Neuts-52.1 ___ Monos-4.7 Eos-2.0 Baso-0.5 ___ 11:14PM BLOOD ___ PTT-33.7 ___ ___ 06:10AM BLOOD Glucose-82 UreaN-16 Creat-0.8 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 ___ 11:14PM BLOOD ALT-13 AST-19 CK(CPK)-69 AlkPhos-70 TotBili-0.2 ___ 11:14PM BLOOD CK-MB-NotDone cTropnT-<0.01 ___ 11:14PM BLOOD TotProt-7.1 Albumin-4.5 Globuln-2.6 Calcium-9.5 Phos-3.7 Mg-2.1 ___ 02:26AM BLOOD %HbA1c-5.7 ___ 11:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Radiology Report MRA BRAIN W/O CONTRAST Study Date of ___ 9:44 AM 1. No acute intracranial abnormality; specifically, there is no evidence of either acute or previous ischemic event. 2. Normal cranial and cervical MRA, with no significant mural irregularity or flow-limiting stenosis. Brief Hospital Course: Ms. ___ is a ___ yo woman with a hx of depression, GERD and migraines, presenting with an episode of facial numbness. 1. Facial numbness. As this episode preceeded a headache, suspect likely due to a migraine equivalent, however episode could also be due to a TIA in the thalamus. The patient had an MRI, which showed no signs of ischemia, and normal vasculature, making migraine equivalent a much more likely diagnosis. However, given the possibility of TIA, she has been started on a daily aspirin for future stroke prophylaxis. Exam on discharge was notable for mild symmetric hyperreflexia in the lower extremities, but otherwise normal neurological exam, with no residual sensory deficits. Medications on Admission: NEXIUM 40 mg--1 capsule(s) by mouth once a day PROZAC 20 mg--1 capsule(s) by mouth once a day Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Migraine Discharge Condition: Mild symmetric hyperreflexia in the lower extremities, otherwise normal neurological exam. Discharge Instructions: You were admitted for left sided facial numbness. You had an MRI which showed no signs of ischemia. It is suspected that this was related to migraine headaches, but we recommend that you start taking a full dose of aspirin. If you notice new numbness, weakness, worsening headaches, or other new concerning symptoms, please return to the nearest ED for further evaluation. Followup Instructions: ___

{'Facial numbness': ['Other forms of migraine'], 'Mild diffuse dull HA': ['Other forms of migraine'], 'Achey': [], 'Diarrhea': [], 'Feeling achey': [], 'Abnormal reflex': ['Abnormal reflex']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: neck pain s/p fall Major Surgical or Invasive Procedure: None on this Admission History of Present Illness: ___ male transferred from outside hospital for evaluation of cervical ___ fracture. Today the patient was attempting to use the bathroom and bent forward and fell hitting the back of his head. There was no loss of consciousness. The patient complains of headache and neck pain. The outside hospital the patient had the head laceration stapled. A CT scan did demonstrate the fracture. The patient denies any numbness, tingling in his arms or legs. No weakness in his arms or legs. Denies any bowel incontinence or bladder retention. No saddle anesthesia. Denies any chest pain, shortness of breath or abdominal pain. Past Medical History: PMH: a. fib, colon ca, htn, copd MED: warfarin, allopurinol, asacol ALL: pcn, sulfa Social History: ___ Family History: NC Physical Exam: C collar in place UEC5C6C7C8T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) Rintact intact intact intact intact Lintact intact intact intact intact T2-L1 (Trunk) intact ___ L2 L3 L4 L5S1S2 (Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) Rintactintactintactintact intactintact Lintactintactintactintact intactintact Motor: UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1) R 5 5 5 5 ___ L 5 5 5 5 ___ ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R ___ 5 5 5 5 L ___ 5 5 5 5 Babinski: negative Clonus: not present Brief Hospital Course: Patient was admitted to the ___ ___ Surgery Service for observation after a C2 fracture. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Diet was advanced as tolerated. The patient was tolerated oral pain medication. Physical therapy was consulted for mobilization OOB to ambulate. He remained hypertensive from 160 - >180. Medicine consult appreciated - felt this was long standing. recommended PRN antihypertensives but cautioned against bringing pressure too low too quickly. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain, temp >100.5, headache 2. Allopurinol ___ mg PO DAILY 3. Mesalamine ___ 400 mg PO TID 4. Metoprolol Tartrate 25 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. Warfarin 1 mg PO DAILY 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 8. Diazepam 2 mg PO Q12H:PRN spasms Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C2 fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: -Activity: You should not lift anything greater than 5 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. -Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. -Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. -Wound Care: Monitor laceration at scalp for drainage/redness. Your PCP may take these staples out. -You should resume taking your normal home medications. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. -Follow up: oPlease Call the office ___ and make an appointment with Dr. ___ 2 weeks after the day of your operation if this has not been done already. oAt the 2-week visit we will check your incision, take baseline x rays and answer any questions. oWe will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: activity as tolerated C-collar full time for 12 weeks may use ambulatory assistive devices for safety no bending twisting, or lifting >5lbs Treatment Frequency: monitor skin at chin and back of head for breakdown in C-collar Followup Instructions: ___

{'neck pain': ['Closed fracture of third cervical vertebra'], 'headache': ['Closed fracture of third cervical vertebra'], 'loss of consciousness': [], 'numbness': [], 'tingling': [], 'weakness': [], 'bowel incontinence': [], 'bladder retention': [], 'saddle anesthesia': [], 'chest pain': [], 'shortness of breath': [], 'abdominal pain': []}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Gait instability, multiple falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a pleasant right handed ___ year old male with Afib, on coumadin, who is quite independent, living with his wife and was in a good state of health until mid last year. At that time his wife reports that he began having periods of disorganized speech and gait instability. He did not have a fall until 3 months ago when he broke several ribs on his coffee table. He did not have any head trauma and was not scanned at an OSH. His garbled speech and unsteadiness have waxed and waned over the past 6 months and his wife reports that they are much improved when he takes his diuretics. Over this period he has lost ~20 lbs. Last night he was sorting papers at the dining room table when he fell from standing because of the dizziness. He reports no LOC, no head trauma and was able to stand back up and continue his work. His wife placed him on the couch, but he got back up and fell in the bathroom - again he denies any LOC or head trauma, blaming his instability and ___ weakness. He had no tongue biting or loss of bowel/bladder continence. He went to bed last night, but the morning of presentation his wife was concerned about his falls and brought him to the ED. He does have a diagnosis of DM II from just over a month ago and has started oral hypoglycemics for which he reports having low ___ at home. He was seen by an outside neurologist the week prior who had ordered a CT head to be completed the following week. In the ED his head was scanned which revealed no bleed but a 3x3 L frontal lobe extra-axial mass with compressive effect but no midline shift. Neurosurgery was contacted for evaluation of the mass and its possible role in the patient's recent symptoms. Past Medical History: DM II, HTN, HL, MI (in past), AF on coumadin, prostate CA treated non-operatively Social History: ___ Family History: Non-contributory Physical Exam: At Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4->3 EOMs intact b/l Lungs: CTA bilaterally. Cardiac: irreg irreg with ___ holosystolic murmur. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech is fluent, good comprehension. Difficulty with repitition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. Mild R sided pronator drift. Gait unsteady, rhomberg test with unsteadiness. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 1 1 Left ___ 1 1 Toes downgoing bilaterally Coordination: heel to shin intact, finger nose-finger slowed and overshooting with R hand. Difficulty with rapid alternating movements with R hand. AT DISCHARGE: Afeb, VSS Gen: NAD. HEENT: Pupils: 3->2 EOMs intact b/l Lungs: clear b/l Cardiac: irreg irreg with ___ holosystolic murmur. Abd: non-tender/non-distended Extrem: no edema or erythema, warm well perfused. Neuro: Mental status: Awake and cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent, good comprehension. Cranial Nerves: II-XII tested and intact b/l Motor: ___ strength b/l in UE and ___. No pronator drift. Gait steady, walking without assistance. Sensation: Grossly intact b/l. Reflexes: B T Br Pa Ac Right ___ 1 1 Left ___ 1 1 Toes downgoing bilaterally Pertinent Results: ___ 04:55AM BLOOD WBC-3.9* RBC-4.39* Hgb-13.5* Hct-40.7 MCV-93 MCH-30.7 MCHC-33.1 RDW-15.5 Plt ___ ___ 04:55AM BLOOD ___ ___ 04:55AM BLOOD Glucose-115* UreaN-33* Creat-1.2 Na-142 K-3.7 Cl-104 HCO3-33* AnGap-9 ___ 06:25AM BLOOD Albumin-3.2* ___ 02:39PM BLOOD %HbA1c-7.7* eAG-174* ___ 06:25AM BLOOD Phenyto-4.6* CT Head ___: IMPRESSION: 1. Extra-axial lesion, containing foci of calcifications measuring up to 3 cm, which likely reflects an extra-axial mass such as a meningioma. An extra-axial hematoma, which would be subacute to chronic, is considered less likely. 2. Loss of gray-white differentiation in the high left frontoparietal lobe, could reflect an acute infarct. MRI Head ___: Acute to subacute bilateral infarctions with the largest focus in the left post-central gyrus. Appearance of the post-gyrus lesion is somewhat heterogeneous however and recommend attention on followup imaging for further evaluation to exclude the presence of an underlying mass. Two meningiomas in the left frontal region without significant mass effect. ECHO ___: Marked symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. Mild aortic valve stenosis. Mild aortic regurgitation. Right ventricular free wall hypertrophy. Pulmonary artery systolic hypertension. Dilated ascending aorta. CLINICAL IMPLICATIONS: The patient has mild aortic stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in ___ years. Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. MRA Head/Neck ___: Mild atherosclerotic disease of the basilar artery. There is no evidence of acute vascular abnormalities involving the intracranial arteries Brief Hospital Course: Mr. ___ was admitted to the neurosurgical service on ___ from the emergency room after having a series of falls on ___. A CT of the head demonstrated a left frontal extra-axial mass as well as a more acute lesion in the parietal lobe on the left. Because of his recent falls, his coumadin was held and he was placed on an insulin sliding scale as there was some concern for hypoglycemia contributing to the unsteadiness. An MRI of this head was obtained which confirmed a meningioma overlying the L frontal lobe and a sub-acute infarct in the post-central gyrus on the left. While he did have distinct right sided weakness in the emergency room, on hospital day #2 this weakness had nearly completely resolved and his confusion was also better. A neurology consult was obtained given what appeared to be a sub-acute stroke on his MRI - they recommended restarting the pt's coumadin, holding the dilantin and checking an EEG, these were done while he was an inpatient. He also underwent a surface echo and an MRA of the brain and neck given the likely embolic nature of his strokes. Neurology will see him in 3 months with a repeat head MRI. ___ also saw him for his diabetes managment and recommended changing his glipizide to 10 BID, and not starting insulin. His sugars were well controlled while in house and he did not have any episodes of hypoglycemia. From a neurologic standpoing, in-house he did quite well with resultion of his right sided weakness although his unsteadiness continued and he needed support while ambulating. ___ recommended he go to a short term rehab until he was better able to compete transfers and ambulate with a walker. He will follow up with neurology and neurosurgery to discuss how to best manage his ischemic strokes and address the meningioma, respectively. Medications on Admission: Coumadin 2.5', prandin 0.5''', glipizide 5'', isosorbide dinitrate 10'', lisinopril 20, allopurinol ___, torsemide 5, metoprolol 50''', lipitor 10' Discharge Medications: 1. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. 7. Torsemide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Left frontal meningioma, left parietal sub-acute infarct, Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You should take your coumadin as prescribed. You do not need anti-seizure medications any longer. You should follow up with Dr. ___ Dr. ___ as listed below. You will need a follow up MRI to evaluate the small stroke you had on the left side of your brain. Take all medications as prescribed and follow up with Dr. ___ this week to check in. General Instructions/Information •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. • If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. •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. 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. •Fever greater than or equal to 101° F. Followup Instructions: ___

{'symptom1': ['disease1', 'disease2'], 'symptom2': ['disease2', 'disease3', 'disease4'], 'symptom3': ['disease1', 'disease3', 'disease5', 'disease6']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Atypical chest pain Major Surgical or Invasive Procedure: Stess Echo History of Present Illness: ___ y/o woman with intermittent chest pain past several months. Pain is located on left posterior shoulder and radiates down arm to fingers where it turns into "pins-n-needles" symptom. No SOB/N/V. Patient does endorse some minimal diaphoresis and gerd like symptoms accompanying it. Pain has been controlled with tylenol #3. Past Medical History: HTN Asthma Diverticulitis several years ago R hip replacement in ___ Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: Vtals: T: 97.6 BP: 167/88 P: 83 R: 20 O2: 99% 2L 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 03:20PM BLOOD WBC-6.2 RBC-4.51 Hgb-13.1 Hct-38.6 MCV-86 MCH-29.1 MCHC-33.9 RDW-15.4 Plt ___ ___ 07:15AM BLOOD WBC-6.0 RBC-4.91 Hgb-13.8 Hct-41.7 MCV-85 MCH-28.1 MCHC-33.0 RDW-15.1 Plt ___ ___ 07:50AM BLOOD WBC-5.2 RBC-4.67 Hgb-13.4 Hct-39.4 MCV-84 MCH-28.7 MCHC-34.1 RDW-15.2 Plt ___ ___ 03:20PM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-139 K-3.5 Cl-100 HCO3-30 AnGap-13 ___ 09:10PM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-137 K-3.3 Cl-99 HCO3-31 AnGap-10 ___ 07:15AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-138 K-4.4 Cl-98 HCO3-35* AnGap-9 ___ 03:20PM BLOOD cTropnT-<0.01 ___ 09:10PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 07:15AM BLOOD CK-MB-4 cTropnT-<0.01 . ___ ___ F ___ ___ Cardiology Report Stress Study Date of ___ EXERCISE RESULTS RESTING DATA EKG: SINUS WITH AEA, LBBB HEART RATE: 68 BLOOD PRESSURE: 146/86 PROTOCOL MODIFIED ___ - TREAD___ STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 0 ___ 1.0 8 100 176/88 ___ 1 ___ 1.7 10 114 178/92 ___ 2.5 12 126 184/98 ___ TOTAL EXERCISE TIME: 9 % MAX HRT RATE ACHIEVED: 83 SYMPTOMS: ATYPICAL PEAK INTENSITY: ___ INTERPRETATION: ___ yo woman was referred to evaluate an atypical chest discomfort. The patient completed 9 minutes of a Gervino protocol representing a fair exercise tolerance for her age; ~ ___ METS. The exercise test was stopped at the patient's request secondary to fatigue. During exercise, the patient reported a non-progressive, isolated upper left-sided chest discomfort; ___. The area of discomfort was reportedly tender to palpation. This discomfort resolved with rest and was absent 2.5 minutes post-exercise. In the presence of the LBBB, the ST segments are uninterpretable for ischemia. The rhythm was sinus with frequent isolated APDs and occasional atrial couplets and atrial triplets. Resting mild systolic hypertension with normal blood pressure response to exercise. The heart rate response to exercise was mildly blunted. IMPRESSION: Fair exercise tolerance. No anginal symptoms with uninterpretable ECG to achieved workload. Resting mild systolic hypertension with appropriate blood pressure response to exercise. Suboptimal study - target heart rate not achieved. SIGNED: ___ Brief Hospital Course: ___ ___ with several month history of left sided arm and chest wall pain in the setting of LBBB presenting for ___. . . # Chest Pain:The patient's symptoms were not typically anginal in nature to suggest ACS. However she does have several cardiac risk factors and a LBBB, so physicians could not r/oMI with EKG alone. Trop. results were negative x3. Stress Echo revealed new regional dysfunction with hypokinesis of the inferior and inferolateral walls consistent with single vessel disease in the PDA distribution. A cardiology consult was obtained and they felt she could be managed medically. Patient was already on an aspirin, and a statin. Given history to suggest asthma B-blocker was contraindicated. She was discharged on 120 mg extended release diltiazem with instructions to follow up in cardiology and with her PCP. . # Supraventricular tachycardia: The patient had multiple runs of SVT that was likley MAT in the setting of severe obstructive lung disease and chronic theophylline use. Cardiology reccomended that we discontinue her theophylline. We spoke with her pulmonologist who agreed this would be the best course of action for her. She was discharged with instructions to discontinue use of theophylline and follow up with her pulmonologist and cardiology. Medications on Admission: Tylenol ___ Q4h PRN pain Albuterol Sulfate 2 puffs q4-6h PRN SOB Fluticasone 50 mcg spray/suspension 2 whiffs PRN allergies Adviar 500/50 1 INH BID HCTZ 50mg One PO daily Singulari 10mg tablet One PO QD omeprazole 20mg 1 PO QD simvastatin 20mg 1 PO QD theophylline 200mg sustained release one PO TID spiriva 18 mcg w/ inhalation ASA 81mg Calcium sig unknown Cod liver oil Sig unk Multivitamin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB wheeze. 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: ___ Nasal once a day as needed for allergy symptoms. 5. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. diltiazem HCl 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 min as needed for chest pain: take one at onset of chest pain. ___ repeat every 5 min x3 with continued chest pain. Call PCP if chest pain persists. Disp:*30 tabs* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ because you had back and arm pain that was worrisome for heart disease. A strees test found that you have coronary artery disease. You were started on a new blood pressure medication and tolerated this well. You should keep all of you follow up appointments as listed below. . While you were here we made the following changes to your medications: . We STARTED you on Diltiazem 120mg once a day . We STOPPED ___ theophylline . We STARTED nitroglycerine to take when you have chest pain . YOU NEED TO STOP SMOKING. IT WILL KILL YOU. Followup Instructions: ___

{'Chest pain': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Arm pain': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Radiates down arm to fingers': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Pins-n-needles symptom': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Minimal diaphoresis': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Gerd like symptoms': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'HTN': ['Unspecified essential hypertension'], 'Asthma': ['Chronic obstructive asthma'], 'Diverticulitis': ['Diverticulosis of colon (without mention of hemorrhage)'], 'R hip replacement': ['Hip joint replacement'], 'CA': ['Tobacco use disorder'], 'Family history': ['Other left bundle branch block', 'Other specified cardiac dysrhythmias', 'Antiasthmatics causing adverse effects in therapeutic use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever, non-productive cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F w/ HTN, CAD, COPD p/w fevers, non-productive cough, since ___. Pt said she was in her usual state of health until ___ evening when she developed a cough producing ___ sputum. She took some robitussin and went to bed. She woke up the next morning and had general malaise, nasal congestion, intermittently productive cough. She did not want to eat and had 4 episodes of water diarrhea and one episode of vomiting without nausea. She denied fevers, chills or sweats at that time. She called her PCP who prescribed ___ Z-pack. Her symptoms persisted and she developed pain with coughing around her upper abdomen and lower chest. Denies other joint or muscle pain. She went to see her PCP on the day of admission. In her PCP's office was hypoxic on RA, here is 89% on RA. Has had flu vaccine this year and pneumovax last year. wheezy on exam, on 2L with o2 sat mid-90s. . In ED VS were afebrile 70 113/66 94%2L, On exam had wheezes with peak flow of 150 (no baseline), speaking in full sentences and no accessory muscle use, euvolemic and no ___ edema. Flu screen not performed, CXR unremarkable compared to prior. Given levoflox, nebs, pred 50 mg. Past Medical History: ASTHMA HYPERTENSION HYPERLIPIDEMIA HEADACHE OSTEOARTHRITIS ATYPICAL CHEST PAIN TOBACCO ABUSE ABNORMAL CHEST XRAY COPD Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: On Admission: VS: T: , BP: 142/70, HR: 70, RR 20, O2 93% on RA (96% 2L) GA: AOx3, pt with nasal cannula on in no respiratory distress HEENT: MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes, good inspiratory effort, but not great air movement, slightly prolonged expiratory phase. Abd: soft, NT, +BS. no g/rt. neg HSM. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no noticeable rashes Neuro/Psych: CNs II-XII intact . ON DISCHARGE: VS: T: , BP: 142/70, HR: 70, RR 20, O2 93% on RA (96% 2L) GA: AOx3, pt with nasal cannula on in no respiratory distress HEENT: MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes, good inspiratory effort, but not great air movement, slightly prolonged expiratory phase. Abd: soft, NT, +BS. no g/rt. neg HSM. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no noticeable rashes Neuro/Psych: CNs II-XII intact Pertinent Results: LABS: ___ 03:26PM BLOOD WBC-4.9 RBC-4.25 Hgb-12.7 Hct-36.5 MCV-86 MCH-30.0 MCHC-34.9 RDW-15.3 Plt ___ ___ 06:50AM BLOOD WBC-8.2# RBC-4.03* Hgb-12.2 Hct-34.8* MCV-87 MCH-30.4 MCHC-35.1* RDW-15.3 Plt ___ ___ 03:26PM BLOOD Glucose-123* UreaN-14 Creat-0.9 Na-136 K-3.3 Cl-97 HCO3-31 AnGap-___ 06:50AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-139 K-3.5 Cl-98 HCO3-30 AnGap-15 . MICRO: **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. REPORTED BY PHONE TO ___ AT 1153 ___. . IMAGING: CXR ___: IMPRESSION: 1. No acute chest pathology with stable pleural parenchymal scar. 2. Flattening of the hemidiaphragms consistent with COPD. Brief Hospital Course: A/P: ___ year old woman with recent onset of fevers, productive cough and costochondral vs. pleuritic pain who tested positive for influenza A. . # Fevers, malaise, cough: Pt seemed to have onset of symptoms consistent with viral infection. She was admitted to the hospital and placed on droplet precautions because there was concern that she had the flu. She was empirically started on Oseltamivir 75mg PO BID. nasopharyngeal swab was positive for influenza A. She was continued on a five day regiment of oseltamivir for her flu and will follow up with Dr. ___ in the outpatient setting. . # COPD exacerbation: Pt tested positive for the flu, but seemed to also be having a COPD exacerbation with worsening dyspnea and sputum production. She was started on prednisone 50mg PO Daily, Azithromycin and O2 via nasal cannula. Her resting O2 sat was initially 85%, but at the time of discharge she was satting 96% on RA, but would desaturate to 84% after walking 75-100feet. She Was given a 5 day course of azithromycin, 5 days of prednisone at 50mg PO Daily and then a week long taper and discharged on home O2 while her symptoms improved. The patient was breathing more comfortably and ambulating well at the time of discharge. She will follow up with Dr. ___ as well as Dr. ___ in the outpatient setting. . # ASTHMA: pt with wheezing in the ED and at PCP office, but not present on my exams, however, she had received duonebs prior to my exam. Likely having asthma symptoms in setting of COPD exacerbations. She was continued on her home regiment and also on standing nebulizers. She was discharged with nebulizer treamtents as well as her home medications. Respiratory status was described above. . HYPERTENSION: Pt slightly hypertensive in the ED, but will continue meds at current regiment and reassess in the morning. Her BP meds are actively being uptitrated in the outpatient setting. She remained normotensive during her hospital stay on the floor. We continued Diltiazem ER 360mg PO Q24H, HCTZ 12.5mg PO DAILY, IMDUR ER 60 mg PO DAILY. . GERD: Currently asymptomatic. We continued omeprazole 20mg PO Daily . CAD: Pt was recently diagnosed with single vessel disease. She is asymptomatic at this time, but we will continue to monitor her for symptoms during this admission. We continued aspirin 81mg PO DAILY . TOBACCO ABUSE: Pt had been smoking for many years, but said that she quit yesterday and has no need for a nicotine patch or gum at this time. . Medications on Admission: 1. Lisinopril 5mg PO Daily 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 9. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 10. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*540 Tablet(s)* Refills:*2* 11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every ___ hours. 3. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 4. oseltamivir 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 3 days. Disp:*5 Capsule(s)* Refills:*0* 5. prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day for 7 days: Take 5 tabs for 2 days, then 4 tabs for 2 days, then 2 tabs for 2 days, then 1 tab for 2 days. Disp:*19 Tablet(s)* Refills:*0* 6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 17. Oxygen Home Oxygen @ 2LPM Continuous via nasal cannula, conserving device for portability. Pulse dose for portability. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Influenza COPD exacerbation . Secondary Diagnosis: ASTHMA HYPERTENSION HYPERLIPIDEMIA HEADACHE OSTEOARTHRITIS ATYPICAL CHEST PAIN TOBACCO ABUSE ABNORMAL CHEST XRAY COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from ___. It was a pleasure taking care of you. You were admitted to the hospital for symptoms that were similar to a common cold as well as worsening respiratory status. You tested positive for the flu and we also believe that you are having a COPD exacerbation. You were started on high dose steroids, azithromycin, tamiflu and nebulizers. You were also placed on oxygen. You are now doing better, but may require O2 at home for some time as your infection resolves and your inflammation improves. . The Following medications were STARTED: Prednisone 50mg 1 day, on ___ decrease to 40mg Daily for 2 days, on ___ decrease to 20mg Daily for 2 days, on ___ take 10mg Daily for 2 days then stop Azithromycin 250mg by mouth Daily 1 day (last dose on ___ Tamiflu 75mg two times a day for 2.5 days (last dose on ___ You will also be sent on home O2 . Please take your other medications as prescribed. Followup Instructions: ___

{'fevers': ['Influenza with other respiratory manifestations'], 'non-productive cough': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'malaise': ['Influenza with other respiratory manifestations'], 'nasal congestion': ['Influenza with other respiratory manifestations'], 'intermittently productive cough': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'water diarrhea': ['Influenza with other respiratory manifestations'], 'vomiting without nausea': ['Influenza with other respiratory manifestations'], 'pain with coughing': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'wheezy': ['Chronic obstructive asthma with (acute) exacerbation'], 'hypoxic': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Dilantin ___ Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is an ___ F with a medical history notable for irritable bowel syndrome and dementia. She reports no problems with her bowels for many years until the acute onset of diarrhea ___ morning. Prior to this event she had no recent travel or sick contacts but did eat corned beef and cabbage at her local ___ hall (last ___ was ___). She noted nausea with non-bloody, non-bilious vomitting and loose watery diarrhea. She had no fever, abdominal cramping, or blood in her stool. Since that time her nausea/vomitting have improved but her diarrhea has not improved despite Imodium. She was unable to keep down oral foods and presented to the ED today. Vital signs on arrival to ___ ED: T 97.6, P 97, BP 167/81, 100% on RA. Her evaluation in the ED was notable for guaiac positive stool, a WBC count of 4.1, and an elevated BUN to 33. In the ED she received 1 liter of normal saline. Review of Systems: Pain assessment on arrival to the floor: ___ (no pain). No recent illnesses. No fevers, chills, or night sweats. No SOB, cough, or chest pain. No urinary symptoms. Other systems reviewed in detail and all otherwise negative. Past Medical History: Hypertension Dementia Osteoporosis Irritable bowel syndrome Macrocytosis of unclear etiology Left ear hearing loss Status post hysterectomy Status post appendectomy Status post ovarian cyst removal Cataract surgery Glaucoma Social History: ___ Family History: Not relevant to the current admission. Physical Exam: Vital Signs: T 98.6, P 64, BP 124/72, 95% on RA. Physical examination: - Gen: Elderly female sitting up in bed in NAD. - HEENT: Hard of hearing. Right ear better than left. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP <5 cm. - Abdomen: Normal bowel sounds. Soft, nontender, nondistended. - Extremities: No ankle edema. - Neuro: Alert, oriented x ___. Most of history aided by daughter. Does not know home medications or specifics timing of recent events. Has short-term memory impairment. Speech and language are normal. - Psych: Appearance, behavior, and affect all normal. Pertinent Results: Admission Labs: ___ 09:35AM BLOOD WBC-4.1 (Neuts-58 Bands-2 Lymphs-24 Monos-15* Eos-0 Baso-1 ___ Myelos-0) RBC-4.40 Hgb-14.9 Hct-43.5 MCV-99* MCH-33.8* MCHC-34.2 RDW-13.2 Plt ___ ___ 09:35AM BLOOD Glucose-118* UreaN-33* Creat-1.1 Na-144 K-3.4 Cl-107 HCO3-21* AnGap-19 ALT-21 AST-22 AlkPhos-53 TotBili-0.6 Lipase-16 Albumin-4.6 - ___ 10:30AM URINE Color-Yellow Appear-Hazy Sp ___ Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG RBC-1 WBC-4 Bacteri-MOD Yeast-NONE Epi-0 CastGr-7* CastHy-93* CastCel-1* . Microbiology: ___ Stool Cultures: ___ 9:58 pm STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . ___ Urine Cultures NGTD ___ 06:47AM BLOOD WBC-6.6# RBC-3.72* Hgb-12.3 Hct-36.5 MCV-98 MCH-33.2* MCHC-33.8 RDW-12.6 Plt ___ ___ 06:47AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-143 K-3.7 Cl-109* HCO3-28 AnGap-10 ___ 09:35AM BLOOD ALT-21 AST-22 AlkPhos-53 TotBili-0.6 ___ 09:35AM BLOOD cTropnT-<0.01 ___ 06:47AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.___ y/o F with PMhx of IBS and Dementia who presented with ___ days of nausea, vomiting and non-bloody diarrhea. Pt was notably dehydrated on admission with acute renal failure and symptomatic orthostasis. She was treated with IVF and bowel rest. Infectious work up including Cdiff returned negative and presentation was most consistent with norovirus. Pt was slowly advanced a diet and diarrhea improved. Renal function returned to baseline with IVF and pt was tolerating a bland diet without any evidence of orthostasis by the day of discharge. Pt was seen by ___ who felt that she was safe for discharge home without services. . Conjunctivitis (left eye): At the time of admission, pt reported being treated with azithromycin drops for left eye conjunctivitis but was having ongoing symptoms. Pt was started on erythromycin opthalmic ointment with some improvement in conjunctival injection. She was instructed to monitor for any worsening in eye symptoms and was scheduled for follow up with her PCP. . Otherwise, there were no changes made to her chronic medication regimen . Code Status: DNR/DNI confirmed on admission with patient and her HCP. Medications on Admission: -list confirmed with primary caregiver on admission- ___ 10 mg daily Namenda 10 mg daily Aspirin 162.5 mg daily Raloxifene (Evista) 60 mg daily Multivitamin daily Glucosamine Calcium supplement Cholecalciferol (Vitamin D3) 1,000 units daily Ascorbic Acid SR 500 mg daily Discharge Medications: 1. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Namenda 10 mg Tablet Sig: One (1) Tablet PO qhs (). 3. aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. raloxifene 60 mg Tablet Sig: One (1) Tablet PO once a week. 5. multivitamin Oral 6. Glucosamine Oral 7. Vitamin D Oral 8. ascorbic acid Oral 9. Calcium 500 Oral 10. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch Ophthalmic four times a day for 5 days: apply to left eye for another 5 days . Disp:*qs tube* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal Virus Dehydration Symptomatic orthostasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with an acute diarrheal illness and dehydration. This was likely due to a virus which can be very contagious. You have been treated with IV fluids and supportive care with improvement in your symptoms. You have been seen by physical therapy who agree that you are safe to return home today. We encourage you take as much oral hydration as possible and continue advancing your diet as tolerated. Please keep your appointment with Dr. ___ on ___. . We have given you a new prescription to help treat the left eye conjunctivitis, please continue using the erythromycin ointment for another 5 days. If you develop any rash on your face, fevers, visual changes or worsening in eye symptoms, please call your PCP or return for urgent evaluation. . Otherwise, we have not made any changes to your medications Followup Instructions: ___

{'diarrhea': ['Enteritis due to norwalk virus', 'Dehydration'], 'nausea': ['Enteritis due to norwalk virus', 'Dehydration'], 'vomiting': ['Enteritis due to norwalk virus', 'Dehydration'], 'conjunctivitis': ['Conjunctivitis', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ___ Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Band adjustment History of Present Illness: Ms. ___ is a ___ s/p lap band in ___ who prsents with a 1 week history of nausea, non-bilious non-bloody emesis of undigested food after eating, intolerance to solids/softs, hypersalivation, and moderate post-prandial epigastric discomfort. She denies fever, chills, hematemesis, BRBPR, melena, diarrhea, or sympotoms of dehydration, but was recently evaluated for dizziness in an ED with a diagnosis given of BPPV. Of note, the patient underwent an unfill of her band from 5.8 to 3.8ml on ___ for similar symptoms, the band was subseqently been filled to 4.8 on ___, 5.2 on ___, and most recently to 5.6ml on ___. Past Medical History: PMHx: Hyperlipidemia and with elevated triglyceride, iron deficiency anemia, irritable bowel syndrome, allergic rhinitis, dysmenorrhea, vitamin D deficiency, question of hypothyroidism with elevated TSH level, thalassemia trait, fatty liver and cholelithiasis by ultrasound study. A history of kissing tonsils that was associated with obstructive sleep apnea and gastroesophageal reflux, these have resolved completely after the tonsillectomy in ___. History of polycystic ovary syndrome Social History: ___ Family History: bladder CA; with diabetes, breast neoplasia, colon CA, ovarian CA and sarcoma Physical Exam: VS: Temp: 97.9, HR: 72, BP: 113/64, RR: 16, O2sat: 100% RA GEN: A&O, NAD HEENT: No scleral icterus, MMM CV: RRR PULM: No W/R/C, no increased work of breathing ABD: Soft, nondistended, non-tender to palpation in epigastric region, no rebound or guarding, palpable port Ext: No ___ edema, warm and well perfused Pertinent Results: ___ 12:16AM PLT COUNT-243 ___ 12:16AM NEUTS-46.0 ___ MONOS-6.9 EOS-1.8 BASOS-0.5 IM ___ AbsNeut-4.88 AbsLymp-4.72* AbsMono-0.73 AbsEos-0.19 AbsBaso-0.05 ___ 12:16AM estGFR-Using this ___ 01:02AM URINE MUCOUS-RARE ___ 01:02AM URINE HYALINE-1* ___ 01:02AM URINE RBC-4* WBC-4 BACTERIA-MOD YEAST-NONE EPI-11 ___ 01:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 01:02AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 01:02AM URINE UCG-NEGATIVE ___ 01:02AM URINE HOURS-RANDOM ___ 01:02AM URINE HOURS-RANDOM Brief Hospital Course: ___ was admitted from ED on ___ for nausea and vomiting after any po intake. Of note, she has had similar symptomes last year. She was started on IV fluids for rehydration. Her laboratory values were unremarkable on admission and her symptoms gradually improved with anti-emetic medications and IV fluid therapy. She was back to her baseline clinical status after unfilling the band by 1.5cc. Water challenge test was done after band adjustment and was negative for any pain, nausea or vomiting. She was discharged in good condition with instructions to follow up with Dr. ___ ___ after 2. Discharge Medications: 1. Lorazepam 0.5 mg PO BID:PRN anxiety 2. BusPIRone 5 mg PO TID Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting due to tight band Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ for your Nausea and vomiting. Your band was tight enough to cause your nausea and vomiting, 1.5 cc has been taken out from your band in which 2.5cc total left. you subsequently tolerated a water bolus test. You have been deemed fit to be discharged from the hospital. Please return if your nausea becomes untolerable or you start vomiting again. Please continue taking your home medications. Thank you for letting us participate in your healthcare. Followup Instructions: ___

{'nausea': ['Nausea with vomiting'], 'vomiting': ['Nausea with vomiting'], 'hypersalivation': [], 'epigastric discomfort': [], 'intolerance to solids/softs': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ___ Attending: ___. Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: ___: 1. Laparoscopic repair of paraesophageal hernia. 2. Laparoscopic adjustable gastric band. History of Present Illness: Per Dr. ___ has class III morbid obesity with ___ of 238.4 pounds as of ___ with initial screen ___ of 241.4 pounds on ___, height is 64 inches and BMI of 40.9. Her previous ___ loss efforts have included ___ Watchers, ___ Loss, Slim-Fast, over-the-counter pancreatic lipase inhibitor ___ visits. She has lost up to 20 pounds but unable to maintain the ___. Her lowest ___ as an adult was 180 pounds and her highest ___ was her initial screen ___ of 241.4 pounds. She weighed 225.4 pounds ___ years ago and 235 pounds one year ago. She stated that she has been struggling with ___ since ___ years of age and cites as factors contributing to her excess ___ genetics, inconsistent meal pattern, late night eating, large portions, too many carbohydrates, grazing and emotional eating at times. For exercise she does ___ one hour ___ times per week, elliptical ___ minutes ___ times per week and some kettle bell training. She denied history of eating disorders and does have depression, has not been seen by a therapist nor has she been hospitalized for any mental health issues and she is not on any psychotropic medications at this time. Past Medical History: PMHx: Hyperlipidemia and with elevated triglyceride, iron deficiency anemia, irritable bowel syndrome, allergic rhinitis, dysmenorrhea, vitamin D deficiency, question of hypothyroidism with elevated TSH level, thalassemia trait, fatty liver and cholelithiasis by ultrasound study. A history of kissing tonsils that was associated with obstructive sleep apnea and gastroesophageal reflux, these have resolved completely after the tonsillectomy in ___. History of polycystic ovary syndrome Family History: bladder CA; with diabetes, breast neoplasia, colon CA, ovarian CA and sarcoma Physical Exam: VSS Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1,S2 Lungs: CTA B Abd: Obese, soft, non-distened, appropriate ___ tenderness, no rebound tenderness/guarding Wounds: Abd lap sites with primary dsg, slight serosanguinous staining x 1, no periwound erythema Ext: No edema Pertinent Results: LABS: ___ 09:20AM BLOOD WBC-9.8 RBC-5.19 Hgb-14.0 Hct-41.9 MCV-81* MCH-27.0 MCHC-33.5 RDW-13.5 Plt ___ ___ 09:20AM BLOOD Plt ___ ___ UGI SGL CONTRAST W/ KUB: IMPRESSION: Slightly horizontally positioned lap band with a patent stoma and no evidence of leak. Brief Hospital Course: Ms. ___ presented to ___ on ___. Pt was evaluated by anaesthesia and taken to the operating room where she underwent a laparoscopic adjustable gastric band placement and repair of paraesophageal hernia. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs. The patient’s pain was well controlled with oral Roxicet prn. The patient remained stable from both a cardiovascular and pulmonary standpoint; she was maintained on CPAP overnight for known sleep apnea. The patient was initially on a bariatric stage 1 diet, but was made NPO at ___ POD1 for an UGI series. The UGI was negative for leak or obstruction, therefore, the patient's diet advanced sequentially to bariatric stage 3 and well tolerated; pt’s intake and output were closely monitored. Urine output remained adequate throughout the hospitalization. The received subcutaneous heparin and venodyne boots were used during admission; early and frequent ambulation were strongly encouraged. The patient was subsequently discharged to home on POD1. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She will follow-up with Dr. ___ the bariatric dietitian in clinic in 2 weeks. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. cholecalciferol (vitamin D3) *NF* 3,000 unit Oral daily 4. Cyclobenzaprine ___ mg PO TID:PRN muscle spasms Discharge Medications: 1. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN Pain RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ ml by mouth every four (4) hours Disp #*250 Milliliter Refills:*0 2. Docusate Sodium (Liquid) 100 mg PO BID:PRN Constipation RX *docusate sodium 50 mg/5 mL ___ ml by mouth twice a day Disp #*250 Milliliter Refills:*0 3. Ascorbic Acid ___ mg PO DAILY 4. cholecalciferol (vitamin D3) *NF* 3,000 unit Oral daily 5. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Morbid obesity Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications except please do not take your cyclobenzaprine while taking pain medicaiton. CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 4. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: ___

{'morbid obesity': ['Morbid obesity'], 'paraesophageal hernia': ['Diaphragmatic hernia without mention of obstruction or gangrene'], 'elevated triglyceride': ['Other and unspecified hyperlipidemia'], 'iron deficiency anemia': ['Iron deficiency anemia'], 'irritable bowel syndrome': ['Irritable bowel syndrome'], 'vitamin D deficiency': ['Unspecified vitamin D deficiency'], 'allergic rhinitis': ['Allergic rhinitis'], 'obstructive sleep apnea': ['Obstructive sleep apnea (adult)(pediatric)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Augmentin / Topamax Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with history of cerebral aneurysm, presenting with shortness of breath, found to have PE at OSH, and transferred here for further management. Earlier in the month, pt developed swelling in RLE with warmth and erythema consistent with cellulitis. LENIs at this time did not demontrate any DVT. She was treated with a course of cephalexin with improvement in erythema and pain. Additionally swelling went down substantially. However, 2 days ago, she begn developing worsening dyspnea on exertion. Promotes chest heaviness but no pain. Denies other URI symptoms. No prior hx of DVT.The patient denies any fever, chills, abdominal pain, bowel or bladder changes. Up to date on all age appropriate cancer screening. No recent weight loss. She was transferred from the ___ the patient has a known history of a brain aneurysm and the inpatient team at the ___ was uncomfortable admitting her in case thrombolytics were used. She was placed on a heparin drip prior to transfer. In the ED, initial vital signs were: 98.4 82 150/70 18 95% Exam was reportedly unremarkable. A bedside echo showed no obvious signs of right heart strain. Patient was given nothing other than heparin gtt continued from ___ with lab notable for PTT 128. On Transfer Vitals were: 97.9 77 119/74 16 97% Nasal Cannula. Her breathing is greatly improved. She denies any chest pain. Past Medical History: CEREBRAL ANEURYSM incidental finding ___ when she was hospialized at ___ ___ with severe HA, dizziness. Head CT also showed tiny lacunar infarcts in both basal ganglia. most recent ___ of ___ without contrast: stable 3 mm protuberance off the genu of the left internal carotid artery. Followed by Dr. ___ at ___. MRA q ___ years advised. BRCA1 GENE MUTATION CHRONIC OBSTRUCTIVE PULMONARY DISEASE SLEEP APNEA COLONIC POLYPS GASTROESOPHAGEAL REFLUX DEPRESSION PRE-DIABETES hx HEMATURIA LOW BACK PAIN VARICOSE VEINS R>L SCABIES HYPERLIPIDEMIA ROTATOR CUFF TEAR syncope vs TIA carotid US ___ no hemodynamically significant stenosis, ECHO nl. TAH/BSO CHOLECYSTECTOMY Social History: ___ Family History: No family hx of DVT or PE, two sisters have atrial fibrillation Physical Exam: ON ADMISSION: VS: 98.9 105/54 65 18 96% on RA GENERAL: NAD, obese HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no appreciable lower exam swelling althught R calf is tender to palpation PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no focal deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes ON DISCHARGE: VS: 98.5 124/61 77 18 98% on RA GENERAL: NAD, obese HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no appreciable lower exam swelling althught R calf is tender to palpation PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no focal deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes ON DISCHARGE: Pertinent Results: ___ 04:52PM ___ PTT-128.0* ___ ___ 04:52PM PLT COUNT-150 ___ 04:52PM NEUTS-56.6 ___ MONOS-6.0 EOS-1.6 BASOS-0.7 ___ 04:52PM GLUCOSE-130* UREA N-16 CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 ___ 04:52PM ___ PTT-128.0* ___ history of cerebral aneurysm, recent treatment for RLE swelling and erythema with keflex x 5 days s/p negative RLE U/S now presenting with shortness of breath, found to have PE. # Pulmonary embolism-Treated with lovenox while hospitalized, transitioned to warfarin at discharge. Shortness of breath resolved while hospitalized without the need for supplemental oxygen. # History of cerebral aneurysm-Per Dr. ___ who follows the patient's aneurysm) she should have another follow up MRI (last was ___ to assess the size of the aneurysm. Careful consideration was given to continuing the aspirin which she takes for her aneurysm and what the ___ anti-coagulant would be in light of the aneurysm to minimize her risk of bleeding. After discussion with Dr. ___ Dr. ___ decision was made to bridge to Coumadin with lovenox and hold the aspirin. Her MRA which was performed to assess the size of the aneurysm while the patient was admitted showed stable size of the aneurysm (4mm) with no change since ___. #Hyperlipidemia: continued atorvastatin 20 #Depression: continued home sertaline #GERD: continued home omeprazole #Asthma: no evidence of reactive airway disease on exam, continued albuterol inhaler as needed. Transitional Issues # Anti-coagulation: Please assess optimal length of treatment for the patient. # Cigarette smoking: The patient quit smoking on admission to the ER ___, please provide encouragement and resources regarding smoking cessation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lovastatin 40 mg oral daily 2. Sertraline 100 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Omeprazole 20 mg PO BID 5. albuterol sulfate 90 mcg/actuation inhalation q4hrs prn wheezing 6. Vitamin D ___ UNIT PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Lovastatin 40 mg oral daily 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Omeprazole 20 mg PO BID 4. Sertraline 100 mg PO DAILY 5. Vitamin D ___ UNIT PO DAILY 6. Enoxaparin Sodium 110 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 120 mg/0.8 mL 110 mg Q12H SQ every twelve (12) hours Disp #*12 Syringe Refills:*0 7. Nicotine Patch 14 mg TD DAILY RX *nicotine [Nicoderm CQ] 14 mg/24 hour Apply one patch daily Disp #*30 Patch Refills:*0 8. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth qdaily Disp #*30 Tablet Refills:*0 9. albuterol sulfate 90 mcg/actuation inhalation q4hrs prn wheezing 10. Outpatient Lab Work Please check INR on ___. ICD-9: 415.1 Please fax result to Dr. ___ at ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pulmonary embolism Secondary Diagnosis: Superficial thrombophlebitis Primary Diagnosis: Pulmonary embolism Secondary Diagnosis: Superficial thrombophlebitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at the ___ ___. You were admitted because of a pulmonary embolism (blood clot in the lungs). We treated this blood clot by giving you anti-coagulation medicine which you will continue to take as an outpatient. You should continue taking this medication until your primary care doctor (___) says it is okay to stop (likely ___ months). We spoke with your neurosurgeon (Dr. ___ who follows your aneurysm and he recommended that you get a repeat MRI of your brain while you were admitted. This MRI showed that the anuerysm has not changed in size since ___, it is still 4mm in size. We wish you all the ___ in your continued recovery. Sincerely, Your ___ Team Followup Instructions: ___

{'Shortness of breath': ['Pulmonary embolism'], 'Swelling in RLE with warmth and erythema': ['Phlebitis and thrombophlebitis of superficial vessels of lower extremities'], 'Worsening dyspnea on exertion': ['Pulmonary embolism'], 'Chest heaviness': ['Pulmonary embolism'], 'Tender R calf': ['Phlebitis and thrombophlebitis of superficial vessels of lower extremities']}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ w/hx of AR, hypothyroidism, Sjogrens, HTN, PNA who presents as a transfer from ___ after a syncopal episode on ___ AM. She was standing and speaking with her daughter when she began to feel weak, lightheaded, and nauseous. She has had a few syncopal episodes in the past, which she reports were concurrent with other health problems such as a recent PNA in ___ with hemoptysis treated at ___ (CT scan showed RML brochiectasis and some consolidation; bronch showed copious mucoid secretions RML>lingula>RUL with some blood, pt was scheduled for rpt CT scan on ___. . On ___, she sat down in her chair and then passed out, and was unresponsive for a few seconds. The pt denies prodrome or palpitations, and regained consciousness quickly with no confusion afterwards. No seizure like activity witnessed, no lose of bowel or bladder. Denies any recent exertion or miturition prior to episode. Denies CP, palpitations, SOB prior or after the episode. She remembers the episode. She states she has been coughing for the past few days, occasionally productive with phlegm, nonbloody, but has otherwise been well, with no fevers/chills. Her last echo for AR ___ years ago. . In the ED, initial vitals were 98.5 96 145/86 20 97%. Labs were notable for WBC 12.0 (with N 76.5%, L 17.3%), Hct 32.6. UA showed lg leuk and 18 WBC. Vitals prior to transfer were 98-85-146/75-25-98. . Currently on the medicine floor, she feels "fine" and does not feel dizzy or lightheaded. She denies fever, chills, vision changes, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. She does say she lost a few pounds in the last few weeks and has not had a great appetite for about a month. Past Medical History: HTN Hypothyroidism Sjo___'s Syd Social History: ___ Family History: Long history of hypertension in her family. She does report that her father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. She denies any history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced (pt not sure which one). Physical Exam: ADMISSION EXAM: VS - Temp 98.1F, BP 112/70, HR 96, R 18, O2-sat 96% RA GENERAL - thin-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, carotid bruits (likely radiating sounds from aortic regurgitation) LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, 3+ mid-systolic murmur loudest at LLS border, radiates to axilla, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, muscle strength ___ b/l. . DISCHARGE EXAM: Unchanged with previous, except for the following: VS - Temp 97.8F, BP 123/74, HR 82, R 16, O2-sat 98% RA LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, 3+ mid-systolic murmur loudest at ___ border, radiates to ___, ___ S1-S2 Pertinent Results: ADMISSION LABS: ___ 05:50PM BLOOD WBC-12.0*# RBC-3.48* Hgb-11.4* Hct-32.6* MCV-94 MCH-32.7* MCHC-34.9 RDW-13.4 Plt ___ ___ 05:50PM BLOOD Neuts-76.5* Lymphs-17.3* Monos-5.2 Eos-0.7 Baso-0.4 ___ 05:50PM BLOOD Plt ___ ___ 05:50PM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-135 K-4.4 Cl-101 HCO3-26 AnGap-12 ___ 05:50PM BLOOD cTropnT-<0.01 ___ 08:05AM BLOOD cTropnT-<0.01 . DISCHARGE LABS: ___ 08:05AM BLOOD WBC-6.0 RBC-3.62* Hgb-11.8* Hct-34.1* MCV-94 MCH-32.7* MCHC-34.7 RDW-13.3 Plt ___ ___ 08:05AM BLOOD Plt ___ ___ 08:05AM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-136 K-4.4 Cl-101 HCO3-28 AnGap-11 ___ 08:05AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9 ___ 11:00AM BLOOD Iron-98 ___ 11:00AM BLOOD calTIBC-354 VitB12-1270* Folate-GREATER TH Ferritn-80 TRF-272 . MICROBIOLOGY: ___ Blood Cx: Pending ___ Urine Cx: pending . IMAGING: ___ Video swallow study: Not likely aspiration. RECOMMENDATIONS: 1. PO diet of thin liquids and soft solids 2. Aspiration precautions including: a) keep solids soft and moist b) use liquid wash to clear solids as needed c) alternate bites and sips 3. Meds whole with water 4. Regular oral care 5. Suggest nutritional supplements at home given reports of recent weight loss. Brief Hospital Course: Ms. ___ is a pleasant ___ w/ a h/o aortic regurgitation, hypothyroidism, Sjogrens, and HTN who presents as a transfer from ___ after a syncopal episode on ___ AM. Upon admission, she was hemodynamically stable, but was found to have asymptomatic pyuria, cough, and a WBC of 12.0. . ACTIVE ISSUES: . #Syncope: Pt's syncopal episode appears to be c/w vasovagal syncope, likely in the setting of her asymptomatic pyuria. She also had a ___ in which her Tn's were negative X2 and EKG's were c/w and unchanged from previous. She was hemodynamically stable and received fluids and bactrim (see below). Given her h/o aortic regurgitation, an Echo was ordered but will be obtained by the pt on an outpatient basis. . #Pyuria: She had 18 WBC and Lg leuk esterase on UA on admission, although she had no bacteria on UA or Sx of burning/dysuria. Given her syncopal episode in the setting of a UTI, treatment with bactrim was started in the ED and continued for a total of 4 days. . #Leukocytosis: Her WBC of 12.0 is likely in the setting of her UTI. She was treated with PO bactrim as above. . INACTIVE ISSUES: . #Anemia: Hct ___ is 32.6, slightly down from baseline of ~35. Her Iron studies, B12, and Folate were within normal limits. . #HTN: Her home lisinopril was decreased to 10mg PO qday, in the setting of her syncope in order to ensure her BP does not drop too low. . #Hypothyroidism: continued home levothyroxin. . TRANSITIONS OF CARE: - ___ Iron studies wnl, B12 1270, and Folate >20. - Pt will obtain Echo as outpt. Medications on Admission: Lisinopril 20mg PO qday Levothyroxine 50mcg PO qday Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 4. Fish Oil Oral 5. calcium Oral Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Syncope Secondary diagnoses: Hypothyroidism Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure providing care for you here at the ___ ___. You were admitted after having a syncopal (fainting) episode on ___. You were found to have some evidence of a urinary tract infection and were treated with an antibiotic called Bactrim. Your chest x-ray at the other hospital did not show evidence of a pneumonia. We monitored your heart rhythm overnight and did not note any abnormalities. Your electrocardiogram did not show any changes. Your blood pressure remained stable. You will need an ultrasound of the heart for further evaluation (echocardiogram), but this can be done after you leave the ___. Your condition has improved and you can be discharged to home. The following changes were made to your medications: NEW: -Bactrim double-strength tab, 1 tab by mouth twice daily for 2 more days (to treat urinary tract infection) CHANGED: - DECREASED Lisinopril to 10mg by mouth daily Please keep your follow-up appointments as scheduled below. We are also working to schedule your echocardiogram. Of note, while you were here you had a video swallow study that did not show evidence that you are aspirating when you swallow. You can continue to eat a regular diet. Followup Instructions: ___

{'weakness': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'lightheaded': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'nausea': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'cough': ['Urinary tract infection', 'site not specified'], 'hemoptysis': ['Urinary tract infection', 'site not specified'], 'brochiectasis': ['Urinary tract infection', 'site not specified'], 'consolidation': ['Urinary tract infection', 'site not specified'], 'mucoid secretions': ['Urinary tract infection', 'site not specified'], 'lost pounds': ['Unspecified acquired hypothyroidism'], 'not great appetite': ['Unspecified acquired hypothyroidism']}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: meropenem Attending: ___. Chief Complaint: left hip pain Major Surgical or Invasive Procedure: Closed reduction and percutaneous pinning, left femoral neck fracture History of Present Illness: This is a ___ yo woman in her USOH until the day of presentation when she sustained a mechanical fall onto her left lower extremity with immediate pain, inability to ambulate. The patient denies LOC, premonitory symptoms and ROS is otherwise at baseline. Past Medical History: Anemia Borderline cholesterol Recurrent C. Diff Flatulence Heart Murmur Hypertension Hypothyroidism Mitral Regurgitation Osteoporosis Pneumonia Sinusitis Sjo___ Social History: ___ Family History: Long history of hypertension in her family. Father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. No history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced. Physical Exam: On admission: Pelvis stable to AP and lateral compression. BLE skin clean and intact LLE Shortened and externally rotated, painful with internal or external rotation of the hip. Thighs and leg compartments soft Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ FHS ___ TA Peroneals Fire 1+ ___ and DP pulses Knee stable to varus and valgus stress. Negative anterior, posterior drawer signs. On discharge: NAD, A+Ox3 INcision: dressing changed ___ - c/d/i Neurovascularly intact, strenght intact, SILT s/s/dp/sp/t distributions WWP, 2+ DP pulse Pertinent Results: Hip XR ___: IMPRESSION: Impacted left subcapital femoral neck fracture. Brief Hospital Course: On ___ the pt was admitted to the ortho trauma service and found to have a valgus impacted left femoral neck hip fracture, for which she underwent closed reduction and percutaneous pinning, left femoral neck fracture by Dr. ___ On ___ the patient was noted to be recovering well from surgery. She became hypotensive with physical therapy, which normalized after stopping exercise. On ___ the patient continued to do well. She was seen by physical therapy and cleared for discharge to a rehab facility. SOcial work saw pt for her difficulty coping with decreased mobility. Her labs showed sodium level of 130, unchanged from ___ and similar to 132 on admission. She was given instructions to f/u with Dr. ___ in clinic in 2 weeks, and will be on lovenox subq 40 mg daily in the interim. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 4. mirtazapine 30 mg Oral QHS Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 4. mirtazapine 30 mg Oral QHS 5. Acetaminophen 1000 mg PO TID 6. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO QID:PRN Dyspepsia 7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 8. Biotene Dry Mouth Rinse (saliva substitution combo no.8) 1 application Mucous Membrane q2hr 9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 10. Calcium Carbonate 1250 mg PO TID 11. Docusate Sodium 100 mg PO BID 12. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis Duration: 14 Days Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe Refills:*0 13. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 14. Multivitamins 1 CAP PO DAILY 15. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #*60 Tablet Refills:*0 16. Pantoprazole 40 mg PO Q24H 17. Senna 2 TAB PO HS 18. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: left femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: touch-down weight-bearing LLE Physical Therapy: Touch-down weight bearing LLE Treatments Frequency: WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Followup Instructions: ___

{'left hip pain': ['Other closed transcervical fracture of neck of femur'], 'inability to ambulate': ['Other closed transcervical fracture of neck of femur'], 'mechanical fall': ['Fall from other slipping, tripping, or stumbling'], 'immediate pain': ['Other closed transcervical fracture of neck of femur'], 'hypotension': ['Unspecified essential hypertension'], 'difficulty coping with decreased mobility': ['Personal history of pneumonia (recurrent)'], 'heart murmur': ['Mitral valve disorders'], 'flatulence': ['Sicca syndrome'], 'borderline cholesterol': ['Other and unspecified hyperlipidemia'], 'hypothyroidism': ['Unspecified disorder of thyroid']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Corgard / Vasotec Attending: ___. Chief Complaint: incarcerated inguinal hernia Major Surgical or Invasive Procedure: Left inguinal hernia repair History of Present Illness: ___ with afib on apixiban, CAD s/p CABG, b/l carotid disease, COPD/emphysema with recent pneumonia presents for elective left inguinal hernia repair (large, with incarcerated sigmoid colon) Past Medical History: Past Medical History: BILATERAL MODERATE CAROTID DISEASE CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION SEVERE EMPHYSEMA PULMONARY HYPERTENSION RIGHT BUNDLE BRANCH BLOCK BENIGN PROSTATIC HYPERTROPHY HYPERLIPIDEMIA PAROXYSMAL ATRIAL FIBRILLATION H/O HISTIOPLASMOSIS Past Surgical History: CARDIOVERSION ___ RIGHT LOWER LOBE LOBECTOMY ___ CORONARY BYPASS SURGERY ___ Social History: ___ Family History: Non-contributory Physical Exam: Gen: Awake and alert CV: Irregularly irregular rhythm, normal rate Resp: CTAB GI: Soft, appropriately tender near incision, non-distended Incision clean, dry, and intact with no erythema Ext: Warm and well perfused Pertinent Results: Brief Hospital Course: Mr. ___ was admitted to ___ ___ on ___ after undergoing repair of a left incarcerated inguinal hernia. For details of the procedure, please refer to the operative report. His postoperative course was uncomplicated. After a brief stay in the PACU, he was transferred to the regular nursing floor. His pain was controlled with IV medication. On POD #1, he was started on a regular diet, and his pain was controlled with PO pain medication. He voided without issue. He was ambulating independently in the halls. He was given a bowel regimen, and passed flatus. On POD #2, he continued to tolerate his diet, his pain was well-controlled on oral medication, and he continued to ambulate independently. He was discharged home in stable condition on POD #2 with plans to follow-up with Dr. ___. Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Omeprazole 10 mg PO DAILY 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 8. Acetaminophen 1000 mg PO Q6H:PRN pain or fever Do not exceed 4 grams per day. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 10. Senna 17.2 mg PO HS Take this while you are taking oxycodone. RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 capsule by mouth daily Disp #*30 Tablet Refills:*0 11. Align (bifidobacterium infantis) 4 mg oral DAILY 12. coenzyme Q10 100 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Inguinal hernia 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 care of you here at ___ ___. You were admitted to our hospital after undergoing repair of your inguinal hernia. You have recovered from surgery and are now ready to be discharged home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - Don't lift more than 10 lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. - You may start some light exercise when you feel comfortable. - You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during surgery. - You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. - You could have a poor appetite for a while. Food may seem unappealing. - All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: - Your incision may be slightly red around the edges. This is normal. - If you have steri strips, do not remove them for 2 weeks. (These are the thin paper strips that are on your incision.) But if they fall off before that that's okay). - You may gently wash away dried material around your incision. - It is normal to feel a firm ridge along the incision. This will go away. - Avoid direct sun exposure to the incision area. - Do not use any ointments on the incision unless you were told otherwise. - You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. - You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. - Over the next ___ months, your incision will fade and become less prominent. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving your bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. -You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directed. - Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. - Your pain medicine will work better if you take it before your pain gets too severe. - If you are experiencing no pain, it is okay to skip a dose of pain medicine. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___

{'incarcerated inguinal hernia': ['Unilateral inguinal hernia'], 'afib': ['Paroxysmal atrial fibrillation'], 'CAD s/p CABG': ['Atherosclerotic heart disease of native coronary artery without angina pectoris', 'Presence of aortocoronary bypass graft'], 'b/l carotid disease': [], 'COPD/emphysema with recent pneumonia': ['Emphysema'], 'large, with incarcerated sigmoid colon': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Mr ___ is a ___ male presents with 1 day general malaise, fever, altered mental status Per patient notes one day of chills, sore throat, dry cough and intermittent headache. He was later brought in by ambulance after being noted by his roommates to be altered. While being assessed by EMS patient was tachycardic to 160. Upon arrival to ED patient was disoriented to time and place. VS: 102.7 136 117/62 18 100% 4L. He underwent LP due to concern for meningitis. LP revealed protein 24 glucose 61. UA negative. CXR wnl. Urine/blood tox screen negative. Patient received 4L IVF, CTX 2gm, 4mg IV ativan pre-treatment for LP. VS prior to transfer: 99.9 119 94/44 18 98%. On arrival to the floor, patient is sleeping but arousable; oriented x3 but intermittently confused. Reports mild HA, sore throat, fever, dry cough, sweats, chills. No recent travel. No known sick contacts. No recent sexual activity. No genital ulcers/lesions. No skin rashes. Lives with 4roommates. Denies recent exposures, ingestions. Last EtOH use on ___ night. Past Medical History: None Social History: ___ Family History: Father: HTN, pre-DM No psych history Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.2 110/52 113regular 18 97%RA GENERAL: Sleeping but arousable, NAD, mildly diaphoretic HEENT: NC/AT, PERRLA, EOMI, no nystagmus, sclerae anicteric, MMM NECK: supple, no appreciable LAD LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: tacycardiac, no MRG, nl S1-S2 ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding SKIN: no obvious rashes, petechiae EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, no clonus, no rigidity, unsteady gait. DISCHARGE PHYSICAL EXAM: VS: 98.3, 112/70, 91, 18, 100%RA GENERAL: awake, NAD HEENT: NC/AT, sclerae anicteric, MMM, red/swollen bilat tonsils without evidence of exudate NECK: supple, no neck stiffness LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding SKIN: no obvious rashes, petechiae EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection NEURO: A&Ox3, CNs II-XII grossly intact, gait normal, no focal deficits Pertinent Results: ADMISSION LABS: ___ 12:00AM GLUCOSE-104* UREA N-14 CREAT-0.8 SODIUM-136 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20 ___ 12:12AM LACTATE-2.1* ___ 12:00AM ALT(SGPT)-25 AST(SGOT)-26 LD(LDH)-187 CK(CPK)-89 ALK PHOS-78 TOT BILI-1.0 ___ 12:00AM CALCIUM-10.4* PHOSPHATE-0.8* MAGNESIUM-1.7 ___ 12:00AM TSH-2.3 ___ 12:00AM WBC-13.6* RBC-5.02 HGB-15.2 HCT-43.8 MCV-87 MCH-30.2 MCHC-34.7 RDW-12.3 ___ 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG MICRO: - ___ 1:17 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. - ___ 1:15 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. - ___ 1:15 pm SEROLOGY/BLOOD **FINAL REPORT ___ 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. - ___ 5:22 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. - Herpes Simplex Virus PCR Specimen Source CSF Result Negative - Test (Serum) Result Reference Range/Units HSV 1 IGG TYPE SPECIFIC AB 3.61 H index HSV 2 IGG TYPE SPECIFIC AB <0.90 index Index Interpretation <0.90 Negative 0.90-1.10 Equivocal >1.10 Positive ___ 01:15PM BLOOD HIV Ab-NEGATIVE Brief Hospital Course: ___ male presents with 1 day general malaise, fever; found to be altered, febrile and tachycardic in the ED. # Altered Mental Status: Was noted to have confusion when at home with roommates, who called EMS given their concern. There was no history of ingestion, and tox screen was negtaive. Blood culture showed no growth, and influenza swab was negative as well. He was noted to be febrile, raising concern for possible meningitis/encephalitis. LP did not show any evidence of infection, and culture results were negative. All other infectious processes which were tested (HIV, RPR, lyme, CSF HSV) were also negative, but arborovirus is still pending at this time. His mental status returned to baseline shortly after he was admitted. # Throat Pain: Complained of throat pain with swallowing. Noted to have erythematous, slightly enlarged tonsils without evidence of exudates. Swab was negative for Strep. He was treated with 7 days of augmentin empirically. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Fever, acute encephalopathy, pharyngitis Secondary: None 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 care of you at ___ ___. You were admitted for evaluation of your acute confusion and fever. While you were here you had a lumbar puncture and blood work to check for evidence of an infection. You were treated with antibiotics, and your symptoms improved. None of the tests which were run show any evidence of infection around your brain or in your blood. The antibiotics were stopped, and you continued to do well. The exact cause of your acute confusion and fever is unknown. Followup Instructions: ___

{'fever': ['Metabolic encephalopathy', 'Fever', 'Acute pharyngitis'], 'altered mental status': ['Metabolic encephalopathy', 'Fever'], 'general malaise': ['Metabolic encephalopathy', 'Fever', 'Acute pharyngitis'], 'tachycardic': ['Metabolic encephalopathy', 'Fever'], 'sore throat': ['Acute pharyngitis'], 'dry cough': ['Acute pharyngitis'], 'intermittent headache': ['Metabolic encephalopathy', 'Fever'], 'chills': ['Metabolic encephalopathy', 'Fever', 'Acute pharyngitis'], 'sweats': ['Metabolic encephalopathy', 'Fever', 'Acute pharyngitis'], 'mild HA': ['Metabolic encephalopathy', 'Fever'], 'oriented x3 but intermittently confused': ['Metabolic encephalopathy', 'Fever']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Mr ___ is a ___ year old male with one week of acute onset abdominal pain. He describes the pain as colicy and it lasts seconds. The pain began one week ago. He reports chills and cold sweats. He denies any subjetive fevers. He decided to go to the ED on ___ morning for further evaluation. In the ED they performed a CT exam and found isolated elevated liver enzymes. The CT showed mildly dilated and fluid-filled loops of jejunum that could be seen with a focal ileus which may reflect a mild inflammatory process such as gastroenteritis. He was discharged home. . On ___ night he again had an episode of severe pain that woke him up at night and came to the ED again for evaluation. In the ED they performed a KUB which showed air-fluid levels which are non-specific without evidence for bowel dilatation; obstruction was not entirely excluded however. They also performed an ultrasound of the liver which showed no evidence of acute cholecystitis. The exam also showed fatty infiltration of the liver, although other forms of more advanced liver disease, including cirrhosis, could not be excluded. . Since his admission on ___, he has not had a bowel movement. He reporets that prior to two days ago his stool was normal without melena or blood. He denies any diarrhea or constipation. He also has been unable to eat for the past two days. He says he has lost his appetite. He says his lack of appetite is not secondary to nausea or abdominal pain. The patient says he occasionally has nausea and feels like vomiting, but has not vomited since his pain began one week ago. The pain returned again last night and he decided to come to the ED for IV antibiotics. . Of note he has been diagnosed with H. pylori in the past but did not complete a full treatment course. . Initial VS in the ED: 96.4 66 165/110 18 100% . Patient was given 2L NS and morphine 2mg and required oxygen for desaturation to 91% afterward. He was admitted for futher workup. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History: - Appendectomy - GERD Social History: ___ Family History: Family History: Non contributory Physical Exam: Exam on Admission Vitals: T:98 BP:140/90 P:67 R:18 18 O2:98% RA General: Alert, oriented, comfortable, moderately obese 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-distended, bowel sounds present, tender in right upper quadrant and feels bloated bilaterally in left and right lower quadrant, no rebound tenderness or guarding Ext: Warm, well perfused, no clubbing, cyanosis or edema Exam on Discharge Vitals: T:97.5-98.4 ___ R: 20 O2:96% RA, 900/700+ General: Alert, oriented, comfortable, moderately obese 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-distended, bowel sounds present, tender in right upper quadrant but less tender than yesterday. Ext: Warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: ___ 05:30AM BLOOD WBC-9.8 RBC-4.66 Hgb-14.0 Hct-42.5 MCV-91 MCH-30.1 MCHC-33.0 RDW-12.9 Plt ___ ___ 09:05AM BLOOD WBC-10.7 RBC-4.99 Hgb-14.6 Hct-45.3 MCV-91 MCH-29.3 MCHC-32.3 RDW-13.1 Plt ___ ___ 12:10PM BLOOD WBC-11.4* RBC-4.91 Hgb-14.7 Hct-44.9 MCV-91 MCH-30.0 MCHC-32.8 RDW-13.2 Plt ___ ___ 09:05AM BLOOD Neuts-76.2* Lymphs-17.8* Monos-4.7 Eos-0.9 Baso-0.4 ___ 12:10PM BLOOD Neuts-85.3* Lymphs-12.2* Monos-2.2 Eos-0.2 Baso-0.2 ___ 05:30AM BLOOD Plt ___ ___ 09:05AM BLOOD Plt ___ ___ 09:05AM BLOOD ___ PTT-28.5 ___ ___ 12:10PM BLOOD Plt ___ ___ 05:30AM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-136 K-3.6 Cl-100 HCO3-23 AnGap-17 ___ 09:05AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-138 K-3.8 Cl-99 HCO3-25 AnGap-18 ___ 12:10PM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-24 AnGap-17 ___ 05:30AM BLOOD ALT-70* AST-82* LD(LDH)-215 AlkPhos-66 TotBili-0.5 ___ 09:05AM BLOOD ALT-89* AST-128* AlkPhos-74 TotBili-0.7 ___ 12:10PM BLOOD ALT-83* AST-164* AlkPhos-78 TotBili-0.4 ___ 09:05AM BLOOD Lipase-30 ___ 12:10PM BLOOD Lipase-45 ___ 07:20PM BLOOD cTropnT-<0.01 ___ 05:30AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 ___ 07:20PM BLOOD Iron-60 ___ 09:05AM BLOOD Albumin-4.9 ___ 12:10PM BLOOD Albumin-4.7 ___ 07:20PM BLOOD calTIBC-341 Ferritn-253 TRF-262 ___ 09:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:24AM BLOOD Lactate-2.1* Brief Hospital Course: # Elevated LFTs: CT, KUB and RUQ US did not show evidence of acute cholecystetis, despite the positive ___ sign. It is possible the patient has underlying viral hepatitis, the serologies were sent in the ED. We are reassured by downtrending LFTs. Iron studies were within normal limits making hemochromotosis less likely. The patient felt significant relief with his bowel movement, and therefore it is likely he had a degree of constipation contributing to his presentation. Troponins were negative and EKG was unremarkable making a cardiac etiology unlikely. He tolerated food well and his pain was significantly improved with minimal need for oxycodone. . # GERD/H. pylori: Patient has known history of GERD and is treated with prilosec with relief of symptoms. He also has a history of untreated H. pylory diagnosed in ___. The patient was given perscriptions at that time by his PCP but he never filled the perscriptions. We started treatment for presumed H. pylori with omeprazole 20mg BID, amoxicillin 1g BID and clarithromycin 500mg BID for ten days . # Anxiety: Patient takes sertraline 75mg daily, we will continue in house. . # Transition issues: Hepatitis serologies were pending at time of discharge. The patient also had stool studies which were pending. His LFTs have been trending downward, but he will need repeat LFTs once he follows up with his PCP. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from PatientFamily/Caregiver. 1. Omeprazole 40 mg PO DAILY 2. Fish Oil (Omega 3) 1000 mg PO BID 3. Sertraline 75 mg PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO BID 2. Amoxicillin 1000 mg PO Q12H RX *amoxicillin 500 mg twice a day Disp #*48 Capsule Refills:*0 3. Clarithromycin 500 mg PO Q12H RX *clarithromycin 500 mg twice a day Disp #*19 Tablet Refills:*0 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain hold for sedation or rr<12 RX *oxycodone 5 mg take once if severe pain Disp #*4 Capsule Refills:*0 5. Fish Oil (Omega 3) 1000 mg PO BID 6. Sertraline 75 mg PO DAILY 7. Docusate Sodium 100 mg PO BID:PRN constipation hold for loose stools RX *docusate sodium 100 mg daily Disp #*30 Capsule Refills:*0 8. Senna 1 TAB PO BID:PRN constipation hold for loose stools 9. Simethicone 40-80 mg PO QID RX *simethicone 180 mg up to four times a day Disp #*60 Capsule Refills:*0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation hold for diarrhea RX *polyethylene glycol 3350 17 gram/dose daily Disp #*30 Packet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Gastritis complicated by constipation and H. pylori infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, You were admitted to the hospital with abdominal pain and elevated liver function tests. We believe your abdominal pain may be related to the liver but it could also be due to untreated H. pylori infection. We started you on medications to treat this infection and you will need to complete a full course of treatment. You should take these medications for ten days total (last dose on ___. While your liver tests were initially midly elevated, they have been trending towards normal again. You had no evidence of gall stones but your ultrasound and CT scan did show fatty liver. Some of your blood tests were not back yet and we recommend that you discuss these results with your primary care doctor and get repeat liver tests next week. Overall we were feel that you are safe to go home. Because you are experiencing constipation which can also contribute to your abdominal pain, we will send you home with some medications that will help you have regular bowel movements. Medicaion Changes START omeprazole 20mg twice a day, after ___ you can start taking your normal home dose of omeprazole once a day (to treat H pylori) START Amoxicillin 1000 mg every 12 hours (last dose on ___ to treat H pylori START Clarithromycin 500 mg every 12 hours (last dose on ___ to treat H pylori Take the following medications if you have constipation Miralax Colace Take the following medications if you have pain Oxycodone (note this medication can make you constipated) Simethicone Thank you for the opportunity to participate in your care. Followup Instructions: ___

{'Abdominal pain': ['Unspecified gastritis and gastroduodenitis', 'Helicobacter pylori [H. pylori]'], 'Chills': ['Unspecified gastritis and gastroduodenitis'], 'Cold sweats': ['Unspecified gastritis and gastroduodenitis'], 'Nausea': ['Unspecified gastritis and gastroduodenitis'], 'Loss of appetite': ['Unspecified gastritis and gastroduodenitis'], 'Constipation': ['Other constipation'], 'Elevated liver enzymes': ['Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]'], 'GERD': ['Esophageal reflux'], 'Anxiety': ['Anxiety state']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: decreased energy Major Surgical or Invasive Procedure: ___ AVR ( 23 mm ___ mechanical) History of Present Illness: ___ year old man with a known childhood murmur who was echoed during a recent admission for pneumonia and found to have severe aortic stenosis. Referred for AVR after cath showed clean coronaries. Past Medical History: bicuspid aortic valve, aortic stenosis, aortic insufficiency, valvular induced cardiomyopathy, moderate pulmonary hypertension (52/23), recent pneumonia Social History: ___ Family History: non-contributory Physical Exam: Pulse: 82 O2 sat: 96% B/P Left: 96/57 Height: 73" Weight: 90.9kg General: Well-developed male in no acute distress Skin: Dry [x] intact [xx] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur II/VI SEM radiating to carotids and across precordium Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema/Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: Conclusions PRE-CPB:1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve is bicuspid. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. There is bilateral retraction of the mitral valve. 8. There is a small to moderate sized pericardial effusion. 9. A moderate left pleural effusion is seen. Drs. ___ were notified in person of the results. POST-CPB: On infusions of epi, neo. AV pacing , then a pacing. Well-seated mechanical valve in the aortic position. Coronary flow seen in LMCA and RCA. Trace AI consistent with washing jets. Preserved ventricular function on inotropic support. LVEF is now 40%. Trace MR. ___ contour is normal post decannulation. I certify that I was present for this procedure in compliance with ___ regulations. Electronically signed by ___, MD, Interpreting physician ___ ___ 14:13 Brief Hospital Course: Mr. ___ was admitted on ___ and underwent AVR( mech AVR #23 ___ with Dr. ___. See operative note for details. Post operatively he remained intubated and was transferred to the CVICU in stable condition on epinephrine, phenylephrine, propofol, and lidocaine drips. He awoke neurologically intact, was weaned from the ventilator and extubated. Vasoactive medications were weaned after hemodynamic stability was achieved. Betablockers, diuretics and statin therapies were initiated and titrated. Chest tubes and temporary pacing wires were removed per protocol. Coumadin therpay was intiated for mechanical AVR. He was evaluated and treated by physical therapy for strength and conditioning. Mr. ___ was cleared for discharge to home on POD#4 with an INR of 2.0 by Dr. ___. Medications on Admission: lasix 20mg daily zocor 40mg daily KCL 20mEq daily coreg 3.125mg daily Amox 500mg (cont. after dental d/t symptoms from pna) ASA Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: goal INR 2.5-3.0 for mechcanical aortic valve. take 2.5 mg on ___ then as directed by Dr. ___. Disp:*60 Tablet(s)* Refills:*2* 11. Outpatient Lab Work ___ for coumadin dosing indication mechanical aortic valve - goal INR 2.5-3.0 with results to ___ clinic fax # ___ ___ clinic and Dr ___ - first draw ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Aortic stenosis, aortic insufficiency s/p Aortic valve replacement (Mech -#23mm St. ___ valvular-induced cardiomyopathy pulmonary hypertension recent Pneumonia chronic systolic/diastolic heart failure Discharge Condition: alert and oriented ambulating with steady gait Sternal pain managed with dilaudid 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Followup Instructions: ___

{'decreased energy': ['Aortic valve disorders', 'Other primary cardiomyopathies', 'Chronic combined systolic and diastolic heart failure'], 'pneumonia': ['Chronic pulmonary heart diseases'], 'aortic stenosis': ['Aortic valve disorders'], 'aortic insufficiency': ['Aortic valve disorders', 'Congenital insufficiency of aortic valve'], 'valvular induced cardiomyopathy': ['Other primary cardiomyopathies'], 'moderate pulmonary hypertension': ['Chronic pulmonary heart diseases'], 'recent pneumonia': ['Chronic pulmonary heart diseases'], 'chronic systolic/diastolic heart failure': ['Chronic combined systolic and diastolic heart failure']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ms ___ / Iodine; Iodine Containing Attending: ___. Chief Complaint: Venous ulcerations with DVT Major Surgical or Invasive Procedure: None History of Present Illness: ___ presented to the ED ___ complaining of increased pain in her LLE at the ulcer site. She's a ___ year old female with history ___ venous stasis with open ulcers on her medial malleous. She has failed 2 STSG and 1 Apligraft before her latest Apligraft 2 weeks ago with Dr. ___. The graft appeared well on her follow up visit on ___. However, patient reported feeling severe pain after being on her feet all day on ___. The pain got worse last night and patient was instructed to come to the ED. She stated that she felt as if the dressing was too constricted. She endorsed some swelling of her LLE but attributed it to being on her feet all day at work. In the ED, her outer dressing was removed and she reported feeling better. She stated that she hasn't taken Dicloxacillin due to nausea with emesis after taking the medication. Upon further questions, patient also reported having multiple watery bowel movements in the past few days. She reported having hx of C. diff in the past. She otherwise denied any fever, chills, cp/sob. Past Medical History: - hypertension - hypercholesterolemia - DVTs, ___ years ago (post-partum) and ___, on coumadin for ___ years, stopped about ___ years ago, PCP started hypercoagulable ___ after learning patient d/c coumadin but this was negative - diverticulosis - skin graft for unhealed left leg ulcer ___ (followed for ___ yr) - fibroids - s/p TAH/BSO ___ years ago for bleeding fibroids in the setting of anticoagulation - hepBcAb pos, hepBsAb and Ag neg in ___ Social History: ___ Family History: - HTN in both parents - mother died age ___ of ESRD (on HD) from HTN - father died age ___ of lung cancer - sister died in ___ of leukemia - no known h/o of hypercoagulable states, DM - two brothers, two sisters who are healthy Physical Exam: Vitals: 98.7 HR; 57 BP: 124/90 RR: 20 Spo2: 95% Gen: NAD, A&Ox3 Chest: CTAB CV: RRR, S1S2 ___: soft, nt/nd Extrem: b/l ___ skin changes, more on L side. There are two ulcers, the large one about 3x7cm and the smaller one more distal about 2x3cm. The Apligraft appeared to be disintergrated. There is minimal erythema around the wound edges. LLE is more swollen compared to RLE, no calf tenderness. Pulses: Fem Pop DP ___ R p p p d L p p p d Pertinent Results: ___ 06:00AM BLOOD WBC-8.2 RBC-3.73* Hgb-11.7* Hct-35.1* MCV-94 MCH-31.4 MCHC-33.4 RDW-14.9 Plt ___ ___ 06:25AM BLOOD WBC-10.2 RBC-3.93* Hgb-12.2 Hct-37.4 MCV-95 MCH-31.2 MCHC-32.8 RDW-15.0 Plt ___ ___ 01:15PM BLOOD WBC-9.8 RBC-4.65 Hgb-14.6 Hct-42.7 MCV-92 MCH-31.3 MCHC-34.1 RDW-15.1 Plt ___ ___ 01:15PM BLOOD Neuts-63.9 ___ Monos-4.5 Eos-2.7 Baso-0.8 ___ 10:25AM BLOOD ___ PTT-30.6 ___ ___ 06:00AM BLOOD Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 01:15PM BLOOD Plt ___ ___ 01:15PM BLOOD ___ PTT-20.0* ___ ___ 01:15PM BLOOD ESR-14 ___ 06:00AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-133 K-3.9 Cl-106 HCO3-22 AnGap-9 ___ 06:25AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-140 K-3.7 Cl-109* HCO3-23 AnGap-12 ___ 08:50PM BLOOD Creat-1.1 Na-142 K-3.8 Cl-110* ___ 01:15PM BLOOD Glucose-97 UreaN-15 Creat-1.2* Na-140 K-2.9* Cl-103 HCO3-24 AnGap-16 ___ 06:00AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6 ___ 06:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7 ___ 01:15PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9 ___ 5:52 am SWAB Source: Left leg. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Preliminary): ___ ___ F ___ ___ Radiology Report BILAT LOWER EXT VEINS Study Date of ___ 2:55 ___ ___ EU ___ 2:55 ___ BILAT LOWER EXT VEINS Clip # ___ Reason: LT CALF PAIN ,R/O DVT UNDERLYING MEDICAL CONDITION: ___ year old woman with left calf pain REASON FOR THIS EXAMINATION: ? DVT Wet Read: ___ ___ 5:24 ___ 1. positive for left DVT, with nonocclusive thrombus seen in the mid SFV extending to occlusive thrombus in the left popliteal and calf veins. 2. no RLE dvt. Wet Read Audit # 1 Final Report INDICATION: ___ female with left calf pain, evaluate for DVT. COMPARISON: None. FINDINGS: Grayscale and color sonographic imaging of the lower extremity veins was performed. On the left, the common femoral and proximal superficial femoral veins demonstrate normal compressibility and flow. However, there is partially occlusive thrombus seen in the mid superficial femoral vein, extending to occlusive thrombus in the left popliteal vein, with a lack of compressibility and no flow seen. Additional occlusive thrombus is seen in the left calf veins. The right leg was also interrogated, demonstrating normal compressibility, flow, and augmentation in the common femoral, superficial femoral, popliteal, and calf veins. IMPRESSION: 1. Left leg DVT in the mid superficial femoral (partially occlusive), and popliteal and calf veins (fully occlusive). 2. No right lower extremity DVT. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: ___ The patient was admitted from the ED with Left ___ DVT with chronic venous ulcerations. She was admitted to the Vascular service. Pain management overnight with Percocet and Dilaudid. DVT confirmed with venous duplex (see report). The decision was made by Dr. ___ anticoagulation. The patient was started on a Lovenox/Coumadin bridge. Her PCP was contacted and agreed to manage the patient's INR during lovenox/coumadin bridge and refer to ___ for additional management. Lovenox teaching was done by nursing, the patient has a good understanding of administration. She was discharged on ___ with ___ services for wound care and ___ checks. She will follow up with Dr. ___ week with a duplex. She was discharged on a 10 day course of Augmentin. Medications on Admission: amlodipine 5 qd, atenolol 50 bid, gabapentin 300 tid, lisinopril 40 qd, ibuprofen prn Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*10 * Refills:*1* 2. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___: Call PCP ___. ___ for Refills. Disp:*30 Tablet(s)* Refills:*2* 4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for fever/pain. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 7. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours. Disp:*40 Tablet(s)* Refills:*0* 10. Outpatient Lab Work ___ to draw labs (INR) q2 days and fax to PCP @ ___. (PCP: ___. ___ or ___ to schedule PCP ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left DVT Venous ulcers Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Uses Cane Discharge Instructions: You were admitted to ___ for your venous stasis ulcers and were found to have a blood clot in your left leg. The decision was made to start you on a blood thinning medication (Coumadin). You will be discharged today with Lovenox until your INR level is greater then 2. You should take coumadin everyday. Your PCP ___ ___ or ___ will be following your blood levels. Followup Instructions: ___

{'pain': ['Acute venous embolism and thrombosis of deep vessels of distal lower extremity', 'Venous (peripheral) insufficiency'], 'swelling': ['Acute venous embolism and thrombosis of deep vessels of distal lower extremity', 'Venous (peripheral) insufficiency'], 'erythema': ['Acute venous embolism and thrombosis of deep vessels of distal lower extremity', 'Venous (peripheral) insufficiency'], 'watery bowel movements': ['Unspecified essential hypertension', 'Other and unspecified hyperlipidemia'], 'nausea with emesis': ['Unspecified essential hypertension', 'Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ms ___ / Iodine; Iodine Containing Attending: ___. Chief Complaint: venous stasis ulcer Major Surgical or Invasive Procedure: Split-thickness skin graft left thigh to left ankle. Past Medical History: - hypertension - hypercholesterolemia - DVTs, ___ years ago (post-partum) and ___, on coumadin for ___ years, stopped about ___ years ago, PCP started hypercoagulable ___ after learning patient d/c coumadin but this was negative - diverticulosis - skin graft for unhealed left leg ulcer ___ (followed for ___ yr) - fibroids - s/p TAH/BSO ___ years ago for bleeding fibroids in the setting of anticoagulation - hepBcAb pos, hepBsAb and Ag neg in ___ Social History: ___ Family History: - HTN in both parents - mother died age ___ of ESRD (on HD) from HTN - father died age ___ of lung cancer - sister died in ___ of leukemia - no known h/o of hypercoagulable states, DM - two brothers, two sisters who are healthy Physical Exam: GENERAL: Well-appearing overweight ___ female in no apparent distress. HEENT: EOMI/PERRL. OP clear with moist mucous membranes. NECK: No cervical lymphadenopathy. No thyromegaly. LUNGS: Clear to auscultation bilaterally. ___: Regular rate and rhythm. Normal S1/S2. No murmurs auscultated. ABDOMEN: Soft, nontender/nondistended. No hepatomegaly. well-healed low transverse abdominal scar. EXT: Left lower extremity wrapped in Ace bandage. Tender to palpation anywhere over the bandage. No lower extremity edema noted. Right knee with palpable metal implant. Calves were atrophied bilaterally. NEUROLOGIC: 2+ biceps and patellar reflexes. Pertinent Results: ___ 07:55AM BLOOD WBC-8.0 RBC-4.16* Hgb-12.9 Hct-39.6 MCV-95 MCH-31.0 MCHC-32.6 RDW-13.4 Plt ___ ___ 07:55AM BLOOD Neuts-48.3* Lymphs-42.9* Monos-4.0 Eos-4.3* Baso-0.5 ___ 07:55AM BLOOD Glucose-99 UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-20* AnGap-18 ___ 12:15AM URINE Color-Straw Appear-Clear Sp ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE Hours-RANDOM Creat-31 Na-80 URINE Osmolal-288 ___ 12:15 am URINE URINE CULTURE (Final ___: NO GROWTH. ___ 3:05 pm TISSUE LEFT ANKLE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). STAPH AUREUS COAG +. SPARSE GROWTH. STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Brief Hospital Course: Mrs. ___ was admitted on ___ with Left venous stasis ulcer. She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a Split-thickness skin graft left thigh to left ankle. She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. VAC dressing placed Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the VICU for further recovery. While in the VICU she recieved monitered care. When stable she was delined. Her diet was advanced. When she was stabalized from the acute setting of post operative care, she was transfered to floor status. She remained on bedrext x 5 days. The VAC was taken down. Graft site looks good. Pt antibiotics tailored to her OR sensitivities. On the floor, she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged home in stable condition on PO AB. Medications on Admission: amlodipine 5 qd, atenolol 50 bid, gabapentin 300 tid, lisinopril 40 qd, ibuprofen prn Discharge Medications: 1. DiCLOXacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Capsule(s)* Refills:*0* 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 7. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours for 10 days: prn. Disp:*40 Tablet(s)* Refills:*0* 8. Cerovite Silver Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Venous stasis ulcer HTN Discharge Condition: Stable Discharge Instructions: Postoperative Care: Do not expose recipient site to prolonged sunlight Follow instructions given for bandaging the grafted area to provide it with appropriate support during the healing process, and to prevent contractures even after healing is complete Inspect site for healing and good circulation, as shown by healthy pink coloration Keep the recipient site clean and dry Outcome A successful skin graft will result in transplanted skin adhering and growing into the recipient area. Cosmetic results may vary, based on factors such as type of skin graft used, and area of recipient site. Call Your Doctor ___ Any of the Following Occurs Cough, shortness of breath, chest pain, or severe nausea or vomiting Headache, muscle aches, dizziness, or general ill feeling Redness, swelling, increasing pain, excessive bleeding, or discharge from the incision site Signs of infection, including fever and chills Followup Instructions: ___

{'venous stasis ulcer': ['Venous (peripheral) insufficiency', 'Ulcer of ankle'], 'hypertension': ['Unspecified essential hypertension'], 'hypercholesterolemia': ['Pure hypercholesterolemia'], 'DVTs': ['Personal history of venous thrombosis and embolism'], 'diverticulosis': [], 'skin graft': [], 'fibroids': [], 's/p TAH/BSO': [], 'hepBcAb pos, hepBsAb and Ag neg': [], 'HTN in both parents': [], 'mother died age ___ of ESRD (on HD) from HTN': [], 'father died age ___ of lung cancer': [], 'sister died in ___ of leukemia': [], 'no known h/o of hypercoagulable states, DM': [], 'two brothers, two sisters who are healthy': [], 'tender to palpation anywhere over the bandage': [], 'no lower extremity edema noted': [], 'Right knee with palpable metal implant': [], 'Calves were atrophied bilaterally': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Percocet / cucumber / Tegaderm Attending: ___. Chief Complaint: cracked tooth, s/p fall Major Surgical or Invasive Procedure: tooth extraction History of Present Illness: Patient is a ___ year old G1P0 at ___ by U/S w/ h/o breast CA on DDAC chemotherapy in pregnancy and thyroid CA who presents after transfer from ED for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder. She reports progressive dental pain in the right lower molar. She has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity. She was therefore referred to the ED. OMFS was consulted while she was in the ED w/ plan for removal in the OR tomorrow. Findings included cracked tooth #29 w/ carriers extending to pulp. The patient was sent to OB triage given the mechanical fall. The patient denies any abdominal trauma or bruising. She has been having very irregular cramping, no contractions. She also reports intermittent sharp shooting pain from the groin to her belly button. Not exacerbated by anything. Pain cannot be reproduced. She denies and VB or LOF. Past Medical History: PNC: - ___ ___ by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: ___, 67%, breech, ___, nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed ___, plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy Social History: ___ Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: ___. Father--prostate cancer (age ___ Physical Exam: On admission: ___ 19:03Temp.: 98.0°F ___ 19:03BP: 121/65 (76) ___ ___: 69 ___ ___: 67 GEN: NAD Respiratory: no increased WOB Abdomen: no bruising, non-tender, gravid SVE: LCP TAUS: vtx, anterior placenta, no sonographic evidence of abruption, MVP 5.4 FHT: 130/moderate/+accels/ no decels On discharge: VS: 98.0, 114/71, 73, 16, O2 96% Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: ___ FHT: 120s, mod var, +accels, no decels reactive Toco: occ ctx Pertinent Results: n/a Brief Hospital Course: Patient is a ___ year old G1 with hx of breast CA on DDAC chemotherapy in pregnancy and thyroid CA admitted at 34w2d after a fall. On admission, she had no evidence of abruption or preterm labor. She reported mild cramping and her cervix was LCP. Fetal testing was reassuring. She also had a painful, cracked tooth and had been evaluated by OMFS in the emergency room. A plan was made for extraction in the OR. On HD#2, she underwent an uncomplicated tooth extraction under local anesthesia. Her pain resolved. She continued to have some intermittent cramping and pink discharge, however, she had no evidence of preterm labor. She was discharged to home in stable condition on HD#3 and will have close outpatient follow up. Medications on Admission: albuterol, levothyroxine Discharge Medications: Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 Levothyroxine Sodium 200 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cracked tooth Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction. You procedure went well and your baby was monitored before and after the procedure. You are now stable to be discharged home. Please see instructions below. You should continue biting down on a piece of gauze for 30 minute interval. You may stop after ___ gauze changes. You should NOT have any hot/solid foods for the time being. You may continue drinking cool liquids. You may transition to soft foods (eggs, pasta, pancake) tonight. For pain control, you may take Tylenol as needed (do not take more than 4000mg in 24 hours). Please call your primary dentist with any questions or concerns. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns Followup Instructions: ___

{'tooth pain': ['Dental caries'], 'irregular cramping': ['Diseases of the digestive system complicating pregnancy, third trimester'], 'intermittent sharp shooting pain': ['Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium'], 'mild asthma': ['Diseases of the respiratory system complicating pregnancy, third trimester', 'Other asthma'], 'breast cancer': ['Personal history of malignant neoplasm of breast'], 'thyroid cancer': ['Personal history of malignant neoplasm of thyroid'], 'history of drug use': ['Personal history of nicotine dependence'], 'gastro-esophageal reflux disease': ['Gastro-esophageal reflux disease without esophagitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Percocet / cucumber Attending: ___ Chief Complaint: Left breast invasive ductal carcinoma Major Surgical or Invasive Procedure: LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY ___ History of Present Illness: Ms ___ is a ___ year old pregnant female with breast cancer. She had a palpable left breast lump, underwent ultrasound, MRI, and core biopsy that showed a grade 2 invasive ductal carcinoma, ER positive, PR positive, HER2 negative. She later was found to be pregnant. She is currently feeling fine apart from tiredness. She reports that her levothyroxine dose was increased earlier this week. She also notes some left nipple crusting, that there initially (after the biopsy) was some bloody output that has since declined and become mild and crusty. Otherwise no changes. Past Medical History: PAST MEDICAL HISTORY: thyroid CA, postsurgical hypothyroidism, IBS, ovarian cysts, PID, spine arthritis, asthma, mononucleosisreported history of Lyme disease status post 3 weeks of antibiotic therapy. Hashimotos negative prior to surgery per her report Social History: ___ Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: ___. Father--prostate cancer (age ___. Physical Exam: VS: Refer to flowsheet GEN: WD, WN in NAD CV: RRR PULM: no respiratory distress BREAST: L breast - No evidence of hematoma, seroma. Small amount of ecchymoses. Mildly tender to palpation. Incision healing well. ABD: soft, NT, ND EXT: WWP NEURO: A&Ox3 Brief Hospital Course: The patient was admitted on ___ with left breast invasive ductal carcinoma for left total mastectomy and left axillary sentinel lymph node biopsy with Dr. ___. Please see operative note. The patient tolerated the procedure well. There were no immediate complications. She was awoken from general anesthesia in the operating room and transferred to the recovery room in stable condition. On post-operative check, she reported pain at the site of the incision and nausea, and had an episode of emesis. The OB/GYN team recommended pain control with Dilaudid. She was placed on subQ heparin and compression devices for prophylaxis. She tolerated a regular diet. On ___, the pain continued to have pain, which was discussed with OB/GYN, and her dosage of Dilaudid was increased. She was given stool softener given the usage of narcotics. She reported some mild pink spotting, which was discussed with OB, and they performed an ultrasound which showed a strong fetal heart rate of 158. Per their report, she has been spotting since earlier in the pregnancy as well. The dressing on the incision site continued to be clean dry and intact. There was no ecchymoses or hematoma on the chest wall. Drain output was serosanguineous. At the time of discharge on ___, vitals were stable, pain well-controlled, and patient felt ready for discharge to home with ___, with follow up appointments in place. Medications on Admission: Meds/Allergies: reviewed in OMR and medications listed here ALBUTEROL SULFATE [PROAIR HFA] - Dosage uncertain - (Prescribed by Other Provider) LEVOTHYROXINE - levothyroxine 175 mcg tablet. 1 tablet(s) by mouth daily in the morning on empty stomach, 90 minutes prior to any food or other meds PNV ___ FUMARATE-FA [PRENATAL] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left breast invasive ductal carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY. You are now stable for discharge. Personal Care: 1. You may keep your incisions open to air or covered with a clean, sterile gauze that you change daily. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) ___ times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may wear a surgical bra or soft, loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your drains so they don't hang down loosely and pull out. 7. The Dermabond skin glue will begin to flake off in about ___ days. Activity: 1. You may resume your regular diet. 2. Walk several times a day. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by Tylenol. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Please assist patient with drain care. A daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon. Followup Instructions: ___

{'tiredness': ['Malignant neoplasm complicating pregnancy, second trimester'], 'left nipple crusting': ['Malignant neoplasm of upper-outer quadrant of left female breast'], 'bloody output': ['Malignant neoplasm of upper-outer quadrant of left female breast'], 'pain at the site of the incision': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'nausea': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'emesis': ['Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure'], 'mild pink spotting': ['Spotting complicating pregnancy, second trimester'], 'strong fetal heart rate of 158': ['14 weeks gestation of pregnancy'], 'pain': ['Postprocedural hypothyroidism', 'Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester'], 'ER positive, PR positive, HER2 negative': ['Estrogen receptor positive status [ER+]', 'Malignant neoplasm of upper-outer quadrant of left female breast'], 'wheezing, dyspnea': ['Unspecified asthma, uncomplicated'], 'history of thyroid CA': ['Personal history of malignant neoplasm of thyroid'], 'history of drug use': ['Personal history of nicotine dependence']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: cucumber / Tegaderm Attending: ___ Chief Complaint: Surgical absence of L breast Major Surgical or Invasive Procedure: 1) ___ - Right prophylactic mastectomy, bilateral ___ reconstruction 2) ___ - take back to OR for exploration of left flap vessels History of Present Illness: ___ is a ___ year old female with history of L breast cancer (Stage I IDC and Paget's) and previous left sided mastectomy & SLNB. She was admitted to the hospital after her prophylactic R mastectomy with ___ reconstruction on ___. She was taken back to the OR on ___ for flap exploration due to declining Vioptix recordings. Past Medical History: PNC: - ___ ___ by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: ___, 67%, breech, ___, nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed ___, plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy Social History: ___ Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: ___. Father--prostate cancer (age ___ Physical Exam: Gen: Well-appearing F in no acute distress. HEENT: Normocephalic. Sclerae anicteric. CV: RRR R: Breathing comfortably on room air. No wheezing. Breasts: Bilateral reconstructed breasts soft and without palpable fluid collection, right mastectomy flap with lateral ecchymosis, ___ skin paddles warm bilaterally with good capillary refill, JP drains x 2 to bulb suction draining serosanguinous fluid Abdomen: Soft, non-distended; umbilicus viable; lower abdominal incision without erythema or drainage; JP drains x2 to bulb suction draining serosanguinous fluid Ext: No cyanosis or edema Pertinent Results: ___ 04:38AM BLOOD WBC-12.0* RBC-2.88* Hgb-8.8* Hct-26.3* MCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-44.3 Plt ___ ___ 03:44AM BLOOD WBC-11.3* RBC-3.32* Hgb-10.2* Hct-29.5* MCV-89 MCH-30.7 MCHC-34.6 RDW-13.0 RDWSD-42.0 Plt ___ - OR - Right prophylactic mastectomy, bilateral ___ reconstruction. Per protocol, patient stayed in PACU overnight. ___ - OR - Patient was recovering well in PACU, with morning plan of clear liquid diet, out of bed to chair, and transfer to floor. However, Vioptix signal of Left breast with declining values, so patient taken back to OR for exploration of L breast flap. Again stayed in PACU overnight per protocol ___ - Recovering well. Febrile overnight to "103" but nurse removed BAIR hugger and re-measured temperature at 99. clear liquid diet, out of bed to chair, transfer to floor She was admitted to the plastic surgery service, where she was began the ___ postoperative pathway. She was given ASA 121.5 daily (to be continued at discharge), Ancef (transitioned to Duricef at discharge), and SCH during her stay. She will discharge home 4 with drains in place, to be removed at office visit. She will daily bacitracin BID application to right mastectomy flap necrosis site. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Discharge Medications: Resume taking your previous home prescriptions, including 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 4. LIDOCAINE-PRILOCAINE - lidocaine-prilocaine 2.5 %-2.5 % topical cream. Apply thick layer to port-a-cath site at least 30 minutes prior to port access. C___ - (Not Taking as Prescribed) 5. OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule by mouth daily for heartburn symptoms - (Not Taking as Prescribed) 6. TAMOXIFEN - tamoxifen 20 mg tablet. 1 tablet(s) by mouth daily In addition, patient discharged with these new medications: 1. Aspirin 121.5 mg QD for 1 month 2. Duricef 500mg PO BID x7 days w/ 1 refill 2. Oxycodone ___ tablets, q4-6 hours #50 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Surgical absence of left breast; breast cancer Discharge Condition: Awake, alert, oriented. Stable Discharge Instructions: Personal Care: 1. You may keep your incisions open to air or covered with a clean, ___ ile gauze that you change daily. If any areas develop blistering, you will need to apply Bactroban cream twice a day. 2. Clean around the drain site(s), where the tubing exits the skin, w ith soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) ___ times per day. 4. A written record of the daily output from each drain should be broug ht to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. DO NOT wear a normal bra for 3 weeks. You may wear a soft, loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your upper drains to a lanyard that hangs down from your neck so they don't hang down and pull out. Y ___ may secure your lower drains to a fabric belt tied around your waist. 7. The Dermabond skin glue will begin to flake off in about ___ days. 8. No pressure on your chest or abdomen 9. Okay to shower, but no baths until after directed by your doctor. . Activity: 1. You may resume your regular diet. 2. Keep hips flexed at all times, and then gradually stand upright as tolerated. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe ___ n. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging 3. Take prescription pain medications for pain not relieved by tyleno l. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescript ion pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain m edication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool soften ers, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, sw ___, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) ___ es, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a c lean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perfo rm drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of d rainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: ___

{'breast cancer': ['Encounter for breast reconstruction following mastectomy', 'Encounter for prophylactic removal of breast', 'Acquired absence of left breast and nipple', 'Personal history of malignant neoplasm of breast'], 'mild asthma': ['Mild intermittent asthma'], 'hypothyroidism': ['Postprocedural hypothyroidism'], 'depressive disorder': ['Major depressive disorder, single episode, unspecified'], 'fever': ['Fever, unspecified'], 'papillary thyroid cancer': ['Personal history of malignant neoplasm of thyroid']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Aspirin Attending: ___. Chief Complaint: L wrist pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old otherwise healthy male presents to ED with 1 day history of L wrist pain. Patient states that he was walking across the street yesterday when he suffered a mechanical fall, landing on his outstretched L hand. He experienced immediate onset of pain but did not present to the hospital until today. He denies numbness or tingling in his fingers or any other symptoms. Past Medical History: Glaucoma Social History: ___ Family History: NC Physical Exam: A&O x 3 Calm and comfortable LUE Skin clean and intact No visible deformity. Diffuse tenderness surrounding the wrist. No erythema, edema, induration or ecchymosis Arms and forearm compartments soft Axillary, Radial, Median, Ulnar SILT EPL FPL EIP EDC FDP FDS fire Fingers WWP Pertinent Results: ___ 05:38AM BLOOD WBC-8.8# RBC-4.53* Hgb-14.1 Hct-40.1 MCV-89 MCH-31.0 MCHC-35.1* RDW-13.3 Plt ___ ___ 05:38AM BLOOD ___ PTT-27.0 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left distal radius fracture and was admitted to the orthopedic surgery service. The patient was reduced and splinted during this admission, but otherwise treated non-operatively. The patient will have outpatient follow-up for assessment and evaluation for any possible surgery intervention following discharge. The patients home medications were continued throughout this hospitalization. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity. The patient will follow up with Dr. ___ in the hand clinic. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*2 2. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #*30 Tablet Refills:*2 3. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet extended release(s) by mouth every 6 hours Disp #*60 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: L distal radius fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ACTIVITY AND WEIGHT BEARING: - Nonweightbearing left upper extremity. - Please remain in your splint and refrain from getting your splint wet until your follow up appointment. Followup Instructions: ___

{'L wrist pain': ['Other closed fractures of distal end of radius (alone)'], 'Diffuse tenderness surrounding the wrist': ['Other closed fractures of distal end of radius (alone)'], 'Immediate onset of pain': ['Fall from other slipping', ' tripping', ' or stumbling'], 'Mechanical fall': ['Fall from other slipping', ' tripping', ' or stumbling']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pelvic mass and uterine fibroid. Major Surgical or Invasive Procedure: Total abdominal hysterectomy, bilateral salpingo-oophorectomy. History of Present Illness: Ms. ___ is a ___, postmenopausal female, who was found to have a left-sided pelvic mass on routine exam. . Pelvic ultrasound revealed large left adnexal mass. Pelvic MRI was done which revealed a 7.9cm left ovarian mass with some imaging features suggestive a fibroma/fibrothecoma but other features atypical for this diagnosis. There was also a multi-fibroid uterus with material within the endometrial cavity at the level of the fundus. A preoperative CA-125 was 17. An endometrial biopsy showed inactive endometrium. She presents today for definitive surgical management. . She reports baseline urinary frequency, urgency, irritable bowel and abdominal bloating. She denies any vaginal bleeding or abdominal/pelvic pain. Past Medical History: PMH: R Breast Dysplasia, Hypercholesterolemia, Anxiety, Osteoarthritis, Hypothyroidism, Herpes. PSH:L leg muscle graft, knee arthroscopy, R hand ganglion cyst removal, R thyroid lobe removal. OB/GYN: G3P1, post-menopausal, last Pap ___ no hx abnl paps, STIs, gyn dx. Social History: ___ Family History: no h/o ovarian, breast, uterine or colon cancer. Physical Exam: On day of discharge: Afebrile, vitals stable General: No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous Pertinent Results: ___ 06:05AM BLOOD WBC-12.1* RBC-4.01* Hgb-12.7 Hct-37.8 MCV-94 MCH-31.8 MCHC-33.7 RDW-14.7 Plt ___ ___ 06:05AM BLOOD Neuts-71.7* ___ Monos-5.6 Eos-1.9 Baso-0.5 ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-104 HCO3-28 AnGap-11 ___ 06:05AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 Brief Hospital Course: Ms. ___ ___ was admitted to the gynecologic oncology service after undergoing total abdominal hysterectomy, bilateral salpingo-oophorectomy, and washings. Please see the operative report for full details. . Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Dilaudid/Toradol. Her diet was advanced without difficulty and she was transitioned to PO Oxycodone and Ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. . By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: hydrocodone 5 mg-acetaminophen 325 mg PO QID ibuprofen 800 mg PO BD prn pain levothyroxine 100 mcg, 1 tablet QD for 5 days, 1.5 tablets for 2 days/wk sertraline 100 mg, PO, QD simvastatin 40 mg, PO, QD valacyclovir 500 mg, PO, BD for 4 days prn breakout Discharge Medications: 1. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID Take to prevent constipation while taking narcotics. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Levothyroxine Sodium 150 mcg PO 2X/WEEK (MO,FR) 4. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 5. Sertraline 100 mg PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain Do not exceed 4000 mg of acetaminophen in 24h. Do not drive. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Benign ovarian fibroma and fibroid uterus. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

{'pelvic mass': ['Benign neoplasm of ovary'], 'uterine fibroid': ['Submucous leiomyoma of uterus'], 'baseline urinary frequency': [], 'urgency': [], 'irritable bowel': [], 'abdominal bloating': [], 'vaginal bleeding': [], 'abdominal/pelvic pain': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "depression and thoughts of suicide" Major Surgical or Invasive Procedure: None History of Present Illness: ___ F w/ h/o HIV, head injury, polysubstance abuse/dependence and reported depression who p/w onset of SI in the context of alcohol and crack cocaine use. Pt reports that she has been feeling "depressed" for "a few days." She describes poor sleep (none over the past night), low energy, decreased appetite, poor self care (not showering, dressing), and anhedonia ("I don't want to do anything"). Acknowledges that drinking "a couple of beers" and smoking crack yesterday worsened her mood. She reports onset of SI overnight that she describes and "just not wanting to live anymore." She denies any plan, but states, "I don't trust myself right now" and "I have nothing to do except contemplate suicide." She is unable to identify any acute or chronic stressors. Asked what she would think would be most helpful, she replies, "I probably would rather be hospitalized...Before, it helped." She reports that she does not currently have any outpatient mental health providers. On psychiatric review of systems, pt endorses AH (intermittent "voices...mutters"- alleviated by Elavil, no a/w substance use), panic attacks (characterized by SOB, palpitations, tremor, diaphoresis, anxiety), and paranoia (intermittent; unable to further describe). She denies current or past decreased need for sleep, IOR, TI/TB, HI, impairment of concentration/memory. Past Medical History: HIV (dx ___ h/o Head injury (___) - pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury PSYCHIATRIC HISTORY: Dx/Sxs- Per pt, depression, panic attacks, polysubstance (ETOH, crack, heroin) abuse/dependence. Hospitalizations- Per pt, multiple hospitalizations at ___ (last, ___ and ___ (last, 5+ yrs ago). Per OMR, multiple (>20) detox admissions. No record of treatment at ___ in Partners system. SA/SIB- Per pt, OD on Ultram "probably to hurt [her]self" ___ ago) Psychiatrist- None Therapist- None Medication Trials- Elavil SUBSTANCE ABUSE HISTORY: ETOH- reports current use < 1/month; reports "a couple of beers" yesterday, last drink at noon; h/o dependence; denies h/o withdrawal seizures or DTs, but has required inpatient detox. Cocaine- reports current use < 1/month; h/o dependence Opiates- h/o IV heroin use; reports last use ___ ago (per OMR note in ___, she endorsed using heroin at that time) Tobacco- ___ Denies use of all other illicit or prescription drugs. Social History: ___ Family History: Denies h/o psychiatric illness, suicide attempts, addictions. Physical Exam: *VS: BP: 118/79 HR: 86 temp: 98.3 resp: 16 O2 sat: 98%height: 62" weight: 136 lbs. Neurological: *station and gait: steady and non-ataxic *tone and strength: full strength cranial nerves: II-XII intact abnormal movements: no adventitious movements or tremors *Appearance: thin woman, hair pulled back, appears clean in hospital gown Behavior: appropriate, calm, irritable and superficially cooperative *Mood and Affect: "depressed", affect somewhat constricted and dysthymic *Thought process: linear, logical, without loose associations *Thought Content: no evidence for delusions or hallucinations SI/HI: Endorses ongoing SI without plan, no HI *Judgment and Insight: both generally limited Cognition: *Attention, *orientation, and executive function: alert, oriented, to person, place, time *Memory: recall intact *Fund of knowledge: appropriate Calculations: not tested Abstraction: not tested Visuospatial: not tested *Speech: appropriate rate, rhythm, tone *Language: appropriate vocabulary for context Gen: Thin well-developed female appearing stated age HEENT: NCAT, MMM, PERRL, CV: RRR no murmur Resp: CTAB ___: NT/ND Neuro: MAEW, CNII-XII intact, gait stable and non ataxic Skin: no rashes or excoriations Heme: no hemorrhage or bruising Pertinent Results: ___ 05:40AM WBC-4.3 RBC-3.87* HGB-10.8* HCT-33.8* MCV-87 MCH-27.9 MCHC-32.0 RDW-16.7* ___ 05:40AM NEUTS-58.7 ___ MONOS-2.9 EOS-0.2 BASOS-0.4 ___ 05:40AM PLT COUNT-313 ___ 05:40AM GLUCOSE-107* UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-18 ___ 05:40AM ALT(SGPT)-40 AST(SGOT)-49* CK(CPK)-216* ALK PHOS-80 TOT BILI-0.2 ___ 05:40AM CALCIUM-9.0 PHOSPHATE-5.0* MAGNESIUM-1.9 ___ 05:40AM cTropnT-<0.01 ___ 05:40AM TSH-0.90 ___ 03:30PM VIT B12-406 FOLATE-15.9 ___ 03:30PM HCG-<5 ___ 05:40AM ASA-NEG ETHANOL-66* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG Brief Hospital Course: ___ F w/ h/o HIV, head injury, polysubstance abuse/dependence and reported depression admitted ___ following onset of SI in the context of alcohol and crack cocaine use. # Depression: Patient unable to identify stressors but notes that she had stopped attending support groups at ___ prior to admission. Also appears to have some degree of housing instability, given "housing court" appearance scheduled for ___. It is unclear how h/o head injury might affect her current presentation or perception of it. Attempts to obtain collateral from PCP ___ infectious disease specialist) regarding depression and substance abuse were unsuccessful, but messages were left to alert provider of ___ admission. Patient declined consent to contact any social supports, including family members. Patient was continued on home amitriptyline. Given previous positive response to sertraline, this was restarted at 25mg and tolerated well. Patient reported improvement in depressed mood, low energy and sleep over the course of admission. SI resolved. Patient felt that poor sleep was likely the trigger for relapse of depression and discussed ways to support good sleep and intervene sooner if she begins to have sleep difficulties. Patient reported no current or previous outpatient mental health providers and requested referrals. Patient remained in good behavioral control on the unit and was appropriate in interactions with staff and other patients. She participated in some groups but was observed to frequently be isolated to her room. # Substance abuse/dependence: Patient reports a history of heavy alcohol and crack cocaine use for which she has undergone multiple detoxes. However, she reports only occasional use in recent months/years. While acknowledging that both substances worsened her mood, she denied any other withdrawal symptoms and did not require detox on this admission. # HIV: CD4 282 on admission. Followed at ___ by ID specialist Dr. ___. Continued on home darunavir (Prezista), ritonavir (Norvir), Truvada. Patient required considerable education and reassurance surrounding naming of her HIV meds, as she refused them initially because she did not recognize the generic names. # Safety: No acute safety concerns. Maintained on Q15min checks. # Legal: ___ Medications on Admission: (Medication confirmed with Dr. ___ MD ___ Dr. ___ Amytriptiline 50 mg PO qhs Truvada 200-300 1 tab PO daily Prezista 600 1 tab PO BID Norvir 100 PO daily *Additionally patient reports taking Vicodin 750 TID but covering physician denied this ___ Disposition: Home Discharge Diagnosis: Depressive disorder Not-Otherwise-Specified (Considerations include Major depressive disorder and Substance-induced mood disorder) HIV h/o Head injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VSS MSE: Mood 'alright', denies SI/HI, feels ok for d/c home, TC WNL, TP linear, logical, speech WNL Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. *It was a pleasure to have worked with you, and we wish you the best of health.* Followup Instructions: ___

{'depression': ['Depressive disorder', 'not elsewhere classified'], 'thoughts of suicide': ['Suicidal ideation'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'polysubstance abuse/dependence': ['Cocaine abuse', 'unspecified', 'Alcohol abuse', 'unspecified'], 'head injury': [], 'poor sleep': [], 'low energy': [], 'decreased appetite': [], 'poor self care': [], 'anhedonia': [], 'panic attacks': [], 'paranoia': [], 'intermittent voices': [], 'substance-induced mood disorder': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hypoglycemia, Alcohol intoxication, Suicidality Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ F with a history of HCV, HIV, and multiple prior admissions for suicidal ideation who presented to the ___ ED this morning after being found down, somnolent and was ultimately found to have an EtOH level of 117 and initial FSBG 42. She was being observed in the ED but hypoglycemia did not readily improve. She is being transferred to the MICU for close monitoring and treatment of refractory hypoglyemia. Per the patient she reports trying to drink "as much as possible" to try and kill herself. She is not sure if she took anything else. She does not recall any other details about last evening. In the ED, initial vitals were 98.0 84 110/65 12 100% RA In the ED, she received: - 4 amps of dextrose - Started on D5 NS gtt - Diazepam 10mg PO @ 10:45a - Octreotide 100mcg - Folic acid 1mg IV x 1 - Thiamine 100mg IV x 1 - Multivitamin Labs/imaging were significant for: - Urine tox: positive for cocaine and benzodiazepines - Serum tox: positive for benzodiazepines, EtOH level of 117 - VBG ___ with AG = 18, lactate 3 - CT head without acute intracranial abnormality on prelim read Vitals prior to transfer were T 95.6 HR 89 BP 106/65 RR 16 SpO2 100% On arrival to the MICU, the patient reports no current complaints. Review of systems: (+) Per HPI, headache Past Medical History: PAST MEDICAL HISTORY: - HIV (dx ___: Previously on ARV - Hepatitis C: Diagnosed ___, genotype 1 - Truamatic brain injury (1980s) - pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury PSYCHIATRIC HISTORY: (per OMR) Dx/Sxs- Per pt, depression, panic attacks, polysubstance (ETOH, crack, heroin) abuse/dependence. Hospitalizations- Per pt, multiple hospitalizations at ___ (last, ___ and ___ (last, 5+ yrs ago). Per OMR, multiple (>20) detox admissions. No record of treatment at ___ in Partners system. SA/SIB- Per pt, OD on Ultram "probably to hurt [her]self" ___ ago) Psychiatrist- None Therapist- None Medication Trials- Amitriptyline Social History: ___ Family History: Denies h/o psychiatric illness, suicide attempts, addictions. Physical Exam: ADMISSION EXAM: Vitals- Tmax: 37.3 °C (99.2 °F) Tcurrent: 37.3 °C (99.2 °F) HR: 89 (87 - 89) bpm BP: 104/51(62) {104/51(62) - 133/70(80)} mmHg RR: 14 (14 - 20) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) General- Well appearing, no apparent distress HEENT- Tattoo on right neck. Pupils 4mm, reactive. Neck- No JVD CV- RRR, III/VI SEM heard best at ___ Lungs- CTAB Abdomen- Soft, nontender. Specifically no tenderness of RUQ. No stigmata of chronic liver disease. GU- No foley Ext- Warm, well perfused. No edema. Neuro- CN II-XII grossly intact. No tremor. DISCHARGE PHYSICAL EXAM Vitals: T98.3 HR83 BP106/73 RR18 100%RA General- Well appearing, no apparent distress HEENT- Tattoo on right neck. Pupils 4mm, reactive. Neck- No JVD CV- RRR, III/VI SEM heard best at ___ Lungs- CTAB Abdomen- Soft, nontender. Specifically no tenderness of RUQ. No stigmata of chronic liver disease. GU- No foley Ext- Warm, well perfused. No edema. Neuro- CN II-XII grossly intact. No tremor. Pertinent Results: ADMISSION LABS: ___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6* MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___ ___ 03:36AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-136 K-3.4 Cl-107 HCO3-21* AnGap-11 ___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69 TotBili-0.2 ___ 03:36AM BLOOD Calcium-7.8* Phos-2.6*# Mg-1.8 ___ 07:35AM BLOOD Osmolal-321* ___ 07:35AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG ___ 09:05AM BLOOD ___ Temp-36.7 pO2-47* pCO2-36 pH-7.26* calTCO2-17* Base XS--9 Intubat-NOT INTUBA ___ 11:10AM BLOOD Glucose-51* Lactate-2.1* HeaD CT: IMPRESSION: 1. No acute intracranial abnormality. 2. Prominence of the posterior nasopharyngeal soft tissues is seen and correlation with direct visualization is recommended. 3. Encephalomalacia in the left parietal lobe with overlying bony defect, possibly from prior trauma. DISCHARGE LABS ___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6* MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___ ___ 06:35AM BLOOD Glucose-97 UreaN-15 Creat-0.5 Na-139 K-3.7 Cl-109* HCO3-23 AnGap-11 ___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69 TotBili-0.2 ___ 06:35AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4* Brief Hospital Course: ___ F with HCV, HIV presenting after being found down with +EtOH, cocaine, benzodiazepines and transferred to the MICU for hypoglycemia, now resolving. 1) HYPOGLYCEMIA: Suspect related to poor PO intake. Hypoglycemia resolved with eating and patient has remained euglycemic for the remainder of her hospital stay. 2) SUICIDALITY: Patient has had prior admissions to psychiatry for SI and has active SI currently. On ___. Psych was following in house. 1:1 sitter at all times. Patient transferred to ___ for active suicidality. 3) ETOH WITHDRAWAL: No active etoh withdrawal during hospital stay. CIWA scale but not scoring. 4) HEPATITIS C INFECTION: Chronic. Elevated transaminases currently, but in classic 2:1 pattern for EtOH and given recent ingestion history, this is more likely the explanation. - Follow-up as outpatient issue 5) HIV: Will bear in mind as transitional issue to consider re-initiating ARVs CODE STATUS: Unable to assess given active suicidality # Transitional issues - New murmur work up - chronic leukopenia - reinitiating HIV treatment and consideration for initiation of HCV treatment - Nystagmus work-up as outpatient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Polyethylene Glycol 17 g PO 1X Duration: 1 Dose 6. Senna 8.6 mg PO BID:PRN Constipation 7. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: hypoglycemia secondary to poor po intake, suicidal ideation, severe depression Discharge Condition: Flat affect, active suicidal ideation Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___. You were admitted to the ICU for low blood sugars that you had when you arrived. You have not had any further blood sugars since. They were probably caused by not eating enough while drinking excessive alcohol. You were transferred back to the general floor and monitored. You continue to have suicidal thoughts and will therefore be going to ___ when you leave ___. We wish you all the best in your recovery. Your ___ tem. Followup Instructions: ___

{'hypoglycemia': ['Other specified hypoglycemia'], 'suicidal ideation': ['Suicidal ideation'], 'acidosis': ['Acidosis'], 'asymptomatic HIV infection': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'chronic pain': ['Other chronic pain'], 'traumatic brain injury': ['Personal history of traumatic brain injury'], 'depressive disorder': ['Depressive disorder'], 'drug abuse': ['Other', 'mixed', 'or unspecified drug abuse'], 'alcohol abuse': ['Alcohol abuse'], 'lack of housing': ['Lack of housing'], 'hepatitis C': ['Chronic hepatitis C without mention of hepatic coma'], 'nystagmus': ['Nystagmus']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Ragweed / morphine / Percocet Attending: ___. Chief Complaint: GI lymphadenopathy Major Surgical or Invasive Procedure: laparoscopic omental biopsy and incisional hernia repair History of Present Illness: ___ with complicated medical history, sarcoidosis on high-dose steroid therapy presenting for re-evaluation for biopsy. Since his last visit here, the patient underwent an emergent ___ patch repair for a perforated duodenal ulcer in ___ of this year. He has since been feeling progressively more tired, and was recently taken off of Remicaide since his mesenteric lymaphdenopathy was worsening despite alleviation of his pulmonary symptoms. He is being followed closely by Rheumatology, and is now on high-dose prednisone, with recent increase to 60mg once daily. He recently underwent a CT A/P which demonstrated new liver lesions and increasing mesenteric and retroperitoneal lymphadenopathy. A CT-guided FNA was unfortunately non-diagnostic. He has also developed what sounds like two episodes of pneumonia, both community-acquired, and was treated with antibiotics. His most recent episode was less severe and did not require hospitalization. He otherwise has diminished, but stable appetite with associated unintentional weight loss that has not changed dramatically. He denies fevers or chills. He overall feels 'okay.' He denies chest pain, shortness of breath or abdominal pain. He denies any urinary symptoms and has been moving his bowels well without hematochezia or melena. Past Medical History: 1. Sarcoidosis, dx skin bx: intestinal & pulmonary involvement, recurrent iritis 2. Inflammatory bowel disease; s/p ileo-hemicolectomy ___, path +sarcoid 3. GERD. 4. Hyperlipidemia 5 OSA on CPAP 6. Asthma. 7. Osteoarthritis. 8. Fractured pelvis, ___ s/p fall. 9. BPH, status post prostatectomy. 10. Depression. 11. History of ITP, status post splenectomy in ___. 12. Hard of hearing and wears hearing aid. Past Surgical History: 1. s/p Ex Lap, R hemicolectomy, ileocecal colostomy for evaluation ileocecal mass. 2. Arthroscopic surgery of both knees. 3. Shoulder surgery. 4. Hernia repair. Social History: ___ Family History: Mother: ___, cardiac disease. Father: diverticulosis, peptic ulcer disease, died at age ___. Maternal grandfather: ___ cancer. Two siblings, living and healthy. Physical Exam: Preoperative Physical Exam: Vital Signs sheet entries for ___: BP: 129/59. Heart Rate: 77. Temperature: 98.1. O2 Saturation%: 99. GEN: chronically ill-appearing male, but in no acute distress. Appears malnourished. HEENT: No scleral icterus, mucus membranes moist. Moon facies. CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: well-healed left subcostal incision consistent with prior splenectomy. Midline incision with large incisional hernia; defect approximates 2.5-3cm, easily reducible. Otherwise non-distended, non-tender Discharge Physical Exam: 98.0 127/68 66 18 96%RA Gen: no acute distress, alert, responsive Pulm: clear to auscultation bilaterally CV: regular rate and rhythm Abd: appropriately tender to palpation, non-distended, soft, incision sites clean, dry, and intact Ext: no c/c/e Pertinent Results: None Brief Hospital Course: ___ is a ___ year old male GI sarcoidosis on prednisone with increasing lymphadenopathy who was admitted on ___ under the general surgery service for biopsy and incisional hernia repair. He was taken to the operating room and underwent an exploratory laparoscopy, lysis of adhesions, partial omentectomy for biopsy, and incisional hernia repair with mesh. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On ___, he was discharged home to follow up in surgery clinic with Dr. ___ in 2 weeks. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. ___ puffs inhaled q ___ hrs prn AZATHIOPRINE - azathioprine 50 mg tablet. 3 tablet(s) by mouth daily CICLOPIROX [LOPROX] - Loprox 0.77 % topical gel. apply topicall twice a day - (Prescribed by Other Provider: Dr. ___ (Not Taking as Prescribed) CLOBETASOL - clobetasol 0.05 % topical cream. apply to affected areas bid prn (rinse fingertips) FEXOFENADINE [ALLEGRA] - Allegra 180 mg tablet. 1 tablet(s) by mouth once a day as needed for seasonal allergies - (Prescribed by Other Provider) FLUOXETINE - fluoxetine 40 mg capsule. TAKE 1 CAPSULE ONCE DAILY FLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation aerosol inhaler. 2 puffs inhaled bid - rinse mouth INFLIXIMAB [REMICADE] - Remicade 100 mg intravenous solution. 350 mg IV Week 0, 2, 6 Wt 68 kg. - (Not Taking as Prescribed) METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg tablet,extended release 24 hr. 1 tablet extended release 24 hr(s) by mouth daily NYSTATIN - nystatin 100,000 unit/mL oral suspension. 5 ml by mouth 4 times a day OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 capsule,delayed ___ by mouth twice a day ONDANSETRON - ondansetron 4 mg disintegrating tablet. ___ tablet,disintegrating(s) by mouth tid with oxycodone OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth tid prn - (Not Taking as Prescribed) PREDNISONE - prednisone 40 mg tablet. 1 tablet(s) by mouth daily - (Not Taking as Prescribed) SIMVASTATIN - simvastatin 40 mg tablet. TAKE ONE-HALF (___) TABLET DAILY TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - Dosage uncertain - (Prescribed by Other Provider) TRIAMCINOLONE ACETONIDE - Dosage uncertain - (Prescribed by Other Provider: Dr. ___ (Not Taking as Prescribed) URSODIOL - ursodiol 250 mg tablet. 1 (One) tablet(s) by mouth three times a day Total of 750mg per day - (Not Taking as Prescribed) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Azathioprine 50 mg PO DAILY 3. Fluoxetine 40 mg PO DAILY 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain RX *hydromorphone 2 mg 1 tablet(s) by mouth every 3 hours Disp #*30 Tablet Refills:*0 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. PredniSONE 40 mg PO DAILY 9. Simvastatin 20 mg PO DAILY 10. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: GI lymphadenopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please keep clear bandage with gauze in place until tomorrow. Please keep steri-strips in place until 2 weeks, or they follow off on their own. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___

{'symptom1': ['disease1', 'disease2'], 'symptom2': ['disease2', 'disease3', 'disease4'], 'symptom3': ['disease1', 'disease3', 'disease5', 'disease6']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Shellfish Derived Attending: ___. Chief Complaint: Esophageal cancer. Major Surgical or Invasive Procedure: ___: Minimally-invasive esophagectomy surgery(thoracoscopic laparoscopic ___, laparoscopic jejunostomy tube, pericardial fat pad buttress (adjusted adjacent tissue transfer). History of Present Illness: The patient is a ___ gentleman who was found to have biopsy-proven intramucosal adenocarcinoma arising in high-grade dysplasia ___. He presents for resection. Past Medical History: GERD x ___ years ___ esophagus with high-grade dysplasia. Colon polyps ___ years ago. Social History: ___ Family History: His mother died at the age of ___ from breast cancer. Father died at age of ___ from coronary artery disease. He has no brothers or sisters. Physical Exam: Discharge VS: T 96.3, BP 112/66, HR 86, RR 20, O2 sats 97%RA General: ___ year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Card: RRR normal ___ HSM murmer Resp: clear b/l GI: soft, NT, NT J-tube site clean , dry, intact. Incision C/D/I Ext: warm no edema Incisions: R chest incision site clean dry intact, margins well approximated Neuro: AA&O x3, no focal deficits Pertinent Results: ___ 06:40AM BLOOD WBC-15.6* RBC-4.56* Hgb-13.4* Hct-39.2* MCV-86 MCH-29.4 MCHC-34.2 RDW-14.2 Plt ___ ___ 06:40AM BLOOD WBC-13.0* RBC-4.33* Hgb-13.0* Hct-37.1* MCV-86 MCH-30.0 MCHC-35.1* RDW-13.7 Plt ___ ___ 06:50AM BLOOD WBC-13.0* RBC-4.22* Hgb-12.8* Hct-36.2* MCV-86 MCH-30.3 MCHC-35.3* RDW-13.7 Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-128* UreaN-18 Creat-0.8 Na-138 K-4.3 Cl-105 HCO3-23 AnGap-14 ___ 06:40AM BLOOD Glucose-80 UreaN-22* Creat-0.7 Na-136 K-3.6 Cl-103 HCO3-23 AnGap-14 ___ 06:50AM BLOOD Glucose-78 UreaN-20 Creat-0.7 Na-141 K-4.2 Cl-106 HCO3-26 AnGap-13 ___ 06:40AM BLOOD Mg-1.9 ___ 06:40AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.0 ___ 06:50AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.8 ___ PA and Lat CXR: IMPRESSION: PA and lateral chest compared to ___: There is no pneumothorax, appreciable pleural effusion, or mediastinal widening relative to ___ following removal of midline and pleural drains. Large cardiomediastinal silhouette and right basal atelectasis are stable as is the caliber of the distended neoesophagus, with small flecks of residual contrast agent from the swallow performed earlier today and reported separately. ___ Barium swallow: FINDINGS: Contrast passes freely through the neoesophagus into the remainder of the stomach and small bowel. There is slight holdup within the stomach, which may be postoperative. There is no evidence for leak or stricture. IMPRESSION: No evidence for leak or stricture. Brief Hospital Course: Mr. ___ was admitted ___ following minimally-invasive esophagectomy surgery (thoracoscopic laparoscopic ___, laparoscopic jejunostomy tube, pericardial fat pad buttress (adjusted adjacent tissue transfer) by Dr. ___. He was extubated in the operating room, and transferred to the ICU with right chest tube, JP, NGT, Foley and Epidural for pain. He transfered to the floor POD 2. Below is a systems review of Mr. ___ hospital course: Respiratory: Postoperative day 1 he had respiratory acidosis secondary to hypoventilation. With aggressive pulmonary toilet, incentive spirometer and good pain control he titrated off oxygen with saturations of 97% on RA. Chest-tube: right with minimal drainage was removed ___ without PTX on postpull films. Card: Sinus tachycardia 110's- IV Lopressor titrated to HR < 90 converted to ___ once diet initiated. BP stable 110-130's. On discharge his heart rate was sinus rhythm 70's and his lopressor was discontinued. GI: PPI, bowel regime continued. Pt had bowel movements following surgery. Nutrition: Jevity was started POD 1 titrated to Goal 105 ml x 18 hours as recommended by the dietician. On ___ he was started on a full liquid following a negative barium swallow which he tolerated. NGT was dc'd on POD 4 Chest tube and JP were removed following barium swallow that showed no leak, POD 6. Renal: He had normal renal function. Electrolytes were replete as needed. Daily weights were stable. The Foley was removed ___ with good urine output thereafter Pain: Epidural was split on POD2 with PCA dilaudid and removed ___. He transitioned to ___ roxicet via J-tube with good control. Disposition: He was seen by physical therapy and deemed safe for home. He was discharged on ___ with his family and ___ ___. He will follow-up with Dr. ___ as an outpatient. Medications on Admission: Protonix 40 mg bid Discharge Medications: 1. Jevity Full Strength Goal 105 mL x 18 hrs Flush J-tube with 50 mL of water before, after starting tube feeds and at NOON Refills: 11 Feeding pump and supplies 2. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1) Tablet,Rapid Dissolve, ___ ___ a day. Disp:*60 Tablet,Rapid Dissolve, ___ Refills:*6* 3. Roxicet ___ mg/5 mL Solution Sig: ___ ml ___ every ___ hours as needed for pain. Disp:*500 ml* Refills:*0* 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml ___ twice a day: take while on narcotics for pain, hold for loose stool. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: GERD ___ esophagus w high-grade dysplasia Colon polyps Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. ___ ___ if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Chest tube site remove dressing and cover site with a bandaid Pain -Roxicet via J-tube as needed for pain -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk ___ times a day for ___ minutes increase to a Goal of 30 minutes daily -Remove chest tube and j-tube site bandages ___ and replace with a bandaid, changing daily until healed. J-tube site: If your j-tube falls out call Dr. ___ ___ immediately. You may keep this covered changing dressing daily to protect site while wearing pants. If not drainage around j-tube you may keep site open to air. Followup Instructions: ___

{'Respiratory acidosis': ['Acidosis'], 'Hypoventilation': ['Acidosis'], 'Sinus tachycardia': ['Malignant neoplasm of lower third of esophagus'], 'Bowel movements': ['Esophageal reflux'], 'Pain': ['Malignant neoplasm of lower third of esophagus', "Barrett's esophagus"], 'Nausea': ['Esophageal reflux'], 'Vomiting': ['Esophageal reflux'], 'Abdominal pain': ['Esophageal reflux'], 'Incision drainage': ['Malignant neoplasm of lower third of esophagus'], 'Chest pain': ['Malignant neoplasm of lower third of esophagus'], 'Fever': ['Malignant neoplasm of lower third of esophagus'], 'Chills': ['Malignant neoplasm of lower third of esophagus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Compazine / codeine Attending: ___. Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: ___: ORIF R Tibial Plateau (___) History of Present Illness: ___ with PMH HTN, HLD, hypothyroidism, DJD of R hip/knee s/p R THR (___), s/p fall this morning onto knees after tripped on the rug. Patient unable to ambulate due to pain in R knee and came to ED. No pain in R hip, ankle. No head strike, LOC, neck/back pain. Past Medical History: - HTN - HLD - Palpitations - Hypothyroidism - Osteopenia - GERD - Vitamin D deficiency - DJD (degenerative joint disease) of hip s/p R total hip arthroplasty ___ at ___ Social History: ___ Family History: Non-contributory Physical Exam: Admission physical exam: Vitals: 97.8 60 121/88 16 100% Right lower extremity: Skin intact. TTP over R knee with limited AROM/PROM ___ pain, no joint effusion. No significant swelling. Soft, non-tender thigh and leg Full, painless AROM/PROM of hip, and ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Discharge physical exam: Soft, non-tender thigh and leg Full, painless AROM/PROM of hip, and ankle ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions ___ pulses, foot warm and well-perfused Pertinent Results: Acute impacted lateral tibial plateau fracture. Horizontally oriented fracture through the inferior aspect of the patella. Associated lipohemarthrosis. ___ 11:55AM BLOOD WBC-14.4* RBC-4.70 Hgb-12.5 Hct-39.6 MCV-84 MCH-26.5* MCHC-31.5 RDW-13.2 Plt ___ ___ 07:10AM BLOOD WBC-10.7 RBC-3.80* Hgb-10.1* Hct-32.5* MCV-85 MCH-26.7* MCHC-31.2 RDW-13.1 Plt ___ ___ 11:55AM BLOOD Glucose-101* UreaN-15 Creat-0.5 Na-135 K-6.3* Cl-101 HCO3-25 AnGap-15 ___ 07:10AM BLOOD Glucose-112* UreaN-12 Creat-0.5 Na-139 K-4.2 Cl-104 HCO3-28 AnGap-___ with HTN, HLD s/p mechanical fall today with R tibial plateau fx. Patient was admitted to the orthopedic surgery service from the ED. The patient was taken to the operating room on ___ for ORIF of tibial plateau fracture. The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patient worked with ___ who determined that discharge to home with ___ was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight bearing the Right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Pravastatin 80 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Pravastatin 80 mg PO DAILY 5. Acetaminophen 1000 mg PO Q6H:PRN pain 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC Q24H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe sc q24 Disp #*30 Syringe Refills:*0 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth q4-6 Disp #*40 Tablet Refills:*0 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right tibial plateau fracture s/p ORIF Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. -Splint must be left on until follow up appointment unless otherwise instructed -Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: TDWB Physical Therapy: TDWB Treatments Frequency: Change dressing daily Staple removal on first postop visit ___ TDWB Followup Instructions: ___

{'Right knee pain': ['Closed fracture of upper end of tibia alone'], 'HTN': ['Unspecified essential hypertension'], 'HLD': ['Other and unspecified hyperlipidemia'], 'hypothyroidism': ['Unspecified acquired hypothyroidism'], 'DJD of R hip/knee': [' Disorder of bone and cartilage', 'unspecified'], 'fall this morning onto knees': ['Fall from other slipping', ' tripping', ' or stumbling'], 'GERD': ['Esophageal reflux'], 'Vitamin D deficiency': ['Unspecified vitamin D deficiency'], 'THR': ['Hip joint replacement']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: R shoulder pain Major Surgical or Invasive Procedure: ___ ORIF R humerus History of Present Illness: This is a deligthful ___ year-old woman RHD with Hx of severe RA who was in her USOH until the day of presentation when the patient sustained a mechanical fall, with immediate right arm pain. She does recall that she did not loose her consciousness. The patient was transferred from on OSH and presented to the ED for evaluation and the orthopaedic service was consulted when imaging was concerning for fracture. Past Medical History: RA, HTN, HLD, shingles, h/o herpetic encephalopathy, feels like she has been declining over past year (refers to lumps in back of head which she does not have an explanation for), knee arthritis, back pain, wears Depends because she cannot make it to bathroom in time, s/p breast reduction Social History: Lives in retirement facility, has medical services. A Minimal smoking, no current alcohol or drugs Physical Exam: admit: A&O x 3 Calm and comfortable BUE skin clean and intact, nonthreatened. Tender over right proximal humerus. Pain with shoulder elevation, internal and external rotation. Arms and forearm compartments soft Axillary, Radial, Median, Ulnar SILT EPL FPL EIP EDC FDP DIO fire 2+ radial pulses bilaterally Elbow stable to varus, valgus, rotatory stresses. d/c: A&O x 3 Calm and comfortable RUE incision c/d/i Arms and forearm compartments soft Axillary, Radial, Median, Ulnar SILT EPL FPL EIP EDC FDP DIO fire 2+ radial pulses bilaterally Elbow stable to varus, valgus, rotatory stresses. Pertinent Results: ___ 02:00AM GLUCOSE-120* UREA N-38* CREAT-1.2* SODIUM-139 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 ___ 02:00AM estGFR-Using this ___ 02:00AM WBC-12.3* RBC-3.73* HGB-10.1* HCT-32.5* MCV-87 MCH-27.1 MCHC-31.1 RDW-15.0 ___ 02:00AM NEUTS-77.3* LYMPHS-14.3* MONOS-7.3 EOS-0.6 BASOS-0.4 ___ 02:00AM PLT COUNT-385 ___ 02:00AM ___ PTT-24.3* ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R ___ humerus fx/dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF R humerus, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the RUE extremity, and will be discharged on ASA 325mg for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: Inderal LA 80 mg capsule,extended release oral QD Nexium 40 mg capsule,delayed release oral QD folic acid 1 mg tablet oral QD prednisone 5 mg tablet oral QD methotrexate sodium 25 mg/mL injection solution injection 0.5ml solution(s) Once monthly on the ___ (12.5mg) leucovorin calcium 10 mg tablet oral 1 tablet(s) Once monthly on ___, 12 hours after methotrexate Vitamin D3 400 unit capsule oral 1 capsule(s) Once Daily lovastatin 20 mg tablet oral 1 tablet(s) Once Daily ___ 8.6 mg-50 mg tablet oral alendronate 70 mg tablet oral 1 tablet(s) Once weekly on ___ Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Alendronate Sodium 70 mg PO QFRI 3. Atorvastatin 20 mg PO DAILY 4. Calcium Carbonate 1250 mg PO Q24H 5. Docusate Sodium 100 mg PO BID 6. Milk of Magnesia 30 ml PO BID:PRN Constipation 7. NexIUM (esomeprazole magnesium) 40 mg oral qd 8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q4hrs Disp #*30 Tablet Refills:*0 9. PredniSONE 5 mg PO DAILY 10. Propranolol LA 80 mg PO DAILY 11. Senna 1 TAB PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Aspirin 325 mg PO DAILY Duration: 6 Weeks Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R proximal humerus fx/dislocation Discharge Condition: stable Discharge Instructions: Medications You will be given a prescription for pain medicine. The pain medication is a codeine derivative and should be taken as directed. Please take one full strength aspirin (325 mg) each day for six weeks to decrease the risk of having a complication related to a blood clot. Please take a stool softener, like Colace (Docusate Sodium 100mg), twice a day while taking narcotics to prevent constipation. Dressing Leave your dressing for 48 hours after your surgery. After 48 hours, you may remove your dressing. LEAVE THE TAPE STRIPS OVER YOUR INCISIONS. These will stay on for 1.5 to 2 weeks and will slowly peel off. Showering You may shower 48 hours after your surgery and get your incisions wet. DO NOT immerse in a tub or pool for 7 – 10 days to avoid excessive scarring and risk of infection. When you shower, let your arm hang at your side (Do NOT raise your arm). To wash under your arm, lean forward carefully and let your arm hang. Using your other hand, wash under your operative arm. Do NOT scrub the incision. When you are done, stand up and let your arm hang at your side. Pat yourself dry and put your sling on. Ice Packs Keep Ice Packs on at all times exchanging every hour while awake. Icing is very important to decrease swelling and pain and improve mobility. After 24 hours, continue to use the cuff 3 – 4 times a day, 15 – 20 minutes each time to keep swelling to a minimum. Activity • Take it easy. • Wear your sling for comfort and safety. • Keep your arm at your side at ALL TIMES – no reaching, grabbing or pulling with your operative arm. When to Contact Us If you experience severe pain that your pain medication does not help, please let us know. If you have a temperature over 101.5º, please contact our office at ___. Physical Therapy: Activity: Activity: Activity as tolerated Activity: OOB to chair for meals Right lower extremity: Non weight bearing Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Wound care: Site: Incision Type: Surgical Dressing: Gauze - dry Comment: To be changed DAILY by ___ starting POD ___. RN - please overwrap any dressing bleedthrough with ABDs and ACE Followup Instructions: ___

{'R shoulder pain': ['Other closed fracture of upper end of humerus', 'Rotator cuff (capsule) sprain'], 'Mechanical fall': ['Unspecified fall'], 'RA': ['Rheumatoid arthritis'], 'HTN': ['Unspecified essential hypertension'], 'HLD': ['Other and unspecified hyperlipidemia'], 'Shingles': [], 'Herpetic encephalopathy': [], 'Knee arthritis': [], 'Back pain': [], 'Depends': [], 'Breast reduction': [], 'Smoking': [], 'Drugs': [], 'Tender over right proximal humerus': ['Other closed fracture of upper end of humerus'], 'Pain with shoulder elevation, internal and external rotation': ['Other closed fracture of upper end of humerus', 'Rotator cuff (capsule) sprain'], 'Lumps in back of head': [], 'Declining over past year': [], 'Wears Depends because she cannot make it to bathroom in time': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: hematemesis Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ female with medical history notable for DM2, HTN, HLD, multiple strokes on Plavix and aspirin, inferior MI, tobacco use, primary hyperparathyroidism, and colon cancer s/p colectomy and chemotherapy who presented with hemoptysis. Patient was initially seen for hemoptysis at ___ on ___ HPI reported "She first noticed coughing and hemoptysis approximately ___ weeks ago, and noticed very small blood clots at that time. She saw her PCP in clinic on ___ for this, and CT with contrast was ordered, but has not yet been scheduled (note, she has allergy to contrast). Over the past 3 days, she has noticed worsening of her cough, sputum production, and hemoptysis, with large clots on the order of teaspoons. No fevers or chills, shortness of breath, chest pain, or lightheadedness. Has some weight loss. No night sweats, homelessness, or prison exposure. No recent travel, surgery, immobility, ___ swelling/pain. Notes some LUQ abdominal pain that began last night, that is worsened by cough. It is not associated with food, and she has no n/v/d/constipation, and has regular BMs with no hematochezia or melena." A CT chest was obtained which was notable for infrahilar mass with complete occlusion of the right middle lobe. She was not able to connect with her PCP to discuss the results. In the ED, initial VS: Pain 0 Temp 97.7 HR 78 BP 170/88 RR 16 POx 97% RA Exam: O: lung mild wheeze in the RLL. Work-up: Leukocytosis to 16, Elevated Ca ___ She received: PO Oxybutynin 5 mg PO Azithromycin 500 mg IV CefTRIAXone (1 g ordered) Consults: IP: Decision was made to admit for expedited oncology work-up. On arrival to the floor, the patient the endorsed the history per above. In addition, she clarified that she has lost 3 pounds in the past month. She denies any decrease PO intake or abdominal pain. She denies SOB. She says she feels a lot better after receiving medications in the ED. Past Medical History: - prior paramedian pontine infarct (___) - right-sided lenticulostriate territory infarct ___ - Hypertension as per prior medical records(patient denies) - Dyslipidemia - Colon cancer 2/p right colectomy in ___ with prolonged stuttering course of adjuvant chemotherapy (diagnosed in setting of GI bleeding) - Cholecystectomy for chronic cholecystitis and gallstones in ___ - Diverticulosis - Hemorrhoids Social History: ___ Family History: Mother had stroke in her ___ or ___. Her paternal grandfather, father, and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam: Admission: General: Older woman who appears stated ago, NAD, lying flat on bed HEENT: EOMI, PERRLA, MMM Neck: No JVD, no JVP elevation, neck supple, no cervical lymphadenopathy Lungs: Decreased breath sounds on R side, L side CTAB @ bases, b/l ronchi in b/l upper lobes CV: RRR, distant heart sounds, bradycardic, no murmurs/rubs/or gallops Lymph: 0.5 cm x 2 R enlarged supraclaviular node, 0.5 cm x1 L enlarged supraclavicular node GI: Soft, nondistended, nonrigid, nontender to palpation Ext: No lower extremity swelling, distal pulses b/l intact in UE and ___ ___: CNII-XII intact, L eyebrow lower than R eyebrow, no lower facial droop, ___ strength R grip strength, RUE flexion and extension @ elbow, RLE ___ strength on plantar flexion and dorsiflexion, RUE +antigravity, L grip strength ___, LUE ___ flexion and extension @ elbow joint, LLE +antigravity, LLE plantar and dorsiflexion ___, A&O grossly Discharge: No significant changes Pertinent Results: Admission: ___ 06:57AM PTH-106* ___ 06:57AM WBC-13.3* RBC-4.63 HGB-12.1 HCT-36.7 MCV-79* MCH-26.1 MCHC-33.0 RDW-14.5 RDWSD-41.5 ___ 06:57AM PLT COUNT-275 ___ 12:05AM ___ PTT-30.5 ___ ___ 10:18PM GLUCOSE-110* UREA N-12 CREAT-1.1 SODIUM-146 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 ___ 10:18PM estGFR-Using this ___ 10:18PM ALT(SGPT)-7 AST(SGOT)-15 LD(LDH)-362* ALK PHOS-107* TOT BILI-<0.2 ___ 10:18PM ALBUMIN-3.4* CALCIUM-10.5* PHOSPHATE-3.0 MAGNESIUM-2.3 URIC ACID-6.7* ___ 10:18PM WBC-16.9* RBC-4.99 HGB-13.3 HCT-39.5 MCV-79* MCH-26.7 MCHC-33.7 RDW-14.7 RDWSD-41.8 ___ 10:18PM NEUTS-75.3* LYMPHS-18.1* MONOS-5.8 EOS-0.2* BASOS-0.2 IM ___ AbsNeut-12.72* AbsLymp-3.05 AbsMono-0.98* AbsEos-0.04 AbsBaso-0.03 ___ 10:18PM PLT COUNT-348 Imaging: CT Chest ___: IMPRESSION: Right infrahilar mass with complete occlusion of the right middle lobe bronchus with complete atelectasis of the right middle lob, concerning for bronchogenic carcinoma mediastinal bilateral hilar adenopathy. Diffuse enlargement the thyroid with multiple hypodense areas within it which most likely represent goiter. Brief Hospital Course: Mrs. ___ is a ___ female with a medical history notable for DM2, HTN, HLD, multiple strokes, inferior MI, tobacco use, and colon cancer, who presented with 3 weeks of increasing hemoptysis i/s/o a R hilar lung mass found on CT. #Hemoptysis, R hilar mass Her hemoptysis and R hilar mass is concerning for bronchogenic carcinoma given her history of smoking, colon cancer, and weight loss. She was stable without hypoxia or respiratory distress. Her home Plavix and aspirin were held, and her hemoptysis improved. IP consulted and planned for biopsy electrocautery/cryo +/- stent placement on ___, ___. She had a brain MRI on the evening of discharge that showed nothing acute, though follow-up on final read will be needed. She will also need a PET-CT for complete staging. She has been told to hold home Plavix until further notice (last dose ___ but continue her home aspirin. #Hypercalcemia She has a history of primary hyperparathyroidism, but an elevated calcium level can also be seen as paraneoplastic syndrome. Her Ca was 10.5 on admission, in the same range as has been historically. She received her home Vitamin D, but no specific treatment was started. # CVA We held her home Plavix and aspirin per above. # T2DM She was on SSI, but did not require any. # HLD We continued her home statin. # Tobacco use She was given a Nicotine patch. TRANSITIONAL ISSUES: ==================== [] MRI wet read negative for acute pathology, will need to be followed up for final read [] PET/CT scan to complete staging [] ___, ___ flex and rigid bronchoscopy + EBUS TBNA and possible stenting [] Discuss restarting Plavix post-procedurally [] Smoking cessation discussion ------------- CODE: Full (confirmed) CONTACT: ___ (Daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Oxybutynin 5 mg PO DAILY 5. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Oxybutynin 5 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. HELD- Clopidogrel 75 mg PO DAILY This medication was held. Do not restart Clopidogrel until you have spoken with your doctors and it is safe to resume. Certainly, not before ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Hemoptysis Secondary: Hypercalcemia 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 ___ was a pleasure taking part in your ___ here at ___! Why was I admitted to the hospital? You were admitted because you were on blood thinners and were coughing up blood. What was done for me while I was in the hospital? - We were concerned about the blood that you were coughing up, so we did a number of tests. We also stopped your Plavix, a medicine that can make you bleed easier - and that helped to reduce the amount of blood that you were coughing up. - The lung doctors spoke with ___ about the results of your recent lung CT, and explained that they will need to get a sample of tissue in order to find out what is in your lungs. - You also got a head MRI to look for any changes in your brain. Since you were stable and did not need to be in the hospital for any other tests, it was decided that you could go home safely. What should I do when I leave the hospital? -You have a bronchoscopy schedule for ___. Please DO NOT eat after 11:59PM on ___ and do not eat breakfast or lunch. You can take your morning medicines with water. -Your appointments are as below -Please DO NOT TAKE Plavix (clopidogrel) UNTIL after your procedure with the pulmonary doctors -___ call Health ___ Associates to make a follow-up appointment with your primary ___ doctor about this hospitalization (number below) Sincerely, Your ___ ___ Team Followup Instructions: ___

{'hemoptysis': ['Hemoptysis', 'Primary hyperparathyroidism', 'Other nonspecific abnormal finding of lung field'], 'weight loss': ['Hemoptysis', 'Primary hyperparathyroidism', 'Type 2 diabetes mellitus without complications'], 'coughing': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field'], 'abdominal pain': ['Primary hyperparathyroidism'], 'wheeze': ['Other nonspecific abnormal finding of lung field'], 'leukocytosis': ['Hemoptysis', 'Primary hyperparathyroidism'], 'elevated calcium level': ['Primary hyperparathyroidism'], 'infrahilar mass': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field'], 'right middle lobe atelectasis': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field'], 'mediastinal bilateral hilar adenopathy': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field'], 'goiter': ['Primary hyperparathyroidism'], 'enlarged supraclavicular node': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field'], 'bronchogenic carcinoma': ['Hemoptysis', 'Other nonspecific abnormal finding of lung field']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ w/ h/o stage III splenic flexure colon cancer s/p resection with colonic anastamosis, HTN, DMII, CAD who presents with one episode of bright red blood per rectum this morning. She never has constipation, but some loose stools since her surgery over a decade ago. Today, she had a normal BM for her, and had some blood on top of the BM, small amount, also some red blood on toilet paper. She states she had some mild left sided abdominal pain that came and went with belching, so she thought it was gas pain. She saw her primary care physician today who noticed a small amount of bright red blood in the rectal vault, she was subsequently sent in to us for evaluation. PCP exam ___ few hours ago with anoscopy demonstrated hemorrhoid and stool with small amount of blood in vault. In the ED intial vitals were: 98.1 58 155/80 18 98% RA - Labs were significant for normal coags, normal CBC, normal LFTs, normal coags. UA shows few bacteria and 2 epithelial cells, otherwise normal. - Urine and blood cultures were sent. Vitals prior to transfer were: 98.4 68 121/65 17 97% RA On the floor, vitals are 98.4 158/86 84 18 100%RA. She is in good spirits, in no distress, in no pain and has had no more red blood since earlier today. Past Medical History: -COLON CANCER -DIABETES TYPE II -HYPERCHOLESTEROLEMIA -LACTOSE INTOLERANCE -STROKE -INFERIOR MYOCARDIAL INFARCTION -HYPERTENSION -HYPERLIPIDEMIA -DIZZINESS Social History: ___ Family History: Mother had stroke in her ___ or ___. Her paternal grandfather, father, and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 98.4 158/86 84 18 100%RA GENERAL: NAD HEENT: PERRL, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 99.1 ___ 58-64 18 99/RA GENERAL: NAD HEENT: PERRL, pink conjunctiva, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 05:51PM BLOOD ___ PTT-31.3 ___ ___ 05:30PM BLOOD Glucose-101* UreaN-10 Creat-1.0 Na-142 K-3.7 Cl-107 HCO3-26 AnGap-13 ___ 05:30PM BLOOD ALT-34 AST-24 AlkPhos-106* TotBili-0.3 ___ 05:30PM BLOOD Albumin-4.0 ___ 06:20PM BLOOD Lactate-1.3 ___ 05:49PM BLOOD Hgb-14.7 calcHCT-44 DISCHARGE LABS: ___ 08:00AM BLOOD WBC-8.1 RBC-4.75 Hgb-13.6 Hct-40.7 MCV-86 MCH-28.6 MCHC-33.4 RDW-13.6 Plt ___ ___ 08:00AM BLOOD Glucose-122* UreaN-8 Creat-0.9 Na-144 K-3.7 Cl-109* HCO3-24 AnGap-15 URINE: ___ 06:05PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:05PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2 ___ 06:05PM URINE Mucous-RARE ___ 6:05 pm URINE ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. EKG ___: Sinus bradycardia. Borderline left atrial abnormality. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Diffuse non-specific repolarization abnormalities. Compared to the previous tracing of ___ complete right bundle-branch block is now present. EKG ___: Sinus bradycardia. Non-specific intraventricular conduction delay. Left axis deviation. Left anterior fascicular block. Compared to the previous tracing right bundle-branch block is no longer present. Brief Hospital Course: PRIMARY REASON FOR ADMISSION: Mrs. ___ is a ___ h/o stage III splenic flexure colon cancer s/p resection, DMII, CAD, HTN who presents from clinic with one episode of bright red blood per rectum this morning. ACTIVE ISSUES: # Rectal Bleeding: Patient with mild abdominal pain earlier today with small amount of blood in stool and on toilet paper. It is likely that her abdominal pain could have been gas pain given the mild intermittent crampy nature that resolved with passing gas. Hemodynamically she was stable, Hct was normal and she had no further bleeding. Given she does have hemorrhoids, it is most likely that this is the cause of her bleeding, but given her history of colorectal cancer, she should have expedited outpatient colonoscopy. She will also be discharged with simethicone. # Abdominal pain/chest pain: Seemed most consistent with gas pain given her description and improvement with belching and passing flatus. EKG was without evidence of new ischemia. # Benign Hypertension: Stable from her baseline. Prescribed lisinopril but does not take. # CAD: On aspirin, statin. # Hyperlipidemia: continue rosuvastatin TRANSITIONAL ISSUES: - She should have an outpatient colonoscopy - She may benefit from hemorrhoidal banding (was refered to ___ clinic) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Oxybutynin 5 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Calcium Carbonate 500 mg PO TID:PRN . 7. FoLIC Acid 1 mg PO DAILY 8. Fish Oil (Omega 3) 1000 mg PO BID 9. Nicotine Lozenge 2 mg PO Q8H:PRN smoking cessation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Oxybutynin 5 mg PO DAILY 4. Calcium Carbonate 500 mg PO TID:PRN . 5. Nicotine Lozenge 2 mg PO Q8H:PRN smoking cessation 6. Rosuvastatin Calcium 10 mg PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. Simethicone 80 mg PO QID:PRN gas RX *simethicone 80 mg 1 tablet by mouth four times a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Bright red blood per rectum Secondary Diagnoses -HTN -Chronic Dizziness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was our pleasure participating in your care here at ___. You were admitted here on ___ after having some bright red blood with your bowel movements. Fortunately, your blood counts remained stable. It will be very important that you have a colonoscopy as an outpatient. Please call ___ to schedule your colonoscopy. Please try to schedule this before your ___ appointments. If you should have more abdominal pain, chest pain, bleeding or any other concerning symptom, please let your doctor know. Again, it was our pleasure participating in your care. We wish you the best! -- Your ___ Medicine Team -- Followup Instructions: ___

{'bright red blood per rectum': ['Hemorrhage of rectum and anus'], 'HTN': ['Benign essential hypertension'], 'Dizziness': ['Dizziness and giddiness'], 'Abdominal pain': ['Abdominal pain', 'unspecified site'], 'Chest pain': ['Chest pain', 'unspecified'], 'CAD': ['Coronary atherosclerosis of native coronary artery'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Colorectal cancer': ['Personal history of malignant neoplasm of large intestine'], 'Aspirin use': ['Long-term (current) use of aspirin']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ / ___ Attending: ___ Chief Complaint: perianal pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ man with history of hypertension who presents with perianal pain and purulent discharge. Patient states that he has had longstanding problems with "hemorrhoids". He reports that for the past ___ years, he has had intermittent sensation of "swelling" and "rectal pain" with defecation. This lasted for a few weeks followed by drainage of pus from the rectal areas, followed by some asymptomatic months. However for the past month, he has felt significant pain and irritation, worse with sitting. He also see bloody drainage occasionally from the anal area. In the past, he was seen at ___ ED in ___ for possibly possibly thrombosed painful internal hemmorhoid. He reports he has tried Anusol HC suppository without relief. He works using computers and therefore is quite sedentary at work. He was recently seen by his PCP ___ ___ due to worsening pain and purulent discharge. His doctor prescribed him augmentin and mupriocin, as well as derm referral. HIV and RPR negative at that time. The patient states that the symptoms have not improved. He denies any history of receptive anal intercourse, Crohn's disease, ulcerative colitis, fevers, chills, abdominal pain, dysuria, hematuria, diarrhea. Patient denies any similar pustules in his inguinal region or armpits. No family history of Crohn's disease. Patient reports exquisite pain with defecation. In the ED, initial VS were: 99.9 96 148/102 16 100% RA ED physical exam was recorded as multiple pustules along the left buttock crease ED labs were notable for WBC 13.7 CT pelvis showed soft tissue thickening in the perianal region and extending along the left buttock, without fluid collection. Patient was given 1g Tylenol and vancomycin 1gm Transfer VS were 98.0 67 141/91 18 100% RA REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: HYPERTENSION SICKLE CELL TRAIT ASTHMA HEMORRHOIDS OBESITY KELOID H/O TOBACCO ABUSE H/O ACL TEAR H/O BACK PAIN Social History: ___ Family History: -Mother: ___ -Grandmother: Lung Cancer (still alive) Physical Exam: ADMISSION & DISCHARGE EXAM: Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: Multiple nodular/pustular lesions on the left ___ region extending to the gluteal folds. Some of these are erythematous and draining pus. On the right perianal region at 6 o clock, there is also an area of condylomatous lesions, with no pus. No anal fissures observed. No external hemorrhoid observed. There are keloid lesions in the pubic area Neuro: AAOx3. No facial droop. Pertinent Results: ___ 12:10AM URINE HOURS-RANDOM ___ 12:10AM URINE UHOLD-HOLD ___ 12:10AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 12:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 12:10AM URINE MUCOUS-RARE ___ 11:24PM estGFR-Using this CT Soft tissue thickening in the perianal region and extending along the left buttock, without fluid collection. Brief Hospital Course: Mr. ___ is a ___ man with history of hypertension who presents with perianal pain and purulent discharge. He has had a history of multiple ___ lesions for ___ years (pustules with some drainage and warts) and discussed this with his PCP for the first time last week. He was prescribed a course of augmentin, which he nearly completed, and referred to Dermatology urgently for consideration of biopsy and further evaluation. Given the weather, his outpatient appointment was canceled so presented to the ED and was admitted. He had no worsening symptoms from the ___ years of his chronic lesions, with the exception of pain relieved with ibuprofen. He denied any fevers, chills, or sweats. His exam did not reveal s/s cellulitis and CT was negative for an abscess. His dermatology appt was rescheduled for the following morning, so he was discharged a few hours after admission in stable condition with instructions to keep his Dermatology appointment. No changes were made to his medications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ___ lesions, chronic HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for ongoing pain due to the lesions in the ___ area. You have an appointment with Dermatology tomorrow AM - it is very important you keep this appointment so these lesions can be evaluated. Please complete the antibiotics Dr. ___ for you last week. No other changes were made to your medications. We wish you the best, ___ Team Followup Instructions: ___

{'perianal pain': ['Disease of anus and rectum'], 'purulent discharge': ['Disease of anus and rectum'], 'swelling': ['Disease of anus and rectum'], 'rectal pain': ['Disease of anus and rectum'], 'irritation': ['Disease of anus and rectum'], 'bloody drainage': ['Disease of anus and rectum'], 'multiple pustules': ['Disease of anus and rectum'], 'erythematous': ['Disease of anus and rectum'], 'draining pus': ['Disease of anus and rectum'], 'condylomatous lesions': ['Disease of anus and rectum'], 'keloid lesions': ['Hypertrophic scar'], 'hypertension': ['Essential (primary) hypertension'], 'sickle cell trait': ['Sickle-cell trait'], 'obesity': ['Obesity'], 'BMI 31.0-31.9': ['Body mass index [BMI] 31.0-31.9'], 'adult': ['adult'], 'history of nicotine dependence': ['Personal history of nicotine dependence']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Chloroquine Attending: ___ Chief Complaint: L2 fracture, back pain Major Surgical or Invasive Procedure: ___: L2 corpectomy (retroperitoneal approach) and revision of posterior L1-L3 fusion History of Present Illness: Mr. ___ is a ___ Ph.D. researcher at ___ who was in ___ for research projects in ___. He had to jump out of a second-floor window secondary to a terrorist attack and broke his leg and fractured his L2 vertebrae. He initially received care for this in ___. The patient continued to have back pain and after exhausting medical treatment, remained symptomatic. The decision was made to proceed with L2 corpectomy with a revision of posterior instrumentation and fusion. Past Medical History: Mitral valve prolapse headaches GERD Past Surgical: ___: L ankle ORIF ___ L1-L3 fusion Social History: ___ Family History: NC Physical Exam: UPON DISCHARGE: Afebrile Vital sigs stable No apparent distress Heart rate regular Respirations non-labored Abdomen, soft, non-tender, non-distended Back incision clean, dry and intact with staples place ___ strength throughout Sensation intact throughout Pertinent Results: ___: Portable abdomen xray IMPRESSION: Diffuse dilatation of the large bowel in a pattern most consistent with ileus. No pneumoperitoneum or pneumatosis. ___: Ultrasound Bilateral ___ veins IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. ___: CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral small nonhemorrhagic pleural effusions and adjacent bibasilar atelectasis. ___: Xray abdomen IMPRESSION: 1. Interval improvement of colonic ileus. 2. Left loculated pleural effusion, better assessed on CT chest from the same day. ___ Lumbosacral spine xray IMPRESSION: Postsurgical changes. No acute fracture. ___ KUB ** Brief Hospital Course: On ___, the patient was admitted for elective L2 corpectomy (retroperitoneal approach) and revision of posterior L1-L3 fusion. He underwent this procedure with Dr. ___ was subsequently transferred out of the OR to the PACU for post-anesthesia care and monitoring. On ___ Patient was neurologically stable. He continued to complain of uncontrolled back pain so pain regimen was adjusted. On ___, the patient continued with back pain which he states was mildly improved. He complained of abdominal pain and distention and KUB showed large bowel ileus. His bowel regimen was increased and he received enema with no immediate BM,but large amount of flatus. The patient underwent workup for tachycardia, EKG showed sinus tach and Trops were negative. LENIs were negative for any DVTs and tachycardia improved to 110 after pain improved. On ___, overnight the patient's oxygen saturation dipped down to 80% while sleeping, and he was therefore placed on 1L NC. In the morning, his neurological and motor exam was stable. When working with ___ he had tachyacardia with a heart rate of 100 that increased to 140 when he rose from sitting to standin. He also had a correlating O2 drop to the ___. A CTA was ordered and was negative for PE, though it revealed some atelectasis. A follow-up KUB was ordered for investigation of resolution of ileus, as he had a BM overnight. It showed interval improvement of colonic ileus. On ___, the patient remained neurologically stable. While trying to reposition himself in bed he reports he "snapped" his low back and has new posterior right sided lumbar pain. He denies numbness, tingling in his lower extremities. He is full strength bilaterally. A repeat AP/LAT xray are stable. Per CPS his diazepam was d/c'd and he was started on Tizanidine. Diet changed to full liquids. On ___ the patient remained neurologically stable, and was awaiting a rehab bed. He continued to endorse right lower back pain, although continued on pain medication as needed. On ___ the patient remained neurologically and hemodynamically stable. The patient was awaiting a rehab bed. On ___, the patient remained neurologically and hemodynamically stable. Patient complaining of diarrhea with intermittent abdominal pain. Ordered repeat KUB to evaluate previous ileus which showed resolving ileus. Diet was advanced as patient tolerates. At the time of discharge on ___ the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient will follow up with Dr. ___ routine. The patient expressed readiness for discharge. Medications on Admission: Gabapentin 300mg PO TID lansoprazole 15mg PO daily oxycodone prn tramadol prn Cialis 20mg q72 hours Discharge Medications: 1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Every four (4) hours as needed Disp #*60 Tablet Refills:*0 2. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. Calcium Carbonate 1000 mg PO QID:PRN indisgestion 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp #*28 Tablet Refills:*0 6. Tizanidine 2 mg PO TID:PRN muscle spasm RX *tizanidine 2 mg 1 tablet(s) by mouth Three times daily as needed Disp #*42 Tablet Refills:*0 7. Cyanocobalamin 1000 mcg PO DAILY 8. FoLIC Acid ___ mcg PO DAILY 9. lansoprazole 15 mg oral DAILY 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L2 fracture, back pain Discharge Condition: Stable Discharge Instructions: Surgery •Your dressing was removed on the second day after surgery. The wound may remain uncovered. •Your incision is closed with staples. You will need to have staple removal. •Do not apply any lotions or creams to the site. •Please keep your incision dry until removal of your staples. •Please avoid swimming for two weeks after staple removal. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc… until cleared by your neurosurgeon. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •New weakness or changes in sensation in your arms or legs. Followup Instructions: ___

{'back pain': ['L2 fracture'], 'abdominal pain': ['Postprocedural intestinal obstruction'], 'tachycardia': ['Other specified complication of internal orthopedic prosthetic devices, implants and grafts'], 'ileus': ['Postprocedural intestinal obstruction'], 'lumbar pain': ['Other intervertebral disc degeneration, lumbar region'], 'snapped low back': ['Other intervertebral disc degeneration, lumbar region'], 'right lower back pain': ['Other intervertebral disc degeneration, lumbar region']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril Attending: ___ ___ Complaint: Perirectal abscess Major Surgical or Invasive Procedure: Incision and drainage of perirectal abscess with placement of Malecot drain History of Present Illness: ___ w hx HTN, HLD, CAD s/p MI (___), s/p ___ placement for R lateral fistula in ano (___) p/w R sided perianal pain x 4 days. At time of EUA in ___, patient was noted to have fistula in ano from R lateral position to posterior midline through which ___ was placed. Another external opening in the R posterolateral location was found to be blind ending and a ___ drain placed to facilitate postoperative drainage. Drain fell out as planned and patient never followed up for definitive treatment. Reports that roughly every other week he develops R sided perianal pain that is alleviated by spontaneous drainage of purulent fluid. States that 4 days ago began developing worsening pain and has not had any spontaneous drainage on this occasion. Came to ED for evaluation. Surgery consult obtained. On surgery eval, patient c/o severe R sided perianal pain. Reports associated constipation with last BM 5 days ago. Also w urinary retention/hesitancy. Denies fever, chills, chest pain, shortness of breath, nausea, vomiting, blood per rectum. Past Medical History: Illness: HTN, HLD, CAD c/b MI s/p PCI/stent (___), Hx perirectal abscess s/p I&D (___) PSH: I&D perirectal abscess (___), EUA, ___ placement (___) Medications: ASA 81', metoprolol succinate ER 25' Allergies: NKDA Social History: ___ Family History: Noncontributory Physical Exam: VS: 98.5 81 140/80 146 100% RA GEN: WD, WN in NAD HEENT: NCAT, anicteric CV: RRR PULM: non-labored, no respiratory distress ABD: soft, NT, ND, no mass, no hernia RECTAL: abscess site appears to be clean and draining via malecot. Pertinent Results: ___ 06:50AM BLOOD WBC-10.9*# RBC-3.79* Hgb-11.9* Hct-35.8* MCV-95 MCH-31.4 MCHC-33.2 RDW-12.7 RDWSD-43.8 Plt ___ ___ 06:20AM BLOOD WBC-3.7*# RBC-4.05* Hgb-12.6* Hct-37.6* MCV-93 MCH-31.1 MCHC-33.5 RDW-12.3 RDWSD-42.4 Plt ___ ___ 02:05PM BLOOD WBC-14.1* RBC-4.76 Hgb-14.7 Hct-43.9 MCV-92 MCH-30.9 MCHC-33.5 RDW-12.5 RDWSD-42.5 Plt ___ ___ 02:05PM BLOOD Neuts-81.5* Lymphs-8.1* Monos-9.4 Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.52* AbsLymp-1.14* AbsMono-1.32* AbsEos-0.01* AbsBaso-0.04 ___ 06:50AM BLOOD Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 02:05PM BLOOD Plt ___ ___ 02:05PM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-136 K-3.9 Cl-100 HCO3-23 AnGap-17 ___ 02:05PM BLOOD estGFR-Using this ___ 06:50AM BLOOD ALT-29 AST-32 AlkPhos-130 TotBili-0.4 ___ 02:05PM BLOOD HoldBLu-HOLD ___ 02:05PM BLOOD LtGrnHD-HOLD ___ 02:17PM BLOOD Lactate-1.1 Brief Hospital Course: On ___, Mr. ___ underwent an I & D of his perirectal abscess in the OR under general anesthesia. Almost 1L of pus was aspirated from the abscess. The prior ___ that had been in place since ___ was removed and a Malecot was placed. He tolerated the procedure well and was extubated in the recovery room. On ___, he was febrile to 101.6 and received acetaminophen 1g IV. He had a CXR ordered which showed no acute pneumonia. He also had blood cultures sent which are still pending as of ___. The gram stain shower gram positive cocci in pairs and clusters. The wound culture contained mixed bacterial types. He was started on Unasyn on ___ but after his abscess was drained, the Unasyn was stopped. He was discharged home with services on ___ with visitation from ___ on how to flush his Malecot. His Unasyn was also stopped before he went home. He was tolerating a regular diet, pain controlled and he was passing gas. Medications on Admission: Aspirin 81 mg PO DAILY Metoprolol Succinate ER 25mg Qday Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, fever 2. Aspirin 81 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perirectal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: An abscess is a pocket of fluid near the rectum that becomes infected. The fluid usually occurs at the site of the anal glands that we all have. The fluid can become infected and require drainage. Once they are drained, they start to feel better very quickly. Most heal completely. Thirty to fifty percent of abscesses either fail to heal over the next ___ weeks or recur at some point in your lifetime. The gland that started the infection may form a fistula, which is a small tunnel connecting the anal gland to the skin of the buttocks outside the anus. Keeping your follow-up appointment is important because it allows us to determine if you develop a fistula. Wound Care You have a malecot drain that is sutured securely on your buttocks in order to drain the abscess. This drain should be flushed every day for hygiene. The dressings that are in place may be removed the following morning or at the first bowel movement. Any packing can be removed at that time or while sitting in the tub. You should expect bloody, foul drainage for several days. This is not a sterile area, and no fancy dressings are required. Dressings mostly act to prevent staining of your undergarments. Feminine mini ___ pads may be easiest to use, and simple gauze pads are also OK. Limiting the use of tape may aid in your comfort. You should begin warm soaks in the bathtub ___ tub after you remove the packing. These soaks may be helpful at relaxing the anal muscle spasms and thus decrease your pain. They may be done for ___ minutes at a time up to every four hours, but at least twice per day. The warm soaks also allow for irrigation of the abscess cavity, which will help speed healing. When in the tub, gentle finger pressure can be applied to the skin around the abscess opening to make sure that it is still completely drained. Cleansing after bowel movements must be performed gently. Baby wipes can be helpful at getting clean with little trauma. Flushable adult wipes are also available. Avoid any “medicated wipes” as these may contain witch ___ or alcohol. They will cause discomfort. Wiping can be avoided all together if one goes directly to the warm soaks after a bowel movement. Nothing needs to be added to the water. Bubbles, oils, or Epsom salts may be added if this improves your comfort or sense of cleaning. The water should not be so hot as to risk a burn injury. Bowel Regimen It is often difficult to move your bowels after anal surgery. Pain and narcotic pain medications are constipating. It is important to keep the bowels moving. The stool only becomes harder if you do not move them for days. You should eat a regular healthy diet. You should take an over-the counter stool softener (Colace [sodium docusate] 100 mg twice daily or Surfak [docusate calcium] 240 mg once daily) to keep the stools soft. It must be taken with ___ glasses of liquid throughout the day. You should also take one teaspoon dose of a fiber supplement (psyllium, Metamucil, Citrucel, Benefiber) daily to keep the bowels soft and moving. Fluids are also required for these to help. Gentle stimulant laxatives (milk of magnesia, dulcolax, senna) should be taken only if you have not moved your bowels for one or two days. At times, all three of these (stool softener, fiber, and laxative) may be required to help the bowels. It is important not to take so much that you have diarrhea. Activity No driving or working until off narcotic pain medications. Otherwise, you may return to work when you feel that you are able. Avoid activity that can cause direct trauma to the area. Your activity is limited mostly by your discomfort. Pain Medication Pain should improve every day after the drainage of the abscess. No pains should be getting worse. Increased pain at the time of bowel movements is expected. Pain can be controlled with Tylenol, ibuprofen, or a prescription pain medication. No topical ointments or topical antibiotics are required. If you were given a prescription for antibiotic pills, please take them as directed. NOTIFY THE DOCTOR IF ANY OF THE FOLLOWING OCCUR: Fever greater than 101 degrees, swelling in the area, or increased pain, as these can be signs of infection. Heavy drainage is common from these wounds. Inability to move your bowels despite the previous laxative recommendation Inability to urinate. Pain and surgery can make it hard to void. Sometimes sitting in warm soaks helps to get started. Heavy bleeding. Followup Instructions: ___

{'Severe right-sided perianal pain': ['Abscess of anal and rectal regions'], 'Constipation': ['Other constipation'], 'Urinary retention/hesitancy': ['Retention of urine', 'Urinary hesitancy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Seizures, Headaches, left frontal cavernous Malformation Major Surgical or Invasive Procedure: ___ craniotomy for RSX of Cavernous malformation History of Present Illness: Mr. ___ is a very pleasant ___ Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately ___ years ago in around ___. He has had an episode where he had twitching of the right side of his tongue, some dysarthria and that resulted into more extensive simple partial seizures. Now, this past ___, he again had a similar episode where he had twitching of the right side of his tongue and he had difficulty speaking. He is currently taking Keppra 1000 mg once a day at night. A recent CT shows some hyperdensity within the lesion that is indicative of recent hemorrhage. Given the fact that he has continuous seizures despite management of antiepileptic drugs and the vicinity of the small cavernoma to the brain surface, we think it is reasonable to remove it surgically. We will set him up for surgical resection to a preresection Wand Brain Lab MRI prior. He reviewed the risks and benefits of this operation and he is okay with preceding. Past Medical History: Left frontal cavernous malformation w/seizures & headaches Social History: ___ Family History: NC Physical Exam: On Discharge: alert, oriented x3. PERRL. Face symmetric. Tongue midline. EOM intact. Strength ___ throughout. Sensation intact to light touch. No pronator drift. Incision c/d/I with staples - no erythema. Mild L facial swelling Pertinent Results: MR HEAD W/ CONTRAST Study Date of ___ 5:16 AM IMPRESSION: 1. Unchanged appearance of a left temporal operculum 1.0 cm lesion compatible with a cavernoma with associated large developmental venous anomaly. 2. Unchanged appearance of a right posterior parasagittal 0.8 cm meningioma. Brief Hospital Course: ___ Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately ___ years ago, with recent recurrent seizure activity, who presents for elective left craniotomy for Cav Mal resection. #Inferolateral frontal lobe cavernous malformation: The patient was taken to the OR on ___ for a left craniotomy for frontal lobe cavernous malformation resection with Dr. ___. The procedure was uncomplicated, the patient was extubated and recovered in the PACU. He was closely monitored and then was transferred to the step down unit when stable. He remained neurologically intact. No postop imaging was indicated. Keppra was increased to 500 mg qAM and 1000 mg q ___. Foley was removed and he was urinating without retention. His diet was advanced and well tolerated, he was ambulating, and pain was well controlled with PO medications. He was discharged home on POD#2. Medications on Admission: Keppra 1gm Daily, lorazepam (PRN seizures), isotretinoin Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache no not take >4g acetaminophen in 24 hours from any source RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ capsule(s) by mouth every 6 hours as needed Disp #*30 Capsule Refills:*0 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 500 mg PO QAM RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills:*0 4. LevETIRAcetam 1000 mg PO QHS 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: cavernous malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Tumor Surgery • You underwent surgery to remove a Cavernous Malformation from your brain. • Please keep your incision dry until your staples are removed. • You may shower at this time but keep your incision dry. • It is best to keep your incision open to air but it is ok to cover it when outside. • Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may experience headaches and incisional pain. • You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. • You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. • Feeling more tired or restlessness is also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: • Severe pain, swelling, redness or drainage from the incision site. • Fever greater than 101.5 degrees Fahrenheit • Nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason Followup Instructions: ___

{'Seizures': ['Epilepsy'], 'Headaches': ['Hemangioma of intracranial structures', 'Nontraumatic intracerebral hemorrhage'], 'Twitching of the right side of the tongue': ['Epilepsy'], 'Dysarthria': ['Epilepsy'], 'Difficulty speaking': ['Epilepsy'], 'Hyperdensity within the lesion': ['Hemangioma of intracranial structures', 'Nontraumatic intracerebral hemorrhage']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ w choledochal cyst and GB mass s/p recent robotic CCY, CBD excision, ___, liver bed resection, fiducial placement ___ p/w fevers. His hospital course was uneventful, except that he pulled his NG tube on POD0. He recovered well and was discharged to home two days ago. The JP drain was removed the day of his discharge due to low output. His father notes that the patient had a fever of 102.8 with tachycardia today, otherwise he was doing well, had good lunch, was passing gas and moving his bowel since his discharge. The called the transplant surgery clinic and was given instruction to be admitted for further work up. ROS: (+) per HPI (-) Denies pain, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency. Past Medical History: Autism HTN ?Gout choledochalcyst,Gallbladder adenocarcinoma 1. Laparoscopic robot-assisted cholecystectomy, complete resection of common bile duct, hilar lymph node dissection, Roux-en-Y hepaticojejunostomy. 2. Laparoscopic partial hepatectomy. 3. Placement of fiducials for radiation Social History: ___ Family History: No known history of sudden cardiac death. Physical Exam: Vitals:98.5 117 136/90 97RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV:irregular, tachycardia, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, incisions healing well, no erythema or drainage Ext: No ___ edema, ___ warm and well perfused Laboratory:pending Imaging:pending Pertinent Results: ___ 04:47AM BLOOD WBC-9.5 RBC-4.01* Hgb-10.9* Hct-34.2* MCV-85 MCH-27.2 MCHC-31.9* RDW-14.4 RDWSD-44.7 Plt ___ ___ 11:55PM BLOOD WBC-15.1*# RBC-3.57* Hgb-9.7* Hct-30.0* MCV-84 MCH-27.2 MCHC-32.3 RDW-14.8 RDWSD-45.4 Plt ___ ___ 05:37AM BLOOD WBC-15.0* RBC-3.59* Hgb-9.6* Hct-30.1* MCV-84 MCH-26.7 MCHC-31.9* RDW-14.8 RDWSD-45.1 Plt ___ ___ 05:37AM BLOOD ___ ___ 05:37AM BLOOD Glucose-112* UreaN-10 Creat-1.2 Na-137 K-3.6 Cl-102 HCO3-20* AnGap-19 ___ 06:10AM BLOOD ALT-79* AST-57* AlkPhos-260* TotBili-1.3 ___ 05:37AM BLOOD ALT-74* AST-55* AlkPhos-264* TotBili-1.2 All BLOOD CULTURE URINE All INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Brief Hospital Course: ___ y.o.M s/p recent lap/robotic CCY, CBD excision, GB fossa excision w/ fever at home to 102 and cough per patient's father. He was admitted to the ___ service and pan cultured. IV antibiotics were started (Vanco/zosyn). He remained with low grade temps overnight to 100.7 during the following day. PE was negative and CT w/o discrete fluid collection. Blood and urine cultures were pending. He felt well the following day and was eating well. Labs were unremarkable except for persistent elevated WBC to 15, LFTS with alk phos 264 and t.bili 1.5. He was started on Ursodiol. Given that he felt well and remained with only low grade temps, he was discharged to home on Cipro 500mg bid for 7 days. He will f/u with Dr. ___ on ___. Nightingale ___ was resumed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 200 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Warfarin 5 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Colchicine 0.6-1.2 mg PO ASDIR 6. Diazepam 5 mg PO DAILY:PRN anxiety Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Pantoprazole 40 mg PO Q24H 3. Warfarin 5 mg PO DAILY 4. Acetaminophen 650 mg PO Q8H:PRN pain/headache 5. Ciprofloxacin HCl 500 mg PO Q12H fever of unknown origin Duration: 7 Doses RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Colchicine 0.6-1.2 mg PO ASDIR 7. Diazepam 5 mg PO DAILY:PRN anxiety 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Ursodiol 300 mg PO BID RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr ___ office at ___ if you develop fever (temperature of 101 or greater), shaking chills, nausea, vomiting, jaundice, diarrhea, constipation, inability to tolerate food or medications, abdomen distension, you have swelling in your ankles, the incision has fluid leaking, bleeding or redness around the incision site or any other concerning symptoms. You have been prescribed Ciprofloxacin (antibiotic) for 7 days Keep incision covered if out in sun to prevent sunburn/scarring. No lifting more than 10 pounds. No straining You may shower, allow water to run over the incision and pat the aresa dry. No lotion or powder near the incision. No tub baths or swimming Continue all home medications as you have been prescribed. Please follow up with your PCP for INR check on _____________ Followup Instructions: ___

{'Fever': ['Postprocedural fever'], 'Tachycardia': ['Postprocedural fever'], 'Autism': ['Autistic disorder'], 'HTN': ['Unspecified essential hypertension'], 'Gout': [], 'Choledochal cyst': [], 'Gallbladder adenocarcinoma': [], 'Laparoscopic robot-assisted cholecystectomy': [], 'Laparoscopic partial hepatectomy': [], 'Placement of fiducials for radiation': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Choledochal cyst with gallbladder carcinoma. Major Surgical or Invasive Procedure: ___ 1. Laparoscopic robot-assisted cholecystectomy, complete resection of common bile duct, hilar lymph node dissection, Roux-en-Y hepaticojejunostomy. 2. Laparoscopic partial hepatectomy. 3. Placement of fiducials for radiation. History of Present Illness: ___ man who presented with cholangitis to the ICU, at which time a long distal biliary stricture was identified and an ERCP stent was placed. The patient was found to have extrahepatic biliary ductal dilatation at the pancreatic head with a long, anomalous pancreaticobiliary junction and a very dilated cystic duct. The gallbladder and cystic duct appeared to contain intraluminal mass, although cytology has been negative for carcinoma. The patient is now taken to the operating room for minimally invasive, robotic-assisted resection of the gallbladder extrahepatic bile duct. Past Medical History: Autism HTN ?Gout Social History: ___ Family History: No known history of sudden cardiac death. Pertinent Results: ___ 04:47AM BLOOD WBC-9.5 RBC-4.01* Hgb-10.9* Hct-34.2* MCV-85 MCH-27.2 MCHC-31.9* RDW-14.4 RDWSD-44.7 Plt ___ ___ 04:47AM BLOOD ___ PTT-27.7 ___ ___ 04:47AM BLOOD Glucose-114* UreaN-11 Creat-1.2 Na-140 K-3.7 Cl-105 HCO3-22 AnGap-17 ___ 09:00PM BLOOD ALT-120* AST-140* AlkPhos-91 TotBili-0.8 ___ 04:47AM BLOOD ALT-77* AST-59* AlkPhos-214* TotBili-1.3 Brief Hospital Course: On ___, he underwent laparoscopic robot-assisted cholecystectomy, with complete resection of common bile duct, hilar lymph node dissection, Roux-en-Y hepaticojejunostomy, laparoscopic partial hepatectomy and placement of fiducials for radiation for choledochal cyst with gallbladder carcinoma. Surgeons were Drs ___ and ___. Please refer to operative notes for details. Immediately postop, the patient pulled out his NG. This was not replaced. He was kept npo until postop day 2 when sips were started. Over subsequent days, diet was advanced and tolerated. He was passing flatus and had 2 BMs on ___. JP drain output was non-bilious and decreased to 15cc/day. The JP was removed on ___. LFTs increased mildly as expected postop. The incision was intact without redness/drainage. Vital signs were notable for sinus tachycardia responice to IV metoprolol. This was later changed to his home dose of extended release metoprolol. Warfarin at home dose (5mg) was resumed for h/o afib. His PCP was contact to resume care of coumadin management. He was oob to chair with assist of one. ___ cleared him for home with rolling walker. He was ambulatory and appeared comfortable. He refused pain medication and was given intermittent doses of tylenol. He as ready for discharge on postop 5. Nightingale ___ was arranged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6-1.2 mg PO BID:PRN pain 2. Diazepam 5 mg PO QHS:PRN insomnia 3. Pantoprazole 40 mg PO Q24H 4. Warfarin 5 mg PO DAILY16 5. Metoprolol Succinate XL 200 mg PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 200 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Warfarin 5 mg PO DAILY16 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 6. Colchicine 0.6-1.2 mg PO BID:PRN pain 7. Diazepam 5 mg PO QHS:PRN insomnia 8. Rolling Walker Diagnosis: postop weakness Length of need: 3 months Supply: 1 Refill: none Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: choledochal cyst and gallbladder mass h/o Afib 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 Dr ___ office at ___ if you develop fever (temperature of 101 or greater), shaking chills, nausea, vomiting, jaundice, diarrhea, constipation, inability to tolerate food or medications, abdomen distension, you have swelling in your ankles, the incision has fluid leaking, bleeding or redness around the incision site or any other concerning symptoms. Keep incision covered if out in sun to prevent sunburn/scarring. No lifting more than 10 pounds. No straining You may shower, allow water to run over the incision and pat the aresa dry. No lotion or powder near the incision. No tub baths or swimming Continue all home medications as you have been prescribed Followup Instructions: ___

{'choledochal cyst': ['Malignant neoplasm of gallbladder'], 'gallbladder mass': ['Malignant neoplasm of gallbladder'], 'cholangitis': ['Acute and chronic cholecystitis'], 'extrahepatic biliary ductal dilatation': ['Acute and chronic cholecystitis'], 'anomalous pancreaticobiliary junction': ['Acute and chronic cholecystitis'], 'dilated cystic duct': ['Acute and chronic cholecystitis'], 'intraluminal mass': ['Malignant neoplasm of gallbladder'], 'Autism': [], 'HTN': ['Unspecified essential hypertension'], '?Gout': ['Gout'], 'sinus tachycardia': ['Atrial fibrillation'], 'afib': ['Atrial fibrillation'], 'postop weakness': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Sulfamethoxazole / Penicillins Attending: ___. Chief Complaint: arrest of descent, gHTN, incisional cellulitis with wound abscess Major Surgical or Invasive Procedure: primary low transverse cesarean section History of Present Illness: Patient is a ___ year-old G3P0 with EDC = ___ (EGA = 37w1d on ___ with elevated blood pressures in the office as high as 140/70 over the past week. Repeat BP in OB triage = 142/70, 141/72, 139/85. PIH labs on ___ showed: CBC 15.6 > 10.6 / 30.3 < 312 ALT 21 Cr 0.5 Uric Acid 5.0 UP:C 0.1 She currently denies headache, visual changes, epigastric or RUQ pain. Denies ctx, VB, LOF. +FM Past Medical History: MEDICAL HISTORY Allergies (Last Verified ___ by ___: Penicillins Sulfamethoxazole --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs every four (4) hours PRN BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day PNV WITH CALCIUM ___ [PRENATAL VITAMINS LOW IRON] - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth once per day, as needed, for constipation --------------- --------------- --------------- --------------- Problems (Last Verified ___ by ___, MD): ASTHMA, EXTRINSIC W/ ACUTE EXACERBATION 493.02 ECZEMATOUS DERMATITIS H/O TOBACCO USE 305.1 Surgical History (Last Verified ___ by ___, MD): Surgical History updated, no known surgical history. Family History (Last Verified ___ by ___, MD): Relative Status Age Problem Comments Other ASTHMA V17.5 F/H GI MALIGNANCY V16.0 Social History: ___ Family History: NC Physical Exam: VSS Gen: NAD Lungs: CTA CV: RRR Abd: 2cm opening on right side of incision with packing, erythema improved from prior, no pus Ext: 1+ pitting edema bilaterally with no calf tenderness Brief Hospital Course: The patient is a ___ G3, P0 at 37 weeks 4 days admitted for induction of labor due to gestational hypertension. After a prolonged induction, the patient progressed to fully dilated and +2 station. However, after 5 hours fully dilated and ___ hours pushing, there was no descent of the fetal head and significant caput was noted. The patient was recommended to undergo delivery via cesarean section. She experienced a PPH with EBL 1200cc from cervical extension, but remained stable postpartum. In terms of her gestational hypertension, she had normal labs. She was started on labetalol 200mg BID on ___, which was increased to 300mg BID on ___ for elevated pressures. During her postpartum course she developed an incisional cellulitis with wound abscess. She was noted to have erythema and induration on right side of incision and extending to mons. She was started on IV gent/clinda -> PO clindamycin started ___ ___, 10d course. She incision was opened at bedside ___ and she underwent BID wet to dry dressing changes. She had a wound culture with mixed flora, a negative urine culture, and blood cultures with no growth. Patient also experienced bilateral lower extremity edema during her stay that she found very bothersome. She received Lasix 20mg PO x1, with improvement of symptoms. She was also maintained on Lovenox 40mg daily. She was discharged on ___ in stable condition with plan for outpatient ___ for BID dressing changes and blood pressure monitoring. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO DAILY:PRN constipation 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs Q4H:PRN wheezing Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma 2. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 5. Clindamycin 450 mg PO Q6H Duration: 10 Days RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs Disp #*108 Capsule Refills:*0 6. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs Disp #*30 Tablet Refills:*0 8. Labetalol 300 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 9. Prenatal Vitamins 1 TAB PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS Q4H:PRN wheezing Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: primary low transverse cesarean section gestational hypertension asthma arrest of descent endometritis, cellulitis, wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: pelvic rest x 6 weeks until postpartum visit no heavy lifting or driving x 2 weeks keep incision clean and dry Followup Instructions: ___

{'elevated blood pressures': ['Gestational [pregnancy-induced] hypertension without significant proteinuria'], 'headache': [], 'visual changes': [], 'epigastric or RUQ pain': [], 'ctx': [], 'VB': [], 'LOF': [], '+FM': [], 'arrest of descent': ['Long labor'], 'gHTN': ['Gestational [pregnancy-induced] hypertension without significant proteinuria'], 'incisional cellulitis with wound abscess': ['Cellulitis of abdominal wall', 'Cutaneous abscess of abdominal wall', 'Infection of obstetric surgical wound'], '1+ pitting edema bilaterally with no calf tenderness': ['Edema']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Sulfasalazine Attending: ___. Chief Complaint: Pelvic pain, ruptured ectopic pregnancy Major Surgical or Invasive Procedure: L/s as above. History of Present Illness: 37 g2po (tab1) presents as transfer from ___ for early pregnancy, ___ constant LLQ. Pt s/p RSO. U/s demonstrated enlarged hyperstimulated left ovary w/ nl flow. S/p IVF, VOR ___, UT ___ embryos transferred. Past Medical History: GYN: IF, ovarian cysts PMH: None PSH: L/S, RSO, for ovarian cyst, ___ MEDS: none ALL: sulfa -hives Social History: ___ Family History: Noncontributory Physical Exam: VSS at ED. BP 100/60, P70. Appeared in no distress.COR RRR, PULM CTAB, abd mildly distended, moderately tender, no rbnd, no guarding. Ext w/o edema. Pertinent Results: Hct 29% (down from 37%). Labs otherwise unremarkable. TV u/s, preliminary read: Left adnexal mass likely hematoma adjacent to the massive left ovary (hyperstimulated). Single viable intrauterine gestation (7wks), a second intrauterine ___ is nonviable. Brief Hospital Course: PREOP DX: Pelvic pain, possible ruptured heterotopic pregnancy vs ruptured adnexal cyst POST OP DX: Ruptured left tubal ectopic pregnancy PROCEDURE: Operative l/s, removal of EP, left salpngectomy ___ ASST: ___: Gen FINDINGS: 1- 150 cc hemoperitoneum 2- 150 cc clot 3- Left FT - ruptured an bleeding at ventral surface ampulla with surrounding clot and presumed gestational tissue. 4 - Enlarged hyperstimulated left ovary w/ normal and vascularized appearance before, during and at the end of case 5 - Surgically absent right FT and ovary 6 - Adhesions of large bowel to LLQ side wall 7 -Enlarged uterus c/w 7 wks GA IVF: ___ cc; 500 cc Hespan U/O:330 cc EBL:350 COMPLICATIONS: none SPECIMEN: Left FT, EP, clot DISPO: Stable to PACU INPATIENT NOTE - ___ SUMMARY Pt seen at ___ontrolled, DTV, no specific complaints. VSS w/ BP 100-110/ 50-60, p70. Exam w/ clear lungs, regular HR, abd mildly distended, mildly tender, incision C/d/i though ecchymosis noted at ___ port site. Labs notalble for : HCT 5 AM 19.7 9 AM 22.4 1PM 21.1 6PM 20 Diet advanced once Hct determined to be stable. TV u/s to be done bedside by residents to assess IU pregnancy viabilit Medications on Admission: None Discharge Medications: 1. Polysaccharide Iron Complex ___ mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp:*0 Tablet(s)* Refills:*0* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ruptured heterotopic pregnancy with concomittant intrauterine pregnancy. Discharge Condition: Excellent. Discharge Instructions: Activity as tolerated; Niferex 2x day; Tylenol as needed. Followup Instructions: ___

{'Pelvic pain': ['Tubal pregnancy with intrauterine pregnancy'], 'Ruptured ectopic pregnancy': ['Tubal pregnancy with intrauterine pregnancy'], 'Hematoma': ['Tubal pregnancy with intrauterine pregnancy'], 'Moderately tender abdomen': ['Tubal pregnancy with intrauterine pregnancy'], 'Left lower quadrant pain': ['Tubal pregnancy with intrauterine pregnancy'], 'Enlarged hyperstimulated ovary': ['Tubal pregnancy with intrauterine pregnancy'], 'Vaginal bleeding': ['Tubal pregnancy with intrauterine pregnancy'], 'Hypotension': ['Acute posthemorrhagic anemia'], 'Anemia': ['Anemia of mother'], 'Adnexal mass': ['Tubal pregnancy with intrauterine pregnancy'], 'Ruptured adnexal cyst': ['Tubal pregnancy with intrauterine pregnancy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol Attending: ___. Chief Complaint: melana Major Surgical or Invasive Procedure: EGD History of Present Illness: ___ with h/o CHF and GIB. Patient was discharged 1 day PTA for GI bleeding. See the discharge summary for that admission for details. In brief, the patient had angioectasia that required cauterization after his INR was 1.5 or less which was done today. The procedure was uncomplicated, but they noted a significant amount of fresh blood in his stomach and his HCT was 25. He was admitted for observation. Of note, the patient was having symptoms of shortness of breath later today before the procedure when walking up there stairs. This was not present after discharge. No CP, palp, melena, hematemsis, or abd pain. ROS:a complete ROS was obtained and negative except for those mentioned above. Past Medical History: -CAD s/p bare metal stent x2 in ___ -Hypertension -Ischemic cardiomyopathy Systolic dysfunction (EF 35%-40% ___ -Dual chamber pacemaker -h/o VF s/p ICD for secondary prevention -Chronic atrial fibrillation -Rectal cancer s/p neoadjuvant chemotherapy, resection and adjuvant chemotherapy for positive LNs found at surgery -BPH -h/o stroke in ___ with residual R hand dysthesia -Cervical spondylosis -Sleep apnea, only uses CPAP intermittently -h/o gastritis ___ year ago -insomnia, has been using chamomile tea and melatonin with minimal relief Social History: ___ Family History: Father died of an MI in his ___, Mother died of a PE in her ___, twin sister died of colitis age ___, no family h/o colon, breast, uterine, or ovarian CA Physical Exam: 96.6 98/58 70 20 98RA NAD, awake, alert, oriented x 3 OP clear, conjunctiva w/o pallor RRR, nml S1 S2, has II/VI holosystolic murmer at apex lungs clear bilaterally abd soft NT, ostomy wnl ___ warm, well perfused with 1+ ___ edema bilaterally strength and sensation intact throughout Pertinent Results: ___ 02:05PM HCT-25.5* ___ 10:15AM SODIUM-132* POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13 ___ 10:15AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.2 ___ 10:15AM ___ Brief Hospital Course: ___ with h/o CHF p/w GI bleeding. . Primary Diagnosis: 285.1 ANEMIA, ACUTE BLOOD LOSS Secondary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS The patient was electively admitted for an EGD(see HPI) that demonstrated there had been active bleeding in the stomach. Cauterization of the angioectasia was performed with achievement of hemostasis. The patient was given 1 U RBC's for symptomatic anemia with appropriate HCT increased to 30. He was discharged the following day without any evidence of bleeding. He will continue PPI bid, holding ASA/Coumadin until f/u with PCP in the middle of next week to have his HCT checked. . Secondary Diagnosis: 414.01 CAD, NATIVE VESSEL BB continued. ASA held as above. . Secondary Diagnosis: 428.20 HEART FAILURE, (A3) CHRONIC SYSTOLIC Patient was discharged on lasix, but by exam he appears a bit more volume up. ___ have been from blood, IVF, and holding diuretics on last admission. Gave 1 dose IV lasix with blood with good effect. He was discharged on lasix 40 qAM and 20qPM(a previous dosing for him) with f/u lytes in 5 days. . Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN on BB/ACEI . Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) PPI as above. . Secondary Diagnosis: 585.3 CHRONIC KIDNEY DISEASE, STAGE III (___) stable Medications on Admission: 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 285.1 ANEMIA, ACUTE BLOOD LOSS Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION Secondary Diagnosis: 414.01 CAD, NATIVE VESSEL Secondary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Secondary Diagnosis: 585.3 CHRONIC KIDNEY DISEASE, STAGE III (___) Secondary Diagnosis: 153.9 MALIGNANT NEOPLASM, COLON Secondary Diagnosis: 428.23 HEART FAILURE, (A2) ACUTE ON CHRONIC SYSTOLIC Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: As we discussed, you were admitted for bleeding in your stomach. An intervention was performed to stop that bleeding and your blood counts have been stable. As before, please be aware of the signs and symptoms of bleeding and call your doctor or return to the ER if these occur. Please continue the omeprazole at the higher dose. We have also increased the dose of your lasix to 40 in the morning and 20 at night. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please do not take your aspirin or coumadin until directed by your doctor. Followup Instructions: ___

{'shortness of breath': ['Acute on chronic systolic heart failure', 'Congestive heart failure'], 'melena': ['Angiodysplasia of stomach and duodenum with hemorrhage'], 'GI bleeding': ['Angiodysplasia of stomach and duodenum with hemorrhage', 'Esophageal reflux'], 'h/o CHF': ['Acute on chronic systolic heart failure', 'Congestive heart failure'], 'h/o gastritis': ['Esophageal reflux'], 'insomnia': ['Obstructive sleep apnea (adult)(pediatric)'], 'BPH': ['Benign prostatic hyperplasia'], 'stroke': ['Other late effects of cerebrovascular disease'], 'colitis': ['Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus'], 'CAD': ['Coronary atherosclerosis of native coronary artery'], 'hypertension': ['Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified'], 'atrial fibrillation': ['Atrial fibrillation'], 'anemia': ['Acute posthemorrhagic anemia'], 'sleep apnea': ['Obstructive sleep apnea (adult)(pediatric)'], 'cervical spondylosis': ['Cervical spondylosis without myelopathy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Phenothiazines / Epinephrine / ppi / Nitrous Oxide / Benadryl / Protonix Attending: ___ Chief Complaint: rectocele Major Surgical or Invasive Procedure: posterior repair History of Present Illness: She is a ___ patient who presents with ___ rectocele after having a sacral colpopexy and supracervical hysterectomy in ___ for uterine prolapse and cystocele. At that time, she had no rectocele at all. She has symptoms of bulge and pressure in the vagina that has gotten worse over the past few months. She also complains of feeling of incomplete emptying. She states that after she goes to the bathroom, she could go back and urinate some more. She had some frequency, urgency symptoms, which had resolved postoperatively. She also has resolved diarrhea after being started on Zenpep. She is followed by Dr. ___ and her fecal incontinence has resolved as well as resolved diarrhea. Past Medical History: Past Medical History: She is a breast cancer survivor, anxiety, arthritis, acid reflux, low back pain, and osteopenia. Past Surgical History: Modified radical mastectomy with reconstruction in ___, vaginal hysterectomy, BSO in ___ for prolapse, Dr. ___ lysis of adhesions, ___ sacral colpopexy, cystoscopy, and TVT in ___. Past OB History: She has had three vaginal deliveries. Social History: ___ Family History: Family History: Positive for heart disease. Mitral valve prolapse in the mother. Father with esophageal cancer. Physical Exam: On admission: General: Well developed, well groomed, thin. Psych: Oriented x3, affect is normal. Skin: Warm and dry. Heart: No peripheral edema or varicosities. Lungs: Normal respiratory effort. Abdomen: Soft, nontender, not distended. No masses, guarding, or rebound. No hernias. Genitourinary: Vulva: Normal hair pattern, no lesions. Urethral Meatus: No caruncle, no prolapse. Urethral meatus nontender, no masses or exudate. Bladder: Moderately atrophic. She is on vaginal estrogen with Vagifem in particular. Caliber and resting tone are normal. There is a stage III rectocele. The anterior wall and apex were extremely well supported. The bladder is nonpalpable and nontender. Cervix is absent as of the uterus and adnexa. No masses in the anus or perineum. Pertinent Results: No labs during this hospitalization. Brief Hospital Course: Ms ___ underwent an uncomplicated posterior repair for stage III rectocele; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication. Medications on Admission: BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply to affected area(s) daily as directed CLONAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth three times a day as needed for prn ESTRADIOL [VAGIFEM] - 10 mcg Tablet - 2 twice per week for maintenence IBANDRONATE [BONIVA] - 150 mg Tablet - 1 Tablet(s) by mouth every month LIPASE-PROTEASE-AMYLASE [ZENPEP] - 20,000 unit-68,000 unit-109,000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth with meals one with snacks SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth up to four times per day SUMATRIPTAN SUCCINATE - 100 mg Tablet - 1 Tablet(s) by mouth first sign of headahce can repeat in two hours if needed ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] GLUCOSAMINE ___ 2KCL-CHONDROIT [GLUCOSAMINE SULF-CHONDROITIN] MICONAZOLE NITRATE - (BID TO AFFECTED AREA) MULTI VIT W MN-FA-LYCO-LUT-ALA Discharge Medications: 1. Clonazepam 0.5 mg PO TID:PRN anxiety 2. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q8 hours Disp #*30 Tablet Refills:*2 3. Sucralfate 1 gm PO TID 4. Zenpep *NF* (lipase-protease-amylase) 20,000-68,000 -109,000 unit Oral with meals Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 2 tab with meals 5. Simvastatin 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: rectocele Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

{'bulge': ['Rectocele'], 'pressure in the vagina': ['Rectocele'], 'feeling of incomplete emptying': ['Rectocele'], 'frequency': ['Rectocele'], 'urgency': ['Rectocele']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Phenothiazines / Epinephrine / ppi / Nitrous Oxide Attending: ___ Chief Complaint: urinary frequency and urgency Major Surgical or Invasive Procedure: robotic sacrocolpopexy Tension free vaginal tape Cystoscopy History of Present Illness: Ms. ___ presented for evaluation of urinary complaints and after review of records and cystocopy was diagnosed with a stage III cystocele and stage I vaginal prolapse, both of which were symptomatic. She also had severe vaginal atrophy despite being on Vagifem. Treatment options were reviewed for prolapse including no treatment, pessary, and surgery. She elected for surgical repair. All risks and benefits were reviewed with the patient and consent forms were signed. Past Medical History: PAST MEDICAL HISTORY: 1. Breast cancer survivor, diagnosed in ___, status post mastectomy, chemotherapy, and tamoxifen treatment. 2. Anxiety. 3. Arthritis. 4. Acid reflux. 5. Low back pain. 6. Osteopenia. 7. Vaginal prolapse. PAST SURGICAL HISTORY: 1. Modified radical mastectomy with reconstruction in ___. 2. Vaginal hysterectomy and bilateral salpingo-oophorectomy in ___ for prolapse, Dr. ___ at ___. PAST OB HISTORY: Twelve number of pregnancies, three number of vaginal deliveries, two number of living children, two number of miscarriages, birth weight of largest baby delivered vaginally 7 pounds 2 ounces, positive for forceps-assisted vaginal delivery, negative for vacuum-assisted vaginal delivery. Menopause: Surgical menopause in ___. Social History: ___ Family History: Mother, heart disease and mitral valve prolapse; father, esophageal cancer; maternal grandfather, asthma; paternal grandmother, stomach cancer. Physical Exam: On postoperative check: VS 97.6 106/70 72 18 100% on 1.5L NC OR/PACU I/O 100PO + 2550 IVF / 420UOP + EBL 100 A+O, NARD RRR, CTAB Abd soft, obese, no TTP, +BS, no R/G Robot port sites with surrounding ecchymosis (all ~2cm in diameter) Dermabond intact, well approximated without erythema/exudate Pad with minimal VB Foley with CYU Ext NT, pboots on Pertinent Results: ___ 07:32AM BLOOD WBC-5.3 RBC-3.73* Hgb-10.9* Hct-33.1* MCV-89 MCH-29.1 MCHC-32.8 RDW-13.0 Plt ___ Brief Hospital Course: Ms. ___ underwent an uncomplicated robotic sacrocolpopexy, TVT, and cystoscopy for stage 3 pelvic organ prolapse and stress urinary incontinence; please see the operative report for full details. Her postoperative course was uncomplicated. She was discharged on postoperative day 1 in good condition after passing her trial of void and meeting all postoperative milestones. Medications on Admission: clonazepam 0.5 TID prn, ibandronate 150 q month, naratriptan 2.5 prn h/a, simvastatin 40', sucralfate 1g TID, ASA (held), vagifem, vitamins allergies: phenothyazides, compazine (anaphy) Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pt request. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 12 tabs in any 24 hr period. do not take if dizzy or lightheaded. Disp:*20 Tablet(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain or pt request. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: pelvic organ prolapse stress urinary incontinence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. - Please call if you have redness and warmth around the incisions, if your incisions are draining pus-like or foul smelling discharge, or if your incisions reopen. - No driving while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below. Followup Instructions: ___

{'urinary frequency and urgency': ['Cystocele', 'Mixed incontinence (female)'], 'vaginal atrophy': ['Cystocele'], 'breast cancer': ['Personal history of malignant neoplasm of breast']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Percocet Attending: ___. Chief Complaint: Right leg/foot pain Major Surgical or Invasive Procedure: ___ Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. ___ Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. History of Present Illness: ___ w Rt AK pop to ___ bypass with NRGSV for a thrombosed popliteal aneurysm in ___ present with worsening new onset right foot claudication. Past Medical History: PMH: DVT R pop v (___), asthma, Rt pop artery thrombus with negative hypercoagulable workup PSH: Rt AK pop to ___ bypass with NRGSV ___ Physical Exam: Physical Exam: Alert and oriented x 3 VS:BP 104/54 HR 72 RR 16 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: palp throughout. Feet warm, well perfused. No open areas Left groin puncture site: Dressing clean dry and intact. Soft, no hematoma or ecchymosis. Pertinent Results: ___ 05:45AM BLOOD WBC-9.0 RBC-3.91 Hgb-11.5 Hct-34.2 MCV-88 MCH-29.4 MCHC-33.6 RDW-12.9 RDWSD-40.8 Plt ___ ___ 05:45AM BLOOD Plt ___ ___ 05:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-107 HCO3-26 AnGap-12 ___ 05:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 Arterial Duplex: Findings. Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right the tibial waveforms are monophasic and there is no audible Waveforms are flat. The left all waveforms are triphasic. The ankle-brachial index is 1.3. Impression severe ischemia right lower extremity Brief Hospital Course: ___ sp Rt AK pop to ___ bypass with NRGSV ___ for arterial thrombosis presents with worsening right leg pain that occurred over predictable distances and acute change over past 24 hours with fullness in her right leg. Her motor and sensation are intact with no signs of limb threat. A heparin infusion was started. Arterial duplex showed occluded right popliteal to posterior tibial artery bypass. She was taken to the OR for right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. A tpa catheter was left in place overnight. She return the next day for right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft and balloon angioplasty of outflow stenosis. At that session, we were able to remove residual thrombus in the native right popliteal artery and bypass with good outflow to the foot via the anterior tibial, and peroneal arteries. At this point she was pain free with a palpable graft AT and DP pulse. The next morning, we discontinued the heparin infusion and started xarelto. She was ambulatory ad lib, voiding qs and tolerating a regular diet. She was discharged to home. We will see her again in followup in one month with surveillance duplex. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05% Soln 1 Appl TP BID 2. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN 3. metroNIDAZOLE 0.75 topical BID 4. ALPRAZolam 0.5 mg PO TID:PRN anxiety 5. Lovastatin 10 mg ORAL DAILY 6. Montelukast 10 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY 8. Pantoprazole 40 mg PO Q24H 9. Aspirin 81 mg PO DAILY 10. Loratadine 10 mg PO BID Discharge Medications: 1. Rivaroxaban 15 mg PO/NG BID FOR THE NEXT 3 WEEKS ONLY. RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily Disp #*42 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY For the next ___ days. RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. metroNIDAZOLE 0.75 topical BID 4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN 5. Clobetasol Propionate 0.05% Soln 1 Appl TP BID 6. ALPRAZolam 0.5 mg PO TID:PRN anxiety 7. Aspirin 81 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY 9. Loratadine 10 mg PO BID 10. Montelukast 10 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Rivaroxaban 20 mg PO DAILY Start ___ after loading dose of 15 mg twice daily. RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 13. Lovastatin 10 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Peripheral Arterial Disease Right Posterior Tibial Deep Vein Thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted to the hospital with right leg pain that we found was secondary to a blockage in your bypass graft. We also noted a clot in a vein in your calf. We did a peripheral angiogram to open up the graft with special catheter and balloons. To do the procedure, a small puncture was made in one of your arteries. The puncture site heals on its own: there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Peripheral Angiography Puncture Site Care For one week: •Do not take a tub bath, go swimming or use a Jacuzzi or hot tub. •Use only mild soap and water to gently clean the area around the puncture site. •Gently pat the puncture site dry after showering. •Do not use powders, lotions, or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one-two weeks. Activity For the first 48 hours: •Do not drive for 48 hours after the procedure For the first week: •Do not lift, push , pull or carry anything heavier than 10 pounds •Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing, sneezing, or moving your bowels. After one week: •You may go back to all your regular activities, including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! Followup Instructions: ___

{'Right leg/foot pain': ['Thrombosis due to vascular prosthetic devices, implants and grafts', 'Acute embolism and thrombosis of right tibial vein', 'Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication'], 'Worsening new onset right foot claudication': ['Thrombosis due to vascular prosthetic devices, implants and grafts', 'Acute embolism and thrombosis of right tibial vein', 'Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication'], 'Fullness in her right leg': ['Thrombosis due to vascular prosthetic devices, implants and grafts', 'Acute embolism and thrombosis of right tibial vein', 'Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication'], 'Severe ischemia right lower extremity': ['Thrombosis due to vascular prosthetic devices, implants and grafts', 'Acute embolism and thrombosis of right tibial vein', 'Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Watery diarrhea, LLQ Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ presenting with epigastic pain and watery diarrea. Pt was in her usual state of health until last evening. Pt had a ___ burger and ___ for dinner. States she tossed and turned in bed overnight and awoke at 6am with worsening abdominal bloating. Pt states she first experienced watery diarrhea at 7am and had >10 episodes throughout the morning. She states she had pain beginging at around 9am. She states the pain is worse in LLQ when compared to RLQ. Denies recent travel, no recent fresh water ingestion. No other individuals had similar symptoms. No fevers, chills. . In the ED, initial VS 99.6 ___ 16. Exam notable for LLQ tenderness and adnexal tenderness without cervical motion tenderness, guiac - trace positive. Labs notable for WBC 16.9, lactate of 3.1 which improved to 1.4. UCG negative. The pt underwent transvaginal u/s (normal ovaries and uterus. no evidence of torsion) and a CT scan that was unrevealing. The pt was seen by surgery that stated there was no urgent surgical need. The pt received IVF, Zofran, Compazine and Dilaudid. Vitals prior to transfer were stable. . On ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, constipation, +BRBPR with hx of hemorrhoids, no melena, hematochezia, dysuria, hematuria. Past Medical History: # Frequent URIs, ?prior PNA # asthma (last on steroids ___ year ago) # Sinusitis, # Seasonal allergies Social History: ___ Family History: Her father has a history of asthma. Physical Exam: VS: 98.7 123/75 92 20 99RA GENERAL: Well-appearing female in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: Tachycardic, RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: +Epigastic tenderness LLQ>RLQ. No rebound or guarding. +BS. No masses or HSM, no rebound/guarding. Negative ___ sign. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. RECTAL: Normal Tone, Guaiac negative, yellowish stool Pertinent Results: Admission Labs: ___ 12:50PM WBC-16.9* RBC-4.75 HGB-14.6 HCT-44.6 MCV-94 MCH-30.6 MCHC-32.6 RDW-13.2 ___ 12:50PM NEUTS-90* BANDS-0 LYMPHS-8* MONOS-2 EOS-0 BASOS-0 ___ MYELOS-0 ___ 12:50PM LIPASE-48 ___ 12:50PM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-57 TOT BILI-0.9 ___ 01:00PM GLUCOSE-95 LACTATE-3.1* NA+-137 K+-3.8 CL--108 TCO2-17* ___ 01:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 07:00PM LACTATE-1.___ with hx of seasonal allergies here with 1d hx of watery diarrhea and abdominal pain. She was diagnosed with Clostridium difficile-associated diarrhea and treatment with oral metronidazole was initiated, to which she responded well. Her symptoms had resolved and she was tolerating regular diet at the time of discharge. Medications on Admission: Zantac OCP Discharge Medications: 1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for c. difficile for 14 days. Disp:*33 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Clostridium difficile diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for abdominal pain and diarrhea. You were found to have an infection called C. difficile diarrhea. You were treated with antibiotics called metronidazole which you should continue for a full 14 day course. It is important that you finish the full course of antibiotics. Do not consume alcohol while taking metronidazole. You were also evaluated for viral studies which showed.... Followup Instructions: ___

{'watery diarrhea': ['Intestinal infection due to Clostridium difficile'], 'epigastric pain': ['Intestinal infection due to Clostridium difficile'], 'abdominal bloating': ['Intestinal infection due to Clostridium difficile'], 'LLQ tenderness': ['Intestinal infection due to Clostridium difficile'], 'adnexal tenderness': ['Intestinal infection due to Clostridium difficile']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: left hip fracture Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with hx of HTN and Meningioma presents from ___ with a fractured right hip while on vacation in ___. The patient states that she suffered a mechincal fall while on vacation 8 days ago. The pt states she underwent a surgical intervention (ORIF) in ___ and has been treat there since that time. The patient states she has been unable to bear weight since that time. The pt denies fevers, chills, increased lower extremity swelling, chest pain or pleuritic pain. . Upon arrival to the ED intial vitals 98.5 131/74 106 18 98% RA. Exam notable for ecchymosis on left ___. Labs notable for BC of 11.6, Hct 27.2 (baseline mid to high ___. itals prior to transfer to the floor 98.8 97 120/57 16 97RA. . Upon arrival to the floor the patient has no complaints. Denies chest pain, pleuritic pain, shortness of breath or increased leg swelling. Past Medical History: # Meningioma - Dx ___ with change in mental status - s/p craniotomy ___ with Dr. ___. Remains on Dilantin for life. Followed annually by Dr. ___. MRI ___ ___ evidence of recurrence. Bone density being monitored. # Hyperparathyroidism: s/p parathyroid adenoma removal (___) with Dr. ___ has ___ with Dr. ___. Has annual followup with Dr. ___. # Hypothyroidism # Right nephrolithotomy for treatment of renal staghorn calculus. ___, hx of recurrent kidney stones, previously seen by Dr. ___. CT scan ___ residual stones were noted. # Hypertension with Renal insufficiency - Cr 1.6. # Psoriasis scalp-well controlled with Neutrogena T/Gel once or twice weekly. # Mild to moderate mitral regurgitation- repeat echocardiogram ___ MR. # Cholelithiasis-asymptomatic # Squamous cell carcinoma -anterior chest wall. No recurrence. Followed by Dr. ___ at ___ dermatology Social History: ___ Family History: Non-Contributory. No known early CAD. Physical Exam: Vitals: 98.8 97 120/57 16 97%RA Gen: NAD, AOX3 HEENT: PERRLA, EOMI, MMM, sclera anicteric, not injected, no exudates Neck: no thyromegally, JVD: Cardiovascular: RRR normal s1, s2, no murmurs, rubs or gallops. No loud P2 or appreciable RV heave. Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non-tender, non distended, no heptosplenomegally, bowel sounds present, guaiac negative Extremities: Left hip with ecchymoses. Surgical site with dressing c/d/i. Bilateral ___ stockings. ___ to palpation on skin bilaerally. No appreciable cords. Neurological: CN II-XII intact, normal attention, sensation normal, Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious Pertinent Results: ___ 08:45PM BLOOD WBC-11.6* RBC-3.00*# Hgb-9.3*# Hct-27.2*# MCV-91 MCH-31.1 MCHC-34.3 RDW-18.3* Plt ___ ___ 06:00AM BLOOD WBC-7.7 RBC-2.88* Hgb-8.8* Hct-25.9* MCV-90 MCH-30.5 MCHC-33.9 RDW-18.1* Plt ___ ___ 08:45PM BLOOD ___ PTT-22.1 ___ ___ 08:45PM BLOOD Glucose-95 UreaN-23* Creat-1.1 Na-146* K-3.6 Cl-109* HCO3-27 AnGap-14 ___ 05:50AM BLOOD Iron-41 ___ 05:50AM BLOOD calTIBC-187* VitB12-470 Folate-8.7 Ferritn-98 TRF-144* ___ 06:40PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 06:40PM URINE RBC-0 ___ Bacteri-MOD Yeast-NONE ___ Discharge: ___ 06:00AM BLOOD WBC-7.7 RBC-2.88* Hgb-8.8* Hct-25.9* MCV-90 MCH-30.5 MCHC-33.9 RDW-18.1* Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-79 UreaN-19 Creat-1.0 Na-142 K-3.7 Cl-108 HCO3-24 AnGap-14 hip XR (prelim read): No e/o acute fx or hardware complication/failure. Increased bony bridging compared to ___. Brief Hospital Course: The patient was admitted after returning from ___, as she was still having severe hip pain with movement. X-rays suggested no hardware malfunction. The Orthopedics service was consulted, who evaluated the patient and recommended rehabilitation with physical therapy. The patient was also noted to have anemia with a hematocrit drop to 27 from the mid-30s approximately 1.5 months ago. This was likely due to her fracture, as a hematoma was noted on the side of the hip without evidence of expansion during the hospitalization. Her hematocrit remained stable. and was 25 at the time of discharge. Additionally, she was found to have pyuria on urinalysis; however, the patient denied dysuria. For this reason, antibiotic treatment was deferred, although this should continue to be followded as an outpatient. Medications on Admission: Phoslo 667mg 2 capsules TID Levothyroxine 112mcg PO Daily Lisinopril 5mg PO Daily Phenytoin 100mg PO TID ASA 81mg PO Daily Calcium Citrate 250mg PO Daily Vitamin D 400mg Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Calcium Citrate 250 mg Tablet Sig: One (1) Tablet PO once a day. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: 1. hip fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were seen at ___ after a hip fracture and repair. You were evaluated by our orthopedic surgeons, who requested X-rays and then recommended that you undergo intensive physical rehabilitation. You were found to have a low red blood cell count compared to two months ago. We suspect that this was because of your fall and surgery, as it appears that you have a blood collection in your leg. We feel that this is stable and you should continue to watch this; if you see signs of increased swelling in your leg, please call your doctor. The following medications were changed during this hospitalization: ADDED tylenol for pain control ADDED oxycodone for pain control ADDED docusate for constipation ADDED senna for constipation Followup Instructions: ___

{'ecchymosis': ['Closed fracture of unspecified part of neck of femur'], 'mechanical fall': ['Unspecified fall'], 'hx of HTN': ['Unspecified essential hypertension'], 'Meningioma': ['Personal history of benign neoplasm of the brain'], 'anemia': ['Anemia'], 'unable to bear weight': ['Closed fracture of unspecified part of neck of femur'], 'fevers': [], 'chills': [], 'increased lower extremity swelling': [], 'chest pain': [], 'pleuritic pain': [], 'shortness of breath': [], 'increased leg swelling': [], 'Hypothyroidism': ['Unspecified acquired hypothyroidism'], 'Hyperparathyroidism': [], 'Right nephrolithotomy': [], 'recurrent kidney stones': [], 'Hypertension with Renal insufficiency': ['Unspecified essential hypertension'], 'Mild to moderate mitral regurgitation': [], 'Cholelithiasis': [], 'Squamous cell carcinoma': [], 'Psoriasis': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Aspirin / ibuprofen Attending: ___. Chief Complaint: Back and left leg pain Major Surgical or Invasive Procedure: L4-5 microdiscectomy History of Present Illness: THis is a ___ year old female with known herniated discs at L4-5 and L5-S1. This was first detected about ___ years ago. She initially did physical therapy which helped significantly, and she has been relatively pain free since that time. HOwever, this past week she spontaneously developed severe pack pain, radiating down her Left leg. She was seen at ___ earlier today, and was found to have persistent herniated disks at these levels. Transferred to ___ ER for further evaluation. She denies weakness, but pain to her L buttocks radiating down the posterior thigh and calf. She also reports numbness to the top of her left foot. Past Medical History: A.D.D Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAM: O: T: 98.1 BP: 92/68 HR: 83 R:18 O2Sats: 100% Gen: WD/WN, comfortable, NAD. Lying on bed with cane Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: Br Pa Ac Right ___ Left ___ Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control Pertinent Results: MRI lumbar spine ___ Shows L4-5 herniated disc with compression of L L5 nerve root. Brief Hospital Course: Pt was admitted to neurosurgery service for further evaluation and pain control. She was intially started on decadron to help with pain control and this offered no relief and she was unable to ambulate. Her physical exam showed trace ___ weakness and it was decided she would benefit from decompression. She was taken to the OR on ___ for L4-5 discectomy. She tolerated this procedure very well with no complications. Post operatively she was transferred back to the floor. On post op exam her leg pain had improved and she only complained of surgical site pain. Her strength was full on examination. She was able to ambulate without difficulty and she will be discharged home on ___ in stable condition. Medications on Admission: 1. Concerta 27mg Daily 2. Immitrex PRN 3. Codeine 4. Colace Discharge Medications: 1. Concerta 27 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO Daily (). 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: L L4-5 herniated disc Discharge Condition: AOx3. Activity as tolerated. No lifting greater than 10 pounds. Discharge Instructions: • Do not smoke • Keep wound clean / No tub baths or pools until seen in follow up/ remove dressing POD#2 / begin daily showers POD#4 • If you have steri-strips in place – keep dry x 72 hours. They will fall off on their own or be taken off in the office • No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. • Limit your use of stairs to ___ times per day • Have a family member check your incision daily for signs of infection • If you are required to wear one, wear cervical collar or back brace as instructed • You may shower briefly without the collar / back brace unless instructed otherwise • Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort • Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. 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: ___

{'Back and left leg pain': ['Displacement of lumbar intervertebral disc without myelopathy'], 'Severe pack pain': ['Displacement of lumbar intervertebral disc without myelopathy'], 'Radiating down her Left leg': ['Displacement of lumbar intervertebral disc without myelopathy'], 'Numbness to the top of her left foot': ['Displacement of lumbar intervertebral disc without myelopathy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal bloating Major Surgical or Invasive Procedure: Right salpingo-oophorectomy Left cystectomy History of Present Illness: Ms. ___ is a ___ gravida 0 woman who complains of abdominal bloating. She has a long gynecological history significant for uterine fibroids, endometriosis, and endometriomas. While she first started having symptoms of abdominal bloating, menorrhagia, severe menstrual cramping, urinary frequency, nocturia, and constipation in ___, her multiple gynecological diagnoses were not made until she received her first pelvic ultrasound in ___. After multiple myomectomies with Dr. ___ patient was followed biannually, then annually, and finally as needed for symptoms. In ___, ___ noticed abdominal bloating, which she described as a sensation of heaviness in her lower abdomen. A pelvic ultrasound in ___ showed an unchanged fibroid uterus, an unchanged 5.6cm left-sided endometrioma, and a new nodular 7.5cm right-sided endometrioma up to 5mm in wall thickness, concerning for malignant transformation. The patient presents today for surgical evaluation of her imaging findings. ROS was negative for F/C, CP, SOB, abdominal pain, N/V, C/D, changes in bowel or bladder habits, or intermenstrual bleeding. ROS was positive for mild dysmenorrhea, relieved by OTC NSAIDs. Past Medical History: Past OB/GYN: The patient has regular menses. She has never had a pregnancy. Her last Pap smear was in ___, which was normal. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner and uses a Mirena IUD. PMH: Allergic rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release – ___ Abdominal MMY Social History: ___ Family History: Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. Physical Exam: DISCHARGE EXAM: VS: Gen: This is a well-developed, well-nourished woman in no apparent distress. HEENT: Mucus membranes moist. Oropharynx clear. CV: Regular rate and rhythm. Normal S1 and S2 without murmurs, rubs, or gallops. Pulm: Clear to auscultation bilaterally Abd: Normoactive bowel sounds. Soft, nondistended, nontender. No hepatosplenomegaly. Well-healed ___ scar from her previous MMY. Incision intact. Pelvic: Normal female external genitalia. No rashes or lesions. Bartholin, urethral, and Skene's glands were normal. The vaginal vault contained normal-appearing vaginal discharge. The cervix was nulliparous, without cervical motion tenderness. Uterus was mobile and adnexa were difficult to appreciate given the patient’s habitus. Ext: 2+ peripheral pulses. No clubbing, cyanosis, or edema. Neuro: Awake, alert, and oriented to person, place, and time. Gross motor and sensory functions intact. Brief Hospital Course: Ms. ___ is a ___ gravida 0 with a history of uterine fibroids, endometriosis, and endometriomas who complains of worsening abdominal bloating and was found to have a 7.5 cm right endometrioma concerning for malignancy. She was taken to the OR for right salpingo-oophorectomy and left cystectomy with possible total abdominal hysterectomy and cancer staging. Intraoperatively, she was found to have an unchanged fibroid uterus, evidence of endometriosis, and bilateral endometriomas. A right salpingo-oophorectomy and left cystectomy were performed. Frozen pathology sections were found to contain only benign columnar epithelium, and therefore the patient was closed. Cystoscopy showed bilateral ureteral jets of indigo ___ dye, suggestive of intact ureters at the end of the procedure. Please refer to the operative note for full details. Postoperatively, the patient did well, tolerating a regular diet and oral pain medications by POD1. On POD1, her Foley catheter was removed. She was discharged to home in good condition on post-operative day 2. Medications on Admission: Duloxetine 60mg PO QD Lorazapam 0.5mg PO QD as needed Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Endometriomas Secondary diagnoses: Fibroid uterus, endometriosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

{'abdominal bloating': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'menorrhagia': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'severe menstrual cramping': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'urinary frequency': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'nocturia': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'constipation': ['Endometriosis of ovary', 'Leiomyoma of uterus'], 'mild dysmenorrhea': ['Endometriosis of ovary', 'Leiomyoma of uterus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: symptomatic fibroid uterus, left ovarian cyst Major Surgical or Invasive Procedure: exploratory laparotomy, lysis of adhesions, multiple myomectomy, left ovarian cystectomy History of Present Illness: Ms. ___ is a ___ gravida 0 with a long history of recurrent ovarian cyst and endometriosis who on ___, underwent a right salpingo-oophorectomy, left ovarian cystectomy for endometriomas. In ___, she had a multiple myomectomies for symptomatic fibroid uterus. The patient presents today for followup of unknown left adnexal cyst. The patient notes that she has no abdominal pain. She is simply experiencing increased bloatedness and pelvic pressure. New symptoms, she has developed stress urinary incontinence with sneezing. We discussed that this certainly can be related to this large adnexal cyst in addition to her overweightedness. On ___, she had an ultrasound, which showed an anteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly smaller than previous measurement on ___, where it measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent with uterine fibroids. The dominant fibroid was seen at the fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was distorted due to fibroids and not well evaluated. An IUD was demonstrated within the endometrial cavity. The patient is status post right oophorectomy, previously seen 10.7 cm left adnexal cyst again visualized and now measuring slightly larger at 10.8 x 10 cm. It predominantly was thin walled; however, there was one area with the appearance of an incomplete septation. This either represented a hydrosalpinx or peritoneal inclusion cyst, less likely a cystadenoma. There was no free pelvic fluid. These findings were discussed with the patient. Past Medical History: Past OB/GYN: The patient has regular menses. She has never had a pregnancy. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner. PMH: ___ rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release – ___ Abdominal MMY Social History: ___ Family History: Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. Physical Exam: Discharge Physical Exam: AVSS Gen NAD CV RRR P CTAB Abd soft, nondistended, appropriately tender to palpation, incision c/d/I Ext WWP Pertinent Results: ___ 07:25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94 MCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6 ___ 07:25AM PLT COUNT-268 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing an exploratory laparotomy, lysis of adhesions, left ovarian cystectomy, abdominal myomectomy for symptomatic fibroid uterus and left ovarian cyst. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen (pain meds). By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Duloxetine 60mg QD Discharge Medications: 1. DULoxetine 60 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 Discharge Disposition: Home Discharge Diagnosis: fibroid uterus, ovarian cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___

{'symptomatic fibroid uterus': ['Leiomyoma of uterus'], 'left ovarian cyst': ['Unspecified ovarian cysts'], 'increased bloatedness': [], 'pelvic pressure': [], 'stress urinary incontinence': ['Stress incontinence (female) (male)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right ankle fracture dislocation Major Surgical or Invasive Procedure: right ankle surgical fixation History of Present Illness: ___ healthy female who sustained a right ankle injury following a mechanical slip and fall down stairs. She states she was packing to fly home tomorrow morning when she was going to load up her suitcase down stairs, slipped on the last step, twisting and injuring her ankle. Denied head strike or loss of consciousness. She is not currently on anticoagulation. She denies any numbness or paresthesias in the right foot. She denies any previous injury to the right ankle. Notably she is currently in town visiting her son. She lives in ___ currently. She is here with her husband and son. Past Medical History: none Social History: ___ Family History: noncontributory Physical Exam: Right lower exam -splint c/d/I -grossly moves exposed toes -silt in exposed toes -toes WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right ankle fracture dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction internal fixation of right ankle fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity in a splint, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. Alternatively, since she is from ___ she may choose to follow-up with an orthopedic provider ___. She was instructed to follow-up in 2 weeks. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain don't drink or drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours PRN Disp #*30 Tablet Refills:*0 5. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: right ankle fracture 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: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing right lower extremity in splint MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Followup Instructions: ___

{'right ankle fracture dislocation': ['Displaced trimalleolar fracture of right lower leg'], 'mechanical slip and fall down stairs': ['Fall (on) (from) other stairs and steps'], 'twisting and injuring ankle': ['Displaced trimalleolar fracture of right lower leg'], 'denied head strike or loss of consciousness': [], 'denies any numbness or paresthesias in the right foot': [], 'denies any previous injury to the right ankle': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Gastroesophageal reflux disease Major Surgical or Invasive Procedure: Laparoscopic ___ fundoplication History of Present Illness: The patient is a ___ gentleman whom I have been asked to see by Dr. ___ evaluation of gastroesophageal reflux disease. The patient has a history of irritable bowel syndrome with symptoms of abdominal pain and diarrhea, although this has largely improved over the past several years. His current symptoms include regurgitation of food, primarily with coughing as well as occasional substernal chest pain. His primary complaint is dysphagia as well as odynophagia on eating solid food. The patient has seen an ENT physician, ___ ___ also underwent a pH testing off of PPIs. This test performed in ___ shows ___ score of 25.9. Past Medical History: The patient has no significant past medical history other than irritable bowel syndrome. Physical Exam: Gen: NAD, A&Ox3 Cardiac: RRR, no m/r/g Pulm: CTAB Abd: Soft, NTND Extremeties: warm and well perfused Incisions: covered with dermabond no evidence of infection, no bleeding or drainage Pertinent Results: Esophageal study ___ While standing, the patient was given a small amount of thin barium contrast to ingest. Barium passed freely through the gastroesophageal junction and into the stomach. There was only a small amount of residual contrast in the distal esophagus which cleared with tertiary contractions. The patient was next laid horizontally and was given more contrast to ingest while in the right anterior oblique position. No reflux was seen. The patient was rolled into a number differentpositions to visualize the fundoplication and there is no evidence of loosening. IMPRESSION: Normal postoperative appearance of ___ fundoplication. Brief Hospital Course: Mr. ___ was admitted on ___ to undergo a laparoscopic ___ fundoplication for his GERD. The procedure was uncomplicated and he tolerated it well. He was extubated and stable in the OR. His stat CXR in the PACU revealved a small R apical pneumothorax however he was asymptomatic and repeat CXR 4 hours later revealed reinflation of the lung. He never dropped his sat's or had difficulty breathing. Post-operatively he has had some acute urinary retention for which he has a urinary foley catheter replaced. Barium swallow on POD #1 showed no extravasation and his diet was advanced without problem. He discharged to home on ___. Medications on Admission: Dexilant 60mg daily albuterol ___ puff ___ prn lorazepam 0.5mg QID:prn oxybutynin ER 5mg QID valacyclovir 500mg daily Vitamin B12 daily Loratidine 10mg daily Lysine 1000mg 3 times per week Discharge Medications: 1. Ondansetron 4 mg IV ONCE:PRN for nausea 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Difficult or painful swallowing -Nausea, vomiting (take antinausea medication) -Increased shortness of breath Pain -Acetaminophen as needed for pain along with your narcotic -Take stool softners with narcotics -No driving while taking narcotics Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision -Walk ___ times a day for ___ minutes increase to a Goal of 30 minutes daily Diet: Full liquid diet for ___ days. Increase to soft solids as tolerates Eat small frequent meals. Sit in chair for all meals. Remain sitting up for ___ minutes after all meals NO CARBONATED DRINKS Followup Instructions: ___

{'regurgitation of food': ['Esophageal reflux'], 'coughing': ['Esophageal reflux'], 'substernal chest pain': ['Esophageal reflux'], 'dysphagia': ['Esophageal reflux'], 'odynophagia': ['Esophageal reflux'], 'abdominal pain': ['Other specified retention of urine'], 'diarrhea': ['Other specified retention of urine'], 'R apical pneumothorax': ['Other pneumothorax'], 'acute urinary retention': ['Other specified retention of urine']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain and sycope Major Surgical or Invasive Procedure: none History of Present Illness: This is ___ year old lady with a history of CAD, gout, hypothyroidism presents to the ___ ED with complaints of abdominal pain x 3 hours and syncope. . She reports she was in her USOH until she had acute onset of "achy" gas like abdominal pain at 18:30 today, non-radiating, relieved by bowel movement. She had decreased liquid intake earlier in the day, and was out shopping with family and she passed out while exiting a car. She was eased to the ground, had cyanotic appeaing lips. She did not immediately regain consciousness, EMS was called who, according to the husband, performed 1 round of CPR, she regained consciousness and was brought to the ED. There as no documentation of the resuscitation event, no report of medications or cardioversion performed. . Of note she was admitted for a syncope work-up in ___. The ddx at that time included a vasovagal event versus symptomatic bradycardia. Her heart rate was in the ___ when EMS first evaluated her. Her amlodipine and atenolol were stopped and she was discharged with PCP ___ and suggestion for outpatient stress test. Her thyroid function tests during this admission were normal. . Speaking to the husband who was present during the event, he tells me that she was diaphoretic immediately following the event, and that her face was cold. . In the ED, initial VS: 97.6 57 146/75 16. On arrival to the ED, she had one large, soft brown, non bloody bowel movement with improvement in abdominal pain. She is conversant, neurologically intact and reports mild residual abdominal pain. Initial labs significant unremarkable liver function tests, chem7 and cbc. A troponin <0.01. A moderate demonstrated moderate leukocytes, small blood and few bacteria. Her stool was guaic negative. A bedside ultrasound was performed to rule out AAA. The aorta measured 1.3 x 1.6 in its maximal dimmension. Orthostatics were performed and were: 160/90 laying, 150/90 standing. She was given a 500cc bolus in the ED. She was started on macrobid ___ q12hrs. . Currently, patient feels well, tells me that she forgot to take her pills today . REVIEW OF SYSTEMS: +rhinorrea for a few days. Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. CARDIAC RISK FACTORS:HTN 2. CARDIAC HISTORY: Catherization ___ years ago at ___, according to patient she was told it was normal and nothing was done. 3. OTHER PAST MEDICAL HISTORY: Gout Hypothyroidism CAD HLD Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS - Temp 97.6- HR 55- BP 166/90 - RR 12- 97%RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - bradycardic to ___, S1, S2 no murmurs LUNGS - CTAB ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, steady gait . DISCHARGE EXAM: unchanged Pertinent Results: ADMISSION LABS: ___ 07:40PM BLOOD WBC-7.0 RBC-4.39 Hgb-13.0 Hct-40.9 MCV-93 MCH-29.6 MCHC-31.8 RDW-13.0 Plt ___ ___ 07:40PM BLOOD WBC-7.0 RBC-4.39 Hgb-13.0 Hct-40.9 MCV-93 MCH-29.6 MCHC-31.8 RDW-13.0 Plt ___ ___ 07:40PM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-143 K-4.1 Cl-106 HCO3-27 AnGap-14 ___ 07:40PM BLOOD ALT-18 AST-35 AlkPhos-68 TotBili-0.3 . DISCHARGE LABS: ___ 07:40AM BLOOD WBC-6.6 RBC-4.22 Hgb-12.9 Hct-40.2 MCV-96 MCH-30.6 MCHC-32.0 RDW-13.4 Plt ___ ___ 07:40AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-141 K-3.6 Cl-105 HCO3-27 AnGap-13 . CARDIAC LABS: ___ 07:40PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 07:40AM BLOOD CK-MB-5 cTropnT-<0.01 ___ 07:40AM BLOOD CK(CPK)-305* . THYROID FUNCTION: ___ 07:40AM BLOOD TSH-8.5* ___ 07:40AM BLOOD Free T4-0.84* . NO IMAGING PERFORMED. . EKG: Sinus brady at 54bmp, 1st degree AV block. Q wave in III, aVF, unchanged from ___SSESSMENT AND PLAN: This is ___ year old lady with a history of CAD, gout, hypothyroidism presents to the ___ ED with complaints of abdominal pain x 3 hours and syncope. . ACTIVE ISSUES: # SYNCOPE: On admission, pt had an unchanged EKG and normal troponins x 2, which effectively ruled out an ACS event. She denied any loss of bowel of bladder function, no tongue biting or post-ictal state to suggest a seizure. She did not experience any palpitations or heart racing prior the event, which made an arrythemia ___. There was high suspicion that this event was secondary to a vasovagal episode, most likely in setting of needing to have a bowel movement. Pt also has a history of bradycardia with 1st degree AV block which may have been contributing factor. The most recent TTE in our system was from ___, however the patient states that she has had one more recently as an outpatient with Dr. ___. Unfortunately, we did not have access to this record. The patient has also worn a Holter monitor in the past, which she reports revealled no events. As part of her work up, TSH was order, which returned elevated. Her free T4 was pending at time of discharge. The patient was monitored on tele during her admission, which was remarkable only for sinus bradycardia. We attempted to get a Holter monitor for the patient prior to discharge, however given the holiday weekend, this was not possible. We have advised the patient to follow up with her PCP and outpatient cardiologist this week and recommend another heart monitor. . # ABDOMINAL PAIN: This appears to have resolved with defacation. The emergency department considered possible AAA and a bedside ultrasound demonstrated 1.3 x 1.6 cm maximal dimmension. Her liver funtion tests and lipase were normal. Her stool guaiac was negative. Pt remained asymptomatic throughout her admission and tolerated PO well with no constipation or diarrhea. . CHRONIC ISSUES: # HYPERTNESION: Pt was slightly hypertensive when she arrived on the floor with systolic BP 160s. With her medications, her blood pressure decreased to 140-150s. She was continued on her hydrochlorothiazide. . # HYPOTHRYOID: Pt was continued on her home dose of levothyroxine 100mcg daily. Her TSH was slightly elevated, and her total T4 was pending at time of discharge. . # GOUT: Pt was continued on her home dose of allopurinol ___ mg daily. . TRANSITIONAL ISSUES: # We have recommended that the patient be set up with a Holter monitor as an outpatient to monitor for any arrythmias that may have contributed to her syncopal episode. We also recommend a repeat TTE if she has not had one recently. . # Her TSH was slightly elevated, with a free T4 pending at time of discharge. This should be followed up as an outpatient, and adjusted as necessary. . # Pt had a urine culture pending at time of discharge. Medications on Admission: 1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 2. Allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY 3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Syncope SECONDARY: bradycardia 1st degree heart block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted for a fainting episode. We kept you on a heart monitor, and did not see any irregular heart rhythms other than your known slow heart rate. You had a blood test to check for a heart attack which was normal. We have made no changes to your medications. We recommend that you get a heart monitor to wear at home, however we were unable to set that up for you today. Followup Instructions: ___

{'Abdominal pain': ['Syncope and collapse', 'Abdominal pain', 'unspecified site'], 'Syncope': ['Syncope and collapse', 'Other specified cardiac dysrhythmias', 'First degree atrioventricular block'], 'Bradycardia': ['Syncope and collapse', 'Other specified cardiac dysrhythmias', 'First degree atrioventricular block'], 'Hypertension': ['Unspecified essential hypertension'], 'Hypothyroidism': ['Unspecified acquired hypothyroidism'], 'Gout': ['Gout', 'unspecified'], 'CAD': ['Coronary atherosclerosis of unspecified type of vessel', 'native or graft'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Thyroid dysfunction': ['Nonspecific abnormal results of function study of thyroid']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Tetracycline / Flagyl Attending: ___. Chief Complaint: diverticular abscess Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman, who presented with ___ abdominal pain since ___ in LLQ. Patient has not had much nausea except for a single episode last ___ when she vomited foodstuff and a small amount of bile. She is still having bowel movements and passing flatus, but her pain was much increased from her simple uncomplicated "diverticular flare" that she has had ___ x year. She has never had an abscess or hospitalization for her prior episodes and has not had abx. CT done thru PCP today which showed an abscess in her colon. Sent here for admission. Unasyn given x 1. Had colonoscopy ___ which showed 2 polyps, moderate diverticulosis. Past Medical History: Symptomatic Cholelithiasis Biliary obstruction s/p ERCP Anemia Social History: ___ Family History: Diverticulitis Physical Exam: Temp: 97.2 HR: 79 BP: 110/61 Resp: 18 O(2)Sat: 100 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, mild LLQ tenderness w/o r/g. Nl BS. Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Pertinent Results: ___ 08:25PM BLOOD WBC-11.8*# RBC-3.99* Hgb-12.4 Hct-33.9* MCV-85 MCH-31.1 MCHC-36.7* RDW-12.3 Plt ___ ___ 08:25PM BLOOD Neuts-75.6* ___ Monos-3.4 Eos-0.7 Baso-0.4 ___ 08:25PM BLOOD Plt ___ ___ 08:25PM BLOOD Glucose-108* UreaN-33* Creat-2.0* Na-136 K-3.6 Cl-95* HCO3-25 AnGap-20 ___ 08:30PM BLOOD Lactate-1.3 ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ 09:36PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:36PM URINE Blood-NEG Nitrite-POS Protein-100 Glucose-NEG Ketone-15 Bilirub-LG Urobiln-1 pH-5.0 Leuks-TR ___ 09:36PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-6 TransE-<1 ___ 09:36PM URINE CastGr-1* CastHy-78* ___ 09:36PM URINE Mucous-OCC ___ 07:45AM BLOOD WBC-7.0 RBC-3.41* Hgb-10.7* Hct-29.1* MCV-85 MCH-31.2 MCHC-36.6* RDW-12.4 Plt ___ ___ 07:45AM BLOOD Plt ___ ___ 07:45AM BLOOD ___ PTT-28.5 ___ ___ 07:45AM BLOOD Glucose-90 UreaN-32* Creat-1.5* Na-140 K-3.7 Cl-102 HCO3-27 AnGap-15 ___ 07:45AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1 CT abd/pelv in ATRIUS 1. Sigmoid diverticulitis with 4.3 x 4.7cm intraluminal abscess versus adjacent pelvic abscess. IV contrast would be helpful to differentiate, which was not administered due to elevated creatinine. Follow-up CT recommended to exclude an underlying mass. 2. 3 mm noncalcified nodule in left lung base. Chest CT advised. Brief Hospital Course: Ms. ___ is a ___ year old female who has a history of diverticulosis and has been having abdominal pain for 4 days. Outpatient CT performed on ___ showed diverticulitis with a 4.3 x 4.7 cm collection. She was referred to the emergency department for further evaluation. Upon ED presentation, pt's abdomen was soft with normoactive bowel sounds, with mild LLQ tenderness w/o rebound tenderness or guarding. Labs were notable for a slightly increased white count, chronic renal insufficiency, and a UTI. Pt was given Unasyn. Given concern for worsening diverticular disease, diverticular abscess, pt was seen by surgery and admitted to ___ service. Pt was made NPO, given IVF, IV abx, to good effect. Symptomatic resolution seen, tolerating regular diet. Given improving clinical picture, patient discharged on 7-day course of Augmentin on ___. Medications on Admission: ___, Calci-Chew, multivitamin, lisinopril-hydrochlorothiazid Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: diverticular abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ACS service for a diverticular abscess. Please resume all regular home medications. Please take any new medications as prescribed. If you have pain, you may take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Please also follow-up with your PCP. Followup Instructions: ___

{'abdominal pain': ['Diverticulitis of colon (without mention of hemorrhage)'], 'nausea': ['Diverticulitis of colon (without mention of hemorrhage)'], 'vomiting': ['Diverticulitis of colon (without mention of hemorrhage)'], 'increased pain': ['Diverticulitis of colon (without mention of hemorrhage)'], 'abscess': ['Abscess of intestine'], 'anemia': ['Chronic kidney disease']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / Adhesive Bandages / Caffeine Attending: ___ ___ Complaint: right knee pain Major Surgical or Invasive Procedure: I&D Right TKA History of Present Illness: ___ y/o woman s/p TKA presents with infected knee and underwent I&D with liner exchange. Past Medical History: 1. Hypertension 2. Hypothyroidism, status post partial thyroidectomy for multinodular goiter 3. Arthritis 4. Spinal stenosis 5. Chronic low back pain 6. Mitral valve prolapse 7. Irritable bowel syndrome 8. Cerebral Aneurysm Social History: ___ Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam: Afebrile, All vital signs stable General: NCAT, NAD Pulm: lungs CTA bilaterally, no w/r/r Card:s1/s2 clear no m/g/r Abd: soft NT/ND, +BS Ext: incision C/D/I calf nt nvi distally Pertinent Results: ___ 05:36PM JOINT FLUID ___ POLYS-97* ___ ___ 04:20PM CRP-130.9* ___ 04:20PM SED RATE-67* ___ 11:30AM BLOOD WBC-9.3 RBC-3.92* Hgb-11.0* Hct-33.4* MCV-85 MCH-28.1 MCHC-33.0 RDW-13.6 Plt ___ ___ 11:30AM BLOOD ESR-67* ___ 11:30AM BLOOD Glucose-112* UreaN-28* Creat-0.8 Na-140 K-4.2 Cl-102 HCO3-29 AnGap-13 ___ 11:30AM BLOOD CRP-12.7* Brief Hospital Course: Ms. ___ was admitted to ___ on ___ for right septic knee s/p B TKAs in ___. Pre-operatively, she was consented and history and physical performed. Intra-operatively, she was closely monitored and remained stable. She tolerated the procedure well without any difficulty. Post-operatively, she was transferred to the PACU and floor for further recovery. On the floor,she remained stable. Her pain was well controlled. She progressed with physical therapy to improve her strength and mobility. On ___ she was changed from vancomycin to Ceftriaxone 2g iv q 24 hours and tolerated this well. She continued to make steady progress. She was discharged to a rehabilitation facility in stable condition. Medications on Admission: levothyroxine, valsartan, venlafaxine, gabapentin, calcium, vitamins Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. Disp:*21 syringe* Refills:*0* 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID, PRN () as needed for pain. 6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 6 weeks: until ___ when has follow up with ID. Disp:*28 * Refills:*0* 13. PICC line care Sig: One (1) daily: PICC line care as per protocol. Disp:*1 * Refills:*2* 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for fever. 20. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea/vomiting. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: septic right TKA 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: Keep the incision clean and dry. Please apply a dry sterile dressing daily as needed for drainage or comfort. If you have any shortness of breath, increased redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may bear weight on your right leg. Please resume all of the medications you took prior to your admission unless discussed with your provider. Take all medication as prescribed by your provider. Please take an aspirin daily to help reduce the chances of developing a blood clot. Feel free to call our office with any questions or concerns. Physical Therapy: CPM advance as tolerated ___ no restrictions on ROM or weight bearing Treatments Frequency: ice and elevate as tolerated Followup Instructions: ___

{'right knee pain': ['Infection and inflammatory reaction due to internal joint prosthesis', 'Pyogenic arthritis', 'Knee joint replacement'], 'Hypertension': ['Unspecified essential hypertension'], 'Hypothyroidism': ['Postsurgical hypothyroidism'], 'Arthritis': ['Infection and inflammatory reaction due to internal joint prosthesis', 'Pyogenic arthritis'], 'Spinal stenosis': [], 'Chronic low back pain': ['Lumbago'], 'Mitral valve prolapse': [], 'Irritable bowel syndrome': [], 'Cerebral Aneurysm': []}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / Adhesive Bandages / Caffeine Attending: ___ ___ Complaint: Progressive bilateral knee pain with activity Major Surgical or Invasive Procedure: Bilateral total knee replacements History of Present Illness: Ms. ___ is a ___ year old female with a history of osteoarthritis and bilateral knee pain with activity. She presents for definitive treatment. Past Medical History: 1. Hypertension 2. Hypothyroidism, status post partial thyroidectomy for multinodular goiter 3. Arthritis 4. Spinal stenosis 5. Chronic low back pain 6. Mitral valve prolapse 7. Irritable bowel syndrome 8. Cerebral Aneurysm Social History: ___ Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: bilateral lower Weight bearing: full weight bearing Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Extensor/flexor hallicus longus intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: ___ 12:30PM GLUCOSE-140* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12 ___ 12:30PM estGFR-Using this ___ 12:30PM WBC-22.2*# RBC-3.42* HGB-10.2* HCT-30.5* MCV-89 MCH-29.8 MCHC-33.4 RDW-14.0 ___ 12:30PM PLT COUNT-248 ___ 06:05AM BLOOD WBC-11.1* RBC-3.02* Hgb-9.0* Hct-27.0* MCV-89 MCH-29.8 MCHC-33.3 RDW-14.3 Plt ___ ___ 09:40PM BLOOD WBC-12.9* RBC-2.83* Hgb-8.4* Hct-24.7* MCV-87 MCH-29.6 MCHC-33.9 RDW-15.0 Plt ___ ___ 07:30AM BLOOD WBC-12.6* RBC-2.87* Hgb-8.4* Hct-25.0* MCV-87 MCH-29.4 MCHC-33.8 RDW-14.8 Plt ___ ___ 06:00AM BLOOD Hct-24.3* ___ 04:50PM BLOOD Hct-24.5* ___ 10:50AM BLOOD Hct-24.6* ___ 10:45PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:45PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM Brief Hospital Course: Ms. ___ was admitted to ___ on ___ for an elective bilateral total knee replacement. Pre-operatively, she was consented, prepped, and brought to the operating room. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any complication. Post-operatively, she was transferred to the PACU and floor for further recovery. On the floor, she remained hemodynamically stable with her pain was controlled. She was transfused with 3 units packed cells, with discharge HCT 24.6. Being treated for UTI. Culture pending. She progressed with physical therapy to improve her strength and mobility. She was discharged in stable condition. Medications on Admission: Verapamil Avapro Levoxyl Neurontin Tramadol Lysine Vit-B complex Glucosamine condroitin Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 11. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qd (). 12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 3 weeks. Disp:*qs * Refills:*0* 15. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qd (). 11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 3 weeks. Disp:*qs * Refills:*0* 14. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 15. Tramadol 50 mg Tablet Sig: ___ Tablets PO TID (3 times a day) as needed for pain: do not take with dilaudid. . Tablet(s) 16. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Osteoarthritis Postoperative anemia UTI Discharge Condition: Stable Discharge Instructions: If you experience any chest pain, shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may bear weight on both legs. Please use your crutches/walker for ambulation. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour ___ through ___, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on ___, ___, or holidays. Please plan accordingly. Continue your Lovenox injections as prescribed to help prevent blood clots. Please finish all of this medication. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: Activity as tolerated Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Treatments Frequency: Keep your incision/dressing clean and dry. Apply a dry sterile dressing daily as needed for drainage or comfort. Keep your knee dry for 5 days after your surgery. Your skin staples may be removed 2 weeks after your surgery or at the time of your follow up visit. Followup Instructions: ___

{'bilateral knee pain': ['Osteoarthrosis'], 'activity': ['Osteoarthrosis'], 'UTI': ['Urinary tract infection'], 'anemia': ['Acute posthemorrhagic anemia'], 'hypertension': ['Unspecified essential hypertension'], 'hypothyroidism': ['Unspecified acquired hypothyroidism'], 'spinal stenosis': ['Spinal stenosis, lumbar region, without neurogenic claudication'], 'mitral valve prolapse': ['Mitral valve disorders'], 'cerebral aneurysm': ['Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / adhesive bandage / Caffeine Attending: ___. Chief Complaint: Wound infection Major Surgical or Invasive Procedure: Washout of lumbar incision History of Present Illness: ___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR, cerebral aneurysm sp clipping, hypothyroidism (sp L hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids), sp R oopheretomy), sp appy, sp CTS release with recent lumbar laminectomy L2-5 with L3-5 fusion on ___ by Dr. ___ presents with fever. Patient states that for the past two days she has had worsening pain and redness at her operative site. She denies any new lower extremity weakness, parasthesias or anesthesia. She does endorse occasional urinary incontinence she attributes to difficulty reaching commode in time. Denies fecal incontinence, saddle anesthesia. Denies CP, dyspnea, cough, abd pain, dysuria. Past Medical History: 1. Hypertension 2. Hypothyroidism, status post partial thyroidectomy for multinodular goiter 3. Arthritis 4. Spinal stenosis 5. Chronic low back pain 6. Mitral valve prolapse 7. Irritable bowel syndrome 8. Cerebral Aneurysm Social History: ___ Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam: In general, the patient is a Vitals: T 102.7dF Hr 93 BP 127/77 RR 18 SpO2 96% RA Spine exam: Wound: Midline lumbar spine wound from L1-L5 has surrounding blanching erthema and induration, no clear fluctuance. No discharge. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L ___ 5 R ___ 5 -Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory ___ L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R nl, L nl L5 (Grt Toe): R nl, L nl S1 (Sm toe): R nl, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri ___ Pat Ach L ___ 2 2 R ___ 2 2 Plantar response was extensor bilaterally. ___: neg Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact Pertinent Results: ___ 06:50PM BLOOD WBC-11.5* RBC-3.75* Hgb-10.3* Hct-32.9* MCV-88 MCH-27.4 MCHC-31.3 RDW-14.4 Plt ___ ___ 10:10AM BLOOD WBC-13.3* RBC-3.54* Hgb-9.9* Hct-31.4* MCV-89 MCH-28.0 MCHC-31.6 RDW-14.2 Plt ___ ___ 03:27PM BLOOD WBC-14.2* RBC-4.03* Hgb-10.9* Hct-35.0* MCV-87 MCH-27.0 MCHC-31.1 RDW-14.2 Plt ___ ___ 03:27PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.9 Eos-0.4 Baso-0.3 ___ 06:50PM BLOOD ESR-128* ___ 03:27PM BLOOD ESR-92* ___ 06:50PM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-145 K-4.5 Cl-99 HCO3-31 AnGap-20 ___ 10:10AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 ___ 03:27PM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-139 K-4.3 Cl-98 HCO3-29 AnGap-16 ___ 09:55AM BLOOD Vanco-15.2 ___ 08:45PM BLOOD Genta-4.0* Vanco-14.0 Brief Hospital Course: Ms. ___ underwent a washout of her posterior lumbar incision. She had a PICC line placed and will receive 10 weeks of IV vancomycin. She will follow up with both the ___ clinic and Dr. ___. Medications on Admission: Trazodone Venlafaxine Pramipexole Synthroid Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*100 Tablet Refills:*0 3. Levothyroxine Sodium 50 mcg PO DAILY 4. pramipexole 0.25 mg oral TID restless leg 5. TraZODone 100 mg PO HS:PRN insomnia 6. Venlafaxine 200 mg PO QHS 7. Vancomycin 1000 mg IV Q 12H X 10 weeks Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lumbar incision infection Discharge Condition: Good Discharge Instructions: You have undergone the following operation: Washout lumbar incision Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity as tolerated Treatments Frequency: Please continue to change the dressing daily Followup Instructions: ___

{'fever': ['Other postoperative infection'], 'pain': ['Other postoperative infection'], 'redness': ['Other postoperative infection'], 'worsening pain': ['Other postoperative infection'], 'urinary incontinence': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'hypothyroidism': ['Postsurgical hypothyroidism'], 'mitral valve prolapse': ['Mitral valve disorders'], 'lumbar laminectomy': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'hypertension': ['Unspecified essential hypertension'], 'irritable bowel syndrome': ['Irritable bowel syndrome'], 'knee joint replacement': ['Knee joint replacement'], 'lumbago': ['Lumbago']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Tylenol / Neurontin Attending: ___. Chief Complaint: Acute Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a ___ year old male, with ETOH and Hep C cirrhosis, child's class B (MELD 16) presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. Patient is now being seen by Transplant surgery in consultation. As above, the patient has a history of cirrhosis secondary to both ethanol and Hep C. Currently compensated. Last paracentesis performed ___ years ago. His surgical history is pertinent for a prior umbilical repair, and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until last night when he developed an acute abdominal pain. He describes the pain as stabbing in nature and constant. The pain is located in his right flank. He has had around 10 episodes of bilious emesis. Denies hematemesis. Last episode of vomiting was this morning at 10:00. He has not felt better after the emesis triggering this ED visit. He describes this pain similar in nature as prior one last year when he required exploration. The patient endorses chills but denies any fever, chest pain, SOB, dysuria, or urinary urgency or frequency. He last passed gas this morning and has not had a bowel movement in the last two days. In the ED, VSS. Patient with persistent nausea. No NG in place. Abdomen soft but tender to right flank. No peritoneal. Labs w/o leukocytosis or acidosis. Imaging studies c/w distal ileum bowel obstruction. No signs of bowel ischemia. Moderate ascites. ROS: (+) per HPI (-) Denies pain, fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: - Hepatitis C (genotype 3) - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic encephalopathy, portal hypertension with ascites and esophageal varices, portal hypertensive gastropathy - Gastric & Duodenal ulcers - Insomnia - Umbilical hernia - Sacral osteoarthritis Past Surgical History: - Umbilical hernia repair (___) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions (___) - Abdominal Hematoma evacuation (___) - Abdominal incision opened, wound vac placed (___) Social History: ___ Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: Vitals: 98.1, 121/70, 57, 18, 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, tender to deep palpation to right flank. No rebound. Ascites. Dull to percussion. Ext: No ___ edema, ___ warm and well perfused . Weight at discharge: 64.5 kg Pertinent Results: Labs on Admission: ___ WBC-6.1 RBC-4.29* Hgb-14.8 Hct-44.0 MCV-103* MCH-34.5* MCHC-33.6 RDW-15.7* RDWSD-56.9* Plt ___ PTT-38.3* ___ Glucose-121* UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-100 HCO3-24 AnGap-14 ALT-27 AST-102* AlkPhos-135* TotBili-4.1* Albumin-3.1* Calcium-8.5 Phos-4.2 Mg-1.6 . Labs at Discharge: ___ WBC-5.8 RBC-3.88* Hgb-13.3* Hct-39.9* MCV-103* MCH-34.3* MCHC-33.3 RDW-15.7* RDWSD-58.6* Plt ___ Glucose-145* UreaN-6 Creat-0.8 Na-136 K-5.3* Cl-105 HCO3-23 AnGap-8 ALT-18 AST-54* AlkPhos-94 TotBili-3.8* Calcium-7.6* Phos-3.7 Mg-1.___ y/o male with HCV, ETOH cirrhosis with prior ex-lap who now presents with acute abdominal pain. On admission the patient had a CT done with findings suspicious for partial small bowel obstruction with adhesive disease in the right lower quadrant involving loops of ileum with alternating areas of luminal narrowing and dilatation. Overall, the appearance of the small bowel is similar to the previous CT from ___. Of note there is liver cirrhosis with small to moderate ascites, mild splenomegaly, and portosystemic varices. There is also a nonocclusive small thrombus in the main portal vein which is slightly smaller compared to ___. An NG tube was placed, and he was having bilious output from the NG tube. He reported passing some flatus, and the abdominal pain was present but stable on exam. On hospital day two, he was reporting an increase in abdominal pain. A KUB was done showing that there was no evidence of free air. The abdominal exam still showed him to be soft, and serial exams over the next ___ hours showed him to be less tender. A suppository was given resulting in a loose bowel movement and he was reporting passing some flatus still. The NG tube output was lightening in colr and less volume. Prior to the NG tube being discontinued, another KUB was obtained, with no evidence of obstruction. The NG tube was removed and he was kept NPO for the next ___ hours. He had no nausea with tube removed, and so he was started on a clear diet which he tolerated without nausea or vomiting. The abdominal exam was significantly improved so he was deemed safe for discharge with plan for clears for three days. Liver function tests were slightly improved at discharge. Additionally the patient has a follow up appointment with his hepatologist this week which the patient was advised to keep. Home medications including diuretics were resumed at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Fentanyl Patch 50 mcg/h TD Q72H 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO QID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 7. Potassium Chloride 20 mEq PO DAILY 8. Spironolactone 50 mg PO DAILY 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Bisacodyl 10 mg PR QHS:PRN constipation 11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 3. Famotidine 20 mg PO BID 4. Fentanyl Patch 50 mcg/h TD Q72H 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Spironolactone 50 mg PO DAILY 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction: Resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office at ___ if you have fever greater than 101, chills, nausea, vomiting, constipation, you are not passing gas, you have a lot of hiccupping or burping, your abdomen is becoming more distended, you have pain in your abdomen or any other concerning symptoms. Continue all your home medications as they have been prescribed to you. Follow up with your primary providers if you have questions about those medications. To help your bowel heal and not become obstructed again, you should continue a clear diet through ___. This means liquids you can see through, clear sodas, water, clear juices, jello and broth. Followup Instructions: ___

{'Acute Abdominal pain': ['Intestinal adhesions [bands] with obstruction (postinfection)', 'Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'Stabbing pain': ['Intestinal adhesions [bands] with obstruction (postinfection)', 'Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'Bilious emesis': ['Intestinal adhesions [bands] with obstruction (postinfection)', 'Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'Tender to right flank': ['Intestinal adhesions [bands] with obstruction (postinfection)', 'Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'No peritoneal': ['Intestinal adhesions [bands] with obstruction (postinfection)', 'Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'Moderate ascites': ['Alcoholic cirrhosis of liver with ascites', 'Portal hypertension'], 'Nonocclusive small thrombus in the main portal vein': ['Portal vein thrombosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Tylenol / Neurontin Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: Paracentesis, ___ History of Present Illness: ___ year old male, with ETOH and Hep C cirrhosis, child's class B (MELD 16) presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. His surgical history is pertinent for a prior umbilical repair, and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until 5 days ago when he started having mild diffuse abdominal pain associated with nausea and multiple episodes of emesis. Denies bilious or bloody emesis. Last episode of emesis was 2 days ago but still complains of nausea and abdominal pain. He also mentions that his last bowel movement was 2 days ago, same time when he last passed flatus. He also mentions some subjective fevers, but denies taking his temperature. Off note, on ___ this year he presented to the ED with similar symptoms which required hospitalization for SBO that was managed conservatively. Other than that he denies shortness of breath, palpitations, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, dysuria. In the ED, VSS. Patient with persistent nausea and abdominal pain. No NG tube in place. Abdomen soft but tender to palpation in right hemi-abdomen. No peritoneal. Labs w/o leukocytosis or acidosis. Imaging studies suggestive of SBO with transition in right hemi-abdomen. No signs of bowel ischemia. Moderate ascites. Past Medical History: - Hepatitis C (genotype 3) - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic encephalopathy, portal hypertension with ascites and esophageal varices, portal hypertensive gastropathy - Gastric & Duodenal ulcers - Insomnia - Umbilical hernia - Sacral osteoarthritis Past Surgical History: - Umbilical hernia repair (___) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions (___) - Abdominal Hematoma evacuation (___) - Abdominal incision opened, wound vac placed (___) Social History: ___ Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: VITAL SIGNS: T97.7, BP 156/76, HR 58, RR 18, SpO2 97%RA GENERAL: AAOx3 NAD HEENT: NCAT, no scleral icterus CARDIOVASCULAR: rrr, S1S2 PULMONARY: CTABL, non-labored respirations GASTROINTESTINAL: soft, minimally distended per baseline, mildly TTP over R abdomen - much improved from admission and consistent with baseline. No guarding, rebound, or peritoneal signs. EXT/MS/SKIN: No cyanosis, clubbing, or edema NEUROLOGICAL: Strength and sensation grossly intact Pertinent Results: Admission labs: ___ 06:10PM BLOOD WBC-7.8 RBC-3.46* Hgb-12.0* Hct-35.9* MCV-104* MCH-34.7* MCHC-33.4 RDW-15.6* RDWSD-58.6* Plt ___ ___ 06:10PM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-134* K-3.6 Cl-98 HCO3-25 AnGap-11 ___ 06:10PM BLOOD ALT-16 AST-44* AlkPhos-122 TotBili-2.7* ___ 06:10PM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.9 Mg-1.4* ___ 06:10PM BLOOD Lipase-___ year old male with ETOH and Hep C cirrhosis, child's class B, presented to the ED with acute abdominal pain, nausea and vomiting concerning for recurrent bowel obstruction. His initial CT abdomen showed slightly dilated loops of jejunum with relative transition point right hemiabdomen followed by decompressed bowel, distal small bowel loops were normal in caliber with air and stool present. No pneumatosis, bowel wall thickening, or pneumoperitoneum were seen. He was admitted to Transplant surgery and kept NPO with IV fluid. Serial abdominal exams were done noting increased distension and tenderness. No free air was seen on KUB. A nasogastric tube was placed to decompress the stomach and a Foley catheter was placed to closely monitor urine output. He was given a dulcolax suppository with passage of a BM. Lactate increased the next day to 2.1 then 3.1. A CT was done that showed colonic thickening but no obstruction. He continued to require IV fluid bolus for low u/o.Lactate decrease to 1.9. By hospital day 4, exam was improved and lactate had decreased. The foley was removed. On ___, he tolerated NG clamp trials and the NG was removed. On ___, a clear diet was tolerated and this advanced to regular diet that he also tolerated. However, over night, he c/o sudden right hemi-abdominal pain and gas pain. Simethicone was administered with relief. He was moving his bowels without difficulty. Hepatology was consulted and recommended a paracentesis. This done on ___ with 0.4 liter removed. Cell count was notable for WBC-TNC and zero polys. Culture of ascites was negative. On ___, he felt ready for discharge to home. His home Nadolol was held as his heart rates were in the ___. SBP ranged between 104-160s. On ___, t.bili increased from 2.0 to 2.4. A liver duplex was done to evaluate his portal vein given h/o portal vein thrombus. U/S demonstrated patent main and right portal vein, small ascites and small right pleural effusion. He was discharged to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain 6. Potassium Chloride 20 mEq PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 9. Bisacodyl ___AILY:PRN constipation 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Simethicone 40-80 mg PO TID:PRN gas pain 2. Bisacodyl ___AILY:PRN constipation 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 4. Famotidine 20 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Multivitamins 1 TAB PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain continue to follow up with your outpatient provider for management 9. Potassium Chloride 20 mEq PO DAILY Hold for K > 5.0 10. Spironolactone 50 mg PO DAILY 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis Discharge Disposition: Home Discharge Diagnosis: Cirrhosis Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, or any other concerning symptoms. You may return to your usual healthy diet. If your abdomen becomes distended, you stop passing gas, or you begin burping, go back to having only sips of clear liquids. If your symptoms worsen or do not resolve, call the clinic number above or come to the ED. No driving if taking narcotic pain medications. You did not have surgery on this admission and do not need a surgical follow-up visit. However, please keep the appointment we have made for you with your usual hepatologist Dr. ___ to monitor your liver function. Followup Instructions: ___

{'Abdominal pain': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Nausea': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Vomiting': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Fever': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Tenderness': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Distension': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Right hemi-abdominal pain': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites'], 'Gas pain': ['Partial intestinal obstruction', 'Alcoholic cirrhosis of liver with ascites']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EGD with biopsies History of Present Illness: PCP: Dr. ___ ___ year-old man with abdominal pain that started the morning of admission. The episodes last ___ minutes, 8 out of 10 in severity, sharp in quality, diffuse, but most severe in upper abdomen, and occurred 4 times prior to presentation. He had black, loose stools x 4 episodes on morning of ___ with stool urgency, but no stool incontinence. He had nausea without vomiting. He drinks ___ beers each weekend, but has been cutting down. He used Ibuprofen 600mg once one week prior to admission for a headache. Otherwise, the patient has loose stools once or twice weekly, but not black-colored. Denies constipation. No current fever or chills. His diet typically consists of pizza, burritos, and beer. Currently states that his pain is 7 out of 10 in the umbilical area. Denies ever having alcohol withdrawal symptoms. Review of Systems: (+) Per HPI (-) Denies night sweats, weight change, visual changes, oral ulcers, bleeding nose or gums, chest pain, shortness of breath, palpitations, orthopnea, PND, lower extremity edema, cough, hemoptysis, dysuria, hematuria, easy bruising, skin rash, myalgias, joint pain, back pain, numbness, weakness, dizziness, vertigo, headache, confusion, or depression. All other review of systems negative. Past Medical History: Anxiety, sees a psychiatrist, Dr. ___ Social History: ___ Family History: Mother with history of heart attack. Father healthy. Physical Exam: VS: 96.3, 138/88, 49, 20, 99% on room air Pain 7 out of 10 in umbilical area GEN: NAD HEENT: EOMI, anicteric sclerae, MMM, no oral lesions NECK: Supple CHEST: CTAB CV: RRR, normal S1 and S2, no murmurs ABD: Soft, nontender, nondistended, bowel sounds present SKIN: No rashes or other lesions EXT: No lower extremity edema NEURO: Alert, oriented x3, CN ___ intact, sensory intact throughout, strength ___ BUE/BLE, fluent speech, normal coordination PSYCH: Calm, appropriate Pertinent Results: Admission Labs: ___ 09:40AM WBC-11.6* Hgb-17.1 Hct-48.4 MCV-85 RDW-13.7 Plt-331 Glu-111* BUN-20 Cr-1.0 Na-140 K-4.4 Cl-105 HCO3-22 ALT-36 AST-46* AlkPhos-74 Amylase-36 TotBili-0.5 Lipase-27 H. Pylori antibody: Negative CXR ___: No acute process CT Abdomen and Pelvis ___: No acute intra-abdominal pathology to explain the patient's pain. Specifically, normal appendix. EGD: Erythema in the antrum compatible with gastritis (biopsy normal); erythema in the duodenal bulb compatible with duodenitis Discharge Labs: ___ 07:20PM WBC-4.3# RBC-4.80 Hgb-13.9*# Hct-40.0 MCV-83 Plt ___ ___ 07:25AM Hct-39.1* Brief Hospital Course: ___ year-old man with heavy alcohol use and poor diet presents with severe abdominal pain and black loose stools (guaiac positive) concerning for a GI bleed. # Gastrointestinal bleed: Guaiac positive in ED, with a decrease in his Hct from 48 to 40. Patient had no further bowel movements while in the hospital, and subsequent Hct was stable at 39. He underwent EGD which was notable for duodenitis and gastritis, biopsies of which were within normal limits. H.pylori antibody was negative. It was felt his duodenitis and gastritis were secondary to heavy alcohol use, and patient was advised to abstain from alcohol. He was started on a twice daily proton pump inhibitor, which he should continue until follow-up with ___ gastroenterology. The patient continued to complain of pain following his EGD, and was advised to avoid NSAIDs given the gastritis noted on EGD. He was prescribed Tylenol and a limited supply of Ultram and advised to follow-up with his PCP if his pain persists. He tolerated a full regular diet prior to discharge with no change in his level of pain. # Anxiety disorder: Mood remained stable on Sertraline and Lorazepam. Medications on Admission: Sertraline 150 mg PO daily Lorazepam 1 mg PO BID prn anxiety Zolpidem 10 mg PO QHS prn insomnia Discharge Disposition: Home Discharge Diagnosis: Gastritis Duodenitis 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 abdominal pain and black stools concerning for bleeding from your GI tract. You underwent a procedure called an EGD which found inflammation in your stomach (gastritis) and in the first part of your small intestine (duodenitis). For this you are being prescribed an acid suppressing medication which you will need to take twice a day for a month. You will also need to follow-up with ___ in Gastroenterology. Due to ongoing abdominal pain you are being prescribed a medication called Ultram. However, this medication can interact with medications you are already taking and is not a good long-term option. You are being given a one day supply of this medication, and will need to discuss your pain control further with your primary care physician ___. It is very important that you stop drinking, as this can worsen the inflammation in your stomach. It is also important that you avoid medications such as Ibuprofen, Motrin, Advil, Naproxen, and Alleve, as these can also worsen the inflammation. You can use Tylenol as needed for pain. Followup Instructions: ___

{'abdominal pain': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'black, loose stools': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'nausea': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'sharp pain': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'diffuse pain': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'upper abdominal pain': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'pain in umbilical area': ['Unspecified gastritis and gastroduodenitis', 'Duodenitis'], 'anxiety': ['Anxiety state']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: ASA overdose Major Surgical or Invasive Procedure: HD History of Present Illness: Initial history and physical is as per ICU team . This is a ___ year-old male with a history of previous suicide attempt who is transferred to ___ from ___ after presenting there following aspirin overdose. He took 200 pills of ASA 325mg in a suicide attempt and then called his brother. He was taken to ___. ASA level on presentation to OSH was 21.7 and then rose to 51. Bicarb gtt was initiated. Reports that this was a suicide attempt sparked by the poor economy, rising gas prices, etc. He currently denies SI/HI and states that he wants to live. . In the ED, initial vital were T: 98.2 BP: 139/107 HR: 103 RR: 20 O2sat: 98%RA. Urine and serum tox screens were negative. Repeat aspirin level here was 105. Creatinine was elevated to 1.3. VBG was 7.43/35/48. Bicarb drip was continued. Renal was consulted who recommended hemodialysis and HD line was placed by renal team upon presentation to the FICU. . ROS: + Tinnitus. He currently denies fevers/chills. He is diaphoretic and feels antsy. He denies LH/dizziness. No changes in vision. No CP/SOB, no cough. No abdominal pain/N/V. No dysuria/urinary frequentcy. No rahses. Past Medical History: Previous suicide attempt appox ___ yrs ago Social History: ___ Family History: Non contributory Physical Exam: Tmax: 36.1 °C (96.9 °F)Tcurrent: 35.9 °C (96.7 °F) HR: 96 (96 - 132) bpm BP: 103/41(53) {93/41(53) - 146/89(98)} mmHg RR: 27 (19 - 27) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm)Height: 67 Inch GEN: Diaphoretic, jittery, anxious HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: Sinus tachycardia, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs clear anteriorly, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II – XII grossly intact. Moves all 4 extremities. Strength and sensation to soft touch grossly intact. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: On admission: ___ 09:45PM BLOOD WBC-8.1 RBC-5.30 Hgb-16.6 Hct-46.1 MCV-87 MCH-31.4 MCHC-36.1* RDW-13.9 Plt ___ ___ 09:45PM BLOOD Glucose-126* UreaN-14 Creat-1.3* Na-141 K-4.2 Cl-101 HCO3-22 AnGap-22 ___ 09:45PM BLOOD ALT-29 AST-26 LD(LDH)-193 CK(CPK)-182* AlkPhos-70 TotBili-0.2 ___ 09:45PM BLOOD Albumin-4.9* Calcium-9.1 Phos-3.7 Mg-2.4 ___ 09:45PM BLOOD ASA-105* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:03AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: This is a ___ year-old male without significant PMH who presents following suicide attempt with aspirin overdose. . # Aspirin overdose/suicide attempt: Pt had no signs or symptoms of bleed and remain afebrile from time of admission until transfer out of the unit. ASA level on admission was 105 and trended down to 15 at time of transfer to the floor. Pt initially had AG met acidosis with compensatory resp alkalosis. He was initially placed on a bicarb gtt but this was d/c'd ___. Toxicology and renal were consulted and pt had HD line placed followed by HD on ___. HD line is to be removed by renal on ___. Psych was consulted and recommended inpatient psychiatry unit placement. He was watched a 1:1 sitter on the floor. At time of transfer to the inpatieent floor, he denied any SI or other thoughts of hurting himself. He remaineed medically stable and will be transferred to ___ 4 for further psychiactric care. . # ARF: Cr was 1.6 at admission. ASA can cause interstitial nephritis, papillary necrosis, proteinuria. Creatinine now down to 1.0 from 1.3 on admission, within normal range . # FEN: Regular diet. . # Code: FULL. # Dispo: transfer to inpatient psychiatry unit Medications on Admission: None Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO daily prn as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Aspirin Overdose, suicide attempt Discharge Condition: Good Discharge Instructions: -Transfer to inpatient psychiatric unit for further care -Follow up with PCP after discharge. Followup Instructions: ___

{'Tinnitus': ['Poisoning by salicylates'], 'Diaphoresis': ['Poisoning by salicylates'], 'Anxiety': ['Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics'], 'Elevated creatinine': ['Acute kidney failure']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: none History of Present Illness: ___ G1P0 at 25w0d with known posterior previa who presents with first episode of spotting in this pregnancy. No ctx, LOF. +FM. Past Medical History: ___ ___ tri us Labs Rh+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS unknown Genetics LR ERA FFS normal, complete posterior previa GLT not yet done Issues 1. post previa on FFS OBHx: G1 GynHx: hx LGSIL ___, no f/u. PMH: denies PSH: denies Social History: ___ Family History: non-contributory Physical Exam: (on admission) VITALS: T 98.6, HR 108, BP 113/71 GENERAL: A&O, comfortable ABDOMEN: soft, gravid, nontender GU: no bleeding on pad EXT: no calf tenderness TOCO no ctx FHT 150/mod var/+accels/-decels On discharge: afebrile, VSS Gen: NAD Abd: soft, nontender, gravid ___: without edema Pertinent Results: n/a Brief Hospital Course: ___ y/o G1P0 with posterior previa diagnosed at 20 weeks admitted to the antepartum service at 25w0d with small spotting. On admission, she was hemodynamically stable with no further bleeding. Speculum exam was deferred given her spotting had resolved. Fetal testing was reassuring. She was admitted to the antepartum service for observation. She had an ultrasound in the CMFM which revealed persistent complete previa. She was given two doses of betamethasone and had no active bleeding so she was discharged home in good condition on hospital day 2 with bleeding precautions and outpatient followup. Medications on Admission: prenatal vitamins Discharge Medications: 1. Prenatal Vitamins 1 TAB PO DAILY 2. Ranitidine 150 mg PO BID:PRN heartburn Discharge Disposition: Home Discharge Diagnosis: posterior placenta previa, spotting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the antepartum service after having some spotting, which has since resolved. You received a complete course of steroids and had reassuring monitoring during your stay. You had an ultrasound done which showed a persistent placenta previa covering the cervix. Your doctors feel ___ are safe to go home with outpatient followup. Please call your doctor right away if you notice any additional vaginal bleeding or start having contractions. Your zantac prescription has been sent to the ___ on ___ ___. Followup Instructions: ___

{'vaginal bleeding': ['Placenta previa without hemorrhage'], 'spotting': ['Placenta previa without hemorrhage', 'antepartum condition or complication']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: EGD Colonoscopy Biopsy during colonoscopy Lumbar puncture attach Pertinent Results: ADMISSION LABS: ___ 11:00AM WBC-10.0 RBC-4.66 HGB-8.4* HCT-30.9* MCV-66* MCH-18.0* MCHC-27.2* RDW-20.1* RDWSD-45.3 ___ 11:00AM NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77 AbsEos-0.00* AbsBaso-0.02 ___ 11:00AM PLT COUNT-225 ___ 11:00AM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15 ___ 11:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT BILI-1.0 ___ 11:00AM ALBUMIN-4.9 ___ 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+* Microcy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13* ___ 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8 Ferritn-5.6* TRF-285 ___ 11:42AM BLOOD Hapto-208* ___ 07:20AM BLOOD TSH-1.1 ___ 07:20AM BLOOD 25VitD-17* ___ 03:30AM BLOOD IgA-162 ___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-146* RBC-7* POLYS-1 ___ MONOS-12 BASOS-1 OTHER-0 ___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-141* RBC-2 POLYS-1 ___ MONOS-3 OTHER-0 ___ 03:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-100* GLUCOSE-57 ___ 11:00AM Lyme Ab-NEG ___ 04:45PM BLOOD Trep Ab-NEG ___ 07:20AM BLOOD HIV Ab-NEG ___ 03:05PM BLOOD Parst S-NEGATIVE MICRO: ___ 3:40 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE TUBE #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. HSV CSF HSV2 + low positive IMAGING: CT head w/o acute intracranial process Discharge Labs: ___ 06:00AM BLOOD WBC-5.6 RBC-3.79* Hgb-7.2* Hct-27.1* MCV-72* MCH-19.0* MCHC-26.6* RDW-22.1* RDWSD-56.4* Plt ___ ___ 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143 K-3.9 Cl-111* HCO3-21* AnGap-11 ___ 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 ___ 05:45AM BLOOD Hapto-126 ___ 07:20AM BLOOD TSH-1.1 ___ 05:50AM BLOOD CEA-1.9 ___ 03:30AM BLOOD IgA-162 Colonoscopy: Circumferential mass of malignant appearance was found in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12 o'clock position. Multiple cold forceps biopsies were performed for histology in the rectal mass. EGD: Normal erythema in the whole esophagus. Erythema in the antrum with gastritis. Erythema in the duodenum compatible with duodenitis. Brief Hospital Course: Hospital Medicine Attending Progress Note Time patient seen and examined today HPI on Admission: Mr. ___ is a ___ male with a PMHX of partial aortic dissection, HTN, who presents w/ HA & fever x2d concerning for meningitis. Patient reports that 3 days ago, he developed malaise and terrible headache: constant, dull, diffuse. The following day, headache was relenting ___ pain. Also had fever of 102 and took tylenol/ibuprofen without relief of symptoms. He reports nausea and decreased PO intake. Denies vision changes, sensitivity to light, syncope, URI sx, chest pain, shortness of breath, abd pain, diarrhea/constipation, sick contacts. Has mild neck stiffness as well. He lives in ___, does a lot of yardwork. Has had exposure to ticks, mosquitoes, but none he memorably recalls recently. No recent travel hx. No rash. He was feeling entirely well prior to onset of these symptoms. Given terrible headache and fever, he presented to the ED. Hospital Course to Date: The pt was admitted for acute onset headache and fever. LP showed a cell count of 141 with lymphocytic predominance and elevated protein to 100. He was initially started on bacterial meningitis coverage, then narrowed to acyclovir based on negative CSF stain and cultures. Doxycycline was added to cover potential lyme meningitis. The pt's CSF came back positive for HSV PCR. Per ID recommendations from ___: "Would recommend continuing on Acyclovir for now but when safe for discharge can change to Valtrex 1 gram po three times per day to complete 14 day course. In setting of only low positive HSV 2 PCR and extensive outdoor activity would also complete 14 day course of doxycycline even though lyme is less likely." The pt improved dramatically. His headache resolved. Throughout his hospitalization, he had no confusion or neurologic deficits. He was transitioned to oral acyclovir the day before discharge and discharged on PO acyclovir + PO doxycycline for a total 14 day course. Of note, the pt was incidentally found to have an abnormally low Hb on admission. He required 1u PRBC transfusion ___. He denies any known bleeding. GI was consulted and recommended EGD + colonoscopy, performed ___. EGD showed diffuse erythema of the mucosa with no bleeding noted in the antrum, consistent with gastritis. Colonoscopy showed a circumferential mass of malignant appearance in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12:00 position. Colorectal surgery was consulted. They recommended follow up at the colorectal cancer clinic. Follow up was arranged prior to discharge and the pt was aware of the diagnosis and need for follow up. The clinic and colorectal surgery asked for a baseline CEA which was normal. They asked for a staging MRI pelvis which did not show any spread of the presumed cancer. Pathology was sent by GI. Initial pathology showed superficial fragments of tubulovillous adenoma. This was pending at the time of discharge, though initial reports had shown the same diagnosis, so the pt was instructed to follow up with GI. The GI phone number was shared with the patient and he was instructed to call them directly if he did not hear from the clinic within 24 hours. The pt received a total of 2u PRBCs this hospitalization. Hb was 7.2 on the morning of discharge and the pt received 1u PRBCs (the second unit this stay) on the day of discharge after the Hb of 7.2 in order to ensure that his Hb did not drop below 7.0 at home. Close follow up was arranged prior to discharge. The pt had no active bleeding at the time of discharge. Return to ER precautions such as dizziness and increased bleeding were reviewed with the patient. The pt's BP meds were held on admission but restarted prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS:PRN insomnia 2. Citalopram 20 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*12 Capsule Refills:*0 3. Pantoprazole 40 mg PO DAILY RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. ValACYclovir 1000 mg PO TID RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0 5. Citalopram 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Viral meningitis ___ HSV Iron deficiency anemia Rectal cancer Discharge Condition: Stable for outpatient follow up Discharge Instructions: Dear ___, You came to the hospital with severe headache and fevers. You were found to have a viral meningitis with testing showing herpes simplex virus to be the cause. Please continue taking Valtrex and doxycycline until ___ to treat this infection. When you were in the hospital, you were found to have iron deficiency anemia. You were seen by the Gastroenterologists. You underwent an EGD and a colonoscopy. The EGD showed a little stomach irritation. Avoid ibuprofen, higher dose aspirin, and naproxen. Take pantoprazole to help with the irritation. There was no cancer found in the stomach. The colonoscopy showed a rectal cancer. Please follow up as instructed with gastroenterology for a better pathology sample and with the multi-disciplinary colorectal cancer team as instructed. Your appointment with the multi-disciplinary team has already been set up. Call the ___ clinic to set up an appointment with them, in order for them to get a better sample of the tumor. This is needed for the pathologists and oncologists. If you do not hear from the office within 48 hours, call them at: ___. We wish you the best in your recovery. -- Your medical team Followup Instructions: ___

{'headache': ['Herpesviral meningitis'], 'fever': ['Herpesviral meningitis'], 'malaise': ['Herpesviral meningitis'], 'nausea': ['Herpesviral meningitis'], 'neck stiffness': ['Herpesviral meningitis'], 'malignant neoplasm of rectum': ['Malignant neoplasm of rectum'], 'ulcer of anus and rectum': ['Ulcer of anus and rectum'], 'gastritis': ['Other gastritis without bleeding'], 'duodenitis': ['Duodenitis without bleeding'], 'hypertension': ['Essential (primary) hypertension'], 'depressive disorder': ['Major depressive disorder, single episode, unspecified'], 'anemia': ['Other iron deficiency anemias']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: atropine eyedrops Attending: ___. Chief Complaint: post-polypectomy bleed Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old woman without significant past medical history who is s/p colonoscopy and polypectomy on ___, presenting with blood per rectum. On colonoscopy, a sessile 8mm benign-appearing polyp and sessile 2cm multilobular poly were completely removed from the proximal transverse and mid -ascending colon respectively. After the colonoscopy she had two episodes "like flowing blood", slept through the night, and then at 8 am on day of presentation had two bloody BMs within 30 minutes where the blood was noticeably darker. She has had occasional dizzininess and weakness recently. In the ED, initial vitals: 97.2 84 114/72 16 94% RA. She was asymptomatic in the ED and no gross rectal bleeding was noted. Guaiac positive with brown/black stools. GI evaluated her and recommended observation for continued bleed and and Hct monitoring q6h. Her admission Hct was 38.9, dropped down to 34.5 over 12 hours. She was admitted due to this Hct drop. At time of admission to medicine, her Hct was 37.8. Vitals prior to transfer: 98.0 72 133/70 16 98%. Currently, the patient reports feeling "good" and has not had any bowel movements over night. She was curious why she was admitted after no episodes of rectal bleeding while under observation. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: Hpylori (started on Pylera ___, not filled script yet), CAD and hypertension. Social History: ___ Family History: Father with CAD and an abnormal prostate. Mother died of colon cancer at age ___. Her siblings are all well. Physical Exam: ADMISSION EXAM --------------- 98.0 72 133/70 16 98% Gen: NAD, AOx3 HEENT: normocephalic / atraumatic. Conjunctiva clear, sclera anicteric. PERRL, EOM intact. Pulm: Clear to auscultation bilaterally, anteriorly and posteriorly. Card: RRR. Normal S1/S2. No MRG. Abd: Normoactive bowel sounds. Soft, NT/ND w/o masses or HSM. Ext: No swelling or deformity. Extremities WWP. Mild bilateral nonpitting edema. Skin: Skin warm and w/o rash, pigmented lesions, petechiae, or ecchymoses. DISCHARGE EXAM --------------- Afebrile, vital signs stable Gen: NAD, AOx3 HEENT: normocephalic / atraumatic. Conjunctiva clear, sclera anicteric. PERRL, EOM intact. Pulm: Clear to auscultation bilaterally, anteriorly and posteriorly. Card: RRR. Normal S1/S2. No MRG. Abd: Normoactive bowel sounds. Soft, NT/ND w/o masses or HSM. Ext: No swelling or deformity. Extremities WWP. Mild bilateral non-pitting edema. Skin: Skin warm and w/o rash, pigmented lesions, petechiae, or ecchymoses. Pertinent Results: ADMISSION LABS -------------- ___ 12:55PM BLOOD WBC-6.7 RBC-4.46 Hgb-13.2 Hct-38.9 MCV-87 MCH-29.7 MCHC-34.0 RDW-13.4 Plt ___ ___ 06:45PM BLOOD Hct-38.0 ___ 01:50AM BLOOD Hct-34.5* ___ 06:55AM BLOOD WBC-6.3 RBC-4.43 Hgb-13.4 Hct-37.8 MCV-85 MCH-30.2 MCHC-35.4* RDW-13.4 Plt ___ ___ 12:55PM BLOOD Neuts-52.1 ___ Monos-4.6 Eos-1.5 Baso-0.7 ___ 06:55AM BLOOD Neuts-45.9* Lymphs-46.1* Monos-4.2 Eos-3.1 Baso-0.7 ___ 12:55PM BLOOD Plt ___ ___ 01:04PM BLOOD ___ PTT-26.6 ___ ___ 06:55AM BLOOD Plt ___ ___ 12:55PM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-142 K-5.7* Cl-106 HCO3-26 AnGap-16 ___ 06:58PM BLOOD K-3.6 DISCHARGE LABS -------------- same as above, same day discharge and no new labs drawn MICROBIOLOGY ----------- none IMAGING ------- none Brief Hospital Course: ___ year old woman who underwent colonoscopy with polypectomy two days prior to presentation, admitted with blood in stools and hematocrit drop; resolved upon admission. ACTIVE ISSUES ------------- #. Rectal Bleeding/Hematocrit drop: Patient with likely mild post-polypectomy bleed 1 day following colonoscopy. She was observed in the ED for 24 hours without bleeding, but was admitted to medicine for further monitoring in light of a 4 point HCT drop (39 to 34). On admission to medicine, HCT improved to 37. The patient had no abdominal pain, cramping, or evidence of bleeding. She was able to tolerate a regular diet. She was discharged to home with PCP and gastroenterology ___. INACTIVE ISSUES --------------- #.Hypertension: Blood pressure was stable. She was not taking her prescribed metoprolol succinate or aspirin prior to admission. These were not given in the hospital. Her home dose of valsartan was continued. The patient should follow up with her PCP for further management of her hypertension. #.Hyperlipidemia: PRAVASTATIN 80 mg was continued. #.H. pylori: No upper gastrointestinal symptoms during admission. She had not started her Pylera treatment yet and this was deferred to outpatient so that she may complete her full course withut interruptions. TRANSITIONAL ISSUES ------------------- ___: PCP and ___ follow up appointments were scheduled Code status: Full Contact: daughter ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Pravastatin 80 mg PO DAILY 3. Valsartan 80 mg PO DAILY hold for SBP < 110 4. Aspirin 81 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Pravastatin 80 mg PO DAILY 3. Valsartan 80 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily 6. Aspirin 81 mg PO DAILY hold for ___ days following discharge 7. Metoprolol Succinate XL 25 mg PO DAILY You were not taking this prior to admission. Please discuss with your PCP whether to resume it. Discharge Disposition: Home Discharge Diagnosis: post-polypectomy bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to the hospital with a small amount of bleeding after a colonoscopy. Your blood counts initially went down in the emergency department, but then returned to your normal blood counts. You had no abdominal pain and no evidence of bleeding for 24 hours when admitted to the medical floor. You were able to tolerate a regular diet and were discharged to home. Follow up with your primary care physician and gastroenterology for routine care. Followup Instructions: ___

{'post-polypectomy bleed': ['Hemorrhage complicating a procedure'], 'hypertension': ['Unspecified essential hypertension'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'dizziness': [], 'weakness': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Nausea, anorexia, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Deafness (uses ASL), GERD, HTN, Metastatic Pancreatic Cancer (mets to liver, recently on palliative gemcitabine), CBD obstruction (s/p sphincerotomy and metal stent placement) who recently was admitted for pain control and possible pancreatitis (s/p celiac plexus block and increased pain regimen), now returns with nausea, vomiting, abdominal pain and decreased PO intake Pt was last discharged on ___ after being admitted for possible pancreatitis vs pain ___ progression of malignancy. She had celiac nerve plexus block and had oxycontin initiated. As a result pain was improved and patient was discharged with outpatient oncology followup OF note, patient is deaf and uses ASL to communicate for complex decision making, but was able to communicate by writing and with lip reading for purposes of this interview. Pt noted that since discharge she has had intermittent abdominal pain which is epigastric and radiating to the back, which comes on in spasms, with sharp stabbing sensation. She noted that her pain may be slightly improved compared to prior though. However, she is more concerned with nausea/vomiting at home with yellow colored vomitus and lack of po intake ___ decreased appetite. Denied fever, chills, sore throat, dysuria, rash, significant diarrhea. In the ED, initial vitals: 98.1 107 122/87 18 99% RA. Labs revealed WBC of 23 (recent baseline was 12), Hgb 11.9 (baseline 9.5), plt 585 (baseline 268). Chem wnl, LFTs unchanged since last admission. Lipase 123 down from 500 on last admit. Lactate normal. She was given IVF, Zofran, and dilaudid. She noted that she felt unsafe going home as did not feel remarkably improved so was admitted to oncology for further care. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per OMR "presented in ___ to ___ with painless jaundice. At the time, she also noted several weeks of nausea, vomiting, postprandial abdominal pain and a 20-pound weight loss. She was referred to ___ where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA ___ was elevated at 180 U/mL. She underwent endoscopic ultrasound ___, which identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by ___ showed adenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding but no definite involvement at the ___ and ___. There was no evidence of distant metastases. Ms. ___ was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX ___. C1D15 was dose reduced for N/V/D. She was hospitalized ___ with diarrhea, nausea, anorexia, and neutropenia. Her C2D15 treatment was held. With cycle 3 she transitioned to mFOLFOX. She completed five infusion and was taken to the OR ___. Liver metastases were identified intraoperatively, and plans for resection were aborted. She initiated palliative chemotherapy with gemcitabine ___. The dose was reduced to 750mg/m2 on C1D8 due to neutropenia. With cycle 2 she transitioned to day 1 and 15 schedule. Following six cycles there was further progression, and she was referred for combination gemcitabine/nab-paclitaxel" PAST MEDICAL HISTORY: 1. Hypertension. 2. Congenital deafness. 3. GERD. 4. Goiter. 5. History of nephrolithiasis. 6. Hypercholesterolemia. 7. Status post C-section x 2. 8. CBD obstruction s/p sphincerotomy and metal stent placement via ERCP Social History: ___ Family History: The patient's father died of an MI at ___ years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at ___ years. Another sister died of ___ disease. She has two sons without health concerns. Physical Exam: Vitals: 98.3 134/84 104 18 98RA ___: Sitting in bed, appears comfortable, no acute distress EYES: PERRLA HEENT: Moist mucous membranes, oropharynx clear NECK: Supple LUNGS: Clear to auscultation bilaterally no wheezes rales or rhonchi, normal respiratory rate CV: Regular rate and rhythm without any murmurs rubs or gallops ABD: Slight epigastric tenderness to moderate palpation, nondistended, normoactive bowel sounds, no ascites EXT: Normal bulk/tone, no deformity SKIN: Warm/dry, no rash NEURO: Alert and oriented ×3, fluent speech but has difficulty with correct pronunciation as is deaf, but reads lips and writes to communicate ACCESS: chest port with dressing c/d/i Pertinent Results: ___ 02:10PM WBC-23.0*# RBC-4.30# HGB-11.9 HCT-37.1 MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* RDWSD-48.4* ___ 02:10PM PLT COUNT-585*# ___ 02:10PM cTropnT-0.05* ___ 02:10PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-153* TOT BILI-0.5 ___ 02:10PM LIPASE-123* ___ 02:10PM GLUCOSE-132* UREA N-10 CREAT-0.4 SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18* ___ 02:53PM LACTATE-1.7 Brief Hospital Course: Ms ___ is a pleasant ___ year-old female with deafness admitted with recurrent abdominal pain, nausea, and poor appetite attributed to her pancreatic cancer. Her anti-nausea and pain medications were adjusted to achieve better symptom control, including increase of her oxycontin dose from bid to tid, and adding baclofen to address some element of back spasm. Her appetite remained minimal, but she was able to tolerate fluids throughout her stay. She met with Dr ___ our ___ Care service and discussed options for home hospice, though at the time of discharge she remains uncertain whether she may pursue palliative chemotherapy instead. Her ___ agency has the ability to deliver hospice care and will continue to offer information on this option after she arrives home. Throughout her admission she was seen at least daily with the assistance of our ASL interpreter. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Ondansetron ODT ___ mg PO Q8H:PRN nausea 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 4. Omeprazole 20 mg PO DAILY 5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 8. Polyethylene Glycol 17 g PO DAILY constipation 9. Senna 17.2 mg PO BID constipation 10. OLANZapine 5 mg PO BID:PRN nausea 11. Magnesium Citrate 300 mL PO ONCE 12. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Baclofen 5 mg PO Q8H:PRN Back Pain RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*2 2. lidocaine 5 % topical QAM RX *lidocaine [Lidoderm] 5 % apply to left upper abdomen qam Disp #*30 Patch Refills:*3 RX *lidocaine 5 % apply to left upper abdomen qam Disp #*30 Patch Refills:*2 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 4. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H abdominal pain 5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area 6. Magnesium Citrate 300 mL PO ONCE 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation 8. Multivitamins W/minerals 1 TAB PO DAILY 9. OLANZapine 5 mg PO BID:PRN nausea 10. Omeprazole 20 mg PO DAILY 11. Ondansetron ODT ___ mg PO Q8H:PRN nausea 12. Polyethylene Glycol 17 g PO DAILY constipation 13. Senna 17.2 mg PO BID constipation Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Metastatic pancreatic cancer 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 take your medications as prescribed. Followup Instructions: ___

{'Nausea': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Anorexia': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Abdominal pain': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Vomiting': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Weight loss': ['Abnormal weight loss'], 'Deafness': ['Sensorineural hearing loss', 'bilateral'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Hypertension': ['Essential (primary) hypertension'], 'Thrombocythemia': ['Essential (hemorrhagic) thrombocythemia'], 'Leukocytosis': ['Elevated white blood cell count', 'unspecified'], 'Hypovolemia': ['Hypovolemia'], 'Pain': ['Neoplasm related pain (acute) (chronic)'], 'Family history': ['Family history of malignant neoplasm of digestive organs'], 'BMI': ['Body mass index [BMI] 21.0-21.9', 'adult']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ w/ HTN, DL, congenital deafness, and recently diagnosed borderline resectable pancreatic head adenocarcinoma, on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. She had ERCP with stent placement done yesterday. No complications with that. She reports multiple episodes of watery brown non-bloody diarrhea for the past two days. She reports not eating or drinking as much over the past several months. Also some nausea on and off over the same time period. She reports mild gas pain but denies abdominal pain and vomiting. In ED, initial vitals were Temp 97.7, HR 91, BP 102/65, RR 15, O2 sat 98% RA. She received 1L NS. CXR was negative for infection. Vitals prior to transfer were Temp 98.1, HR 77, BP 106/66, RR 16, O2 sat 100% RA. On arrival to the floor, she reports that she is feeling well. She denies fevers/chills, headache, dizziness/lightheadedness, shortness of breath, cough, chest pain, palpitations, abdominal pain, vomiting, constipation, dysuria, and rashes. Past Medical History: HTN congenital deafness GERD Goiter Social History: ___ Family History: Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased, ___. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.3, BP 125/89, HR 69, RR 18, O2 sat 100% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: Alert, oriented, good attention and linear thought, CN II-XII intact. Strength full throughout. SKIN: No significant rashes. Brief Hospital Course: ___ is a pleasant ___ w/ HTN, DL, congenital deafness, and recently diagnosed borderline resectable pancreatic head adenocarcinoma, on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. Diarrhea- She has 2 loose watery diarrhea everyday mostly at AM. Her stool c diff was negative. She was started on Imodium and the dose was titrated up to 4mg TID but she still continued to have loose watery diarrhea. Her diarrhea is most likely from Irinotecan. She was also started on peptobismol to help her diarrhea Elevated Lipase- She had a mild elevation of lipase levels but this is likely from her having a ERCP on the day prior to admission. She does not have any epigastric abdominal pain or lipase levels high enough to suspect pancreatitis. Her blood and urine cultures were negative during this admission. She was discharged home in a stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. LORazepam 0.5 mg PO BID:PRN anxiety,nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate 7. Dexamethasone 4 mg PO BID Discharge Medications: 1. Bismuth Subsalicylate 30 mL PO TID ___ cause black discoloration of stool RX *bismuth subsalicylate [Bismatrol] 525 mg/15 mL 15 ml by mouth three times daily Refills:*0 2. LOPERamide 4 mg PO Q8H RX *loperamide 2 mg 2 tablets by mouth three times daily Disp #*50 Capsule Refills:*1 3. Dexamethasone 4 mg PO BID take for 2 days after chemotherapy 4. Lisinopril 20 mg PO DAILY 5. LORazepam 0.5 mg PO BID:PRN anxiety,nausea RX *lorazepam 0.5 mg 1 tablet by mouth twice daily Disp #*30 Tablet Refills:*1 6. Omeprazole 20 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 9. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Diarrhea-likely from Irinotecan. Pancreatic cancer Discharge Condition: stable alert and oriented to time place and person independent ambulation Discharge Instructions: Dear ___, It was a pleasure taking care of you. You were admitted since you developed loose stools. We found out that you had no infections causing the diarrhea. It is likely a adverse reaction from chemotherapy agent. Please take Imodium and Peptobismol as directed until your diarrhea is controlled. Please follow up for your appointment with ___ on ___. Sincerely, ___ MD Followup Instructions: ___

{'diarrhea': ['Toxic gastroenteritis and colitis', 'Adverse effect of antineoplastic and immunosuppressive drugs'], 'nausea': ['Adverse effect of antineoplastic and immunosuppressive drugs'], 'gas pain': [], 'abdominal pain': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: CHIEF COMPLAINT: Headache, RLE cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Pt is a ___ year old ___ speaking M w/ PMH of CAD s/p CABG, HTN and HLD presenting to the ED with hypertension recorded at home, found to have RLE cellulitis. Per pt, on the day prior to admission, he began to experience RLE leg pain that was described as more discomfort. This was followed one hour later by an acute onset of headache, chills, shivering/shaking and felt feverish. Pt felt warm to the touch but Temp taken at home was not elevated. Pt took Excedrin at the time of symptom onset, checked his BP at home which showed a reading of 211/110. Pt took 2 doses of Captopril 25mg tablets, and came into the ___ ED for further evaluation. Of note, pt reports that he has had well controlled BP on a beta blocker (trade name: ___ 25mg x1 a day, a Bblocker not available in the US), with baseline BPs in the 120s/50s per home readings. Pt had been fasting for ___ in the day-light hours, but of note, he has been fasting for ___ but states he has been taking his BP meds, as well as his Aspirin 81mg and Lipitor 40mg. In the ED, initial vitals were: 97.7 98 ___ - Labs were significant for Labs were significant for initial Wbc of 9.6 which increased to 17.8 (initial Diff 93.2%N), low Phos at 1.4, low Mg of 1.5 but otherwise normal Mg and lactate of 1.6. Pt received ___, CT head, and Chest CXR were negative for acute process. - The patient was given 500NS bolus, 125ml/hr maintenance. Cefazolin, Vanc, Ceftriaxone, Tylenol and , IV Mag, IV Phos + 3 packets NeutraPhos, Potassium Chloride 40 mEq - EKG was notable for 1mm STD V3-V4 and TWI when BP was in 200's systolic. First trop neg and second value .02. Repeat ECG after control of BP shows sub-1mm STD in V3-V4. Trop resolved. - Cards was consulted who believed patient had demand ischemia in setting of febrile cellulitis and hypertensive emergency which resolved. They had no suspicion of plaque rupture and no need for anticoagulation. While in the ED he spiked to T100.5 HR 81 BP 103/50 RR 24 SpO2 96% RA. Pt continued to improve on IV Abx therapy, with vitals prior to transfer T 97.8 HR 73 BP 106/53 RR 24 SpO2 97% RA. Upon arrival to the floor, pt was afebrile with stable VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA. Pt was comfortable sitting in bed, with no pain in the LLE, resolution of his headache symptoms and no chills or shakes. Pt did endorse feeling subjectively warm, and endorsed 2x episodes of diarrhea. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: HLD HTN CAD s/p CABG Social History: ___ Family History: Denies family history of CAD Physical Exam: PHYSICAL EXAM: Vitals: VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA General: Alert, oriented, sitting upright in bed, in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Systolic murmur, regular rate and rhythm, audible S1 S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Full ROM of RLE at knee and ankle. Skin: Warm, smooth, erythematous area extending from ankle to upper calf just below knee. Area marked. Warm to touch, with minimal tenderness to palpation Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission ========== ___ 05:10PM GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-134 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16 ___ 05:10PM CALCIUM-8.7 PHOSPHATE-3.2# MAGNESIUM-2.0 ___ 01:00PM cTropnT-<0.01 ___ 06:45AM cTropnT-0.02* ___ 10:30AM ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-146 CK(CPK)-50 ALK PHOS-47 TOT BILI-2.4* DIR BILI-0.2 INDIR BIL-2.2 ___ 10:30AM WBC-17.8*# RBC-4.95 HGB-14.4 HCT-41.6 MCV-84 MCH-29.1 MCHC-34.6 RDW-12.9 RDWSD-39.2 ___ 01:09AM URINE HOURS-RANDOM ___ 01:09AM URINE UHOLD-HOLD ___ 01:09AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Discharge =========== ___ 07:17AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-102 HCO3-22 AnGap-15 ___ 07:17AM BLOOD Calcium-8.4 Phos-1.5*# Mg-1.8 ___ 07:17AM BLOOD ALT-28 AST-37 AlkPhos-49 TotBili-1.4 ___ 07:17AM BLOOD WBC-11.9* RBC-4.73 Hgb-13.9 Hct-40.0 MCV-85 MCH-29.4 MCHC-34.8 RDW-13.2 RDWSD-40.7 Plt ___ Imaging ========== Chest Xray ___ IMPRESSION: No acute cardiopulmonary abnormality. CT Head ___ IMPRESSION: Mild involutional change. No evidence of hemorrhage. ___ ___ IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. The peroneal veins are not visualized. Brief Hospital Course: This is a ___ year old ___ male recently immigrated to ___ with past medical history of CAD s/p CABG presenting ___ with headache, chills, and subjective fever in setting of fasting for ___, as well as hypertension on check at home, in ED found to have RLE cellulitis and hypertensive emergency (SBP 211mmHg with EKG changes concerning for demand ischemia), with quick normalization of blood pressures on oral regimen (and normalization of EKG changes), treated with antibiotics with significant improvement, discharged home with scheduled appointment to establish care at ___. # Acute Cellulitis right leg: patient presented after acute onset of RLE pain, swelling and progressively worsening erythema; exam consistent with acute cellulitis; otherwise notable for leukocytosis WBC 17.9, afebrile. He was started on Cefazolin 2G IV Q8H with rapid improvement, receding from the area marked in the ED, WBC downtrending to 11.9. He was transitioned to PO Cephalexin 2GM Q8H prior to discharge with an expected ___nding on ___. # Malignant Hypertensive / Accelerated Hypertension - patient admitted with SBP 211mmHg; during that time he had nonspecific ST/Twave changes noted and troponin peaking at 0.02. His blood pressures rapidly improved with oral metoprolol. Repeat EKG improved, troponins downtrended. Underlying etiology felt to relate to possible missed doses of home antihypertensive. On day of discharge BP ranged 110s-120s/60s-70s. Patient on nabivolol from ___ (not available here), declined transition to blood pressure agent sold here, but willing to discuss when establishing with PCP. # Hyponatremia / Hypokalemia / Hypophosphatemia / Hypomagnesemia - Na of 132, K of 3.4, Phos 1.0 and Mg 1.5 on presentation, all thought to related to insensible losses from infection as well as ongoing fasting during ___. He was repleted with improvement. Counseled patient that due to his acute illness, team advised against additional fasting which could pose a risk to his health. #CAD s/p 3 vessel CABG - as above, he had evidence of cardiac strain in setting of hypertension that resolved with blood pressure control; while inpatient he was given metoprolol (as nabivolol is not available here), home Aspirin and Atorvastatin. See above re: blood pressure management medications. Transitional ------------- - In setting of fasting for ___, he was noted to have some electrolyte deficiencies - he was counseled that, given his illness, would avoid fasting - To complete a 10 day course of antibiotics end date ___ - Noted to have mild thrombocytopenia during this admission, stable; could consider outpatient workup Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. nebivolol 25 ng oral DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Acetaminophen 325-650 mg PO Q6H:PRN fever RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills:*0 3. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp #*33 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. nebivolol 25 ng oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Cellulitis Hypertensive emergency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was our pleasure caring for you in ___ ___. You came to the hospital because you were feeling unwell and had high blood pressure. You were found to have a skin infection and we gave you antibiotics and you improved. Your blood pressure improved as well. You were doing better so you were able to go home. Followup Instructions: ___

{'headache': ['Other acute and subacute forms of ischemic heart disease'], 'chills': ['Other acute and subacute forms of ischemic heart disease'], 'shivering/shaking': ['Other acute and subacute forms of ischemic heart disease'], 'felt feverish': ['Other acute and subacute forms of ischemic heart disease'], 'leg pain': ['Cellulitis and abscess of leg, except foot'], 'erythematous area': ['Cellulitis and abscess of leg, except foot'], 'tenderness': ['Cellulitis and abscess of leg, except foot'], 'warm to touch': ['Cellulitis and abscess of leg, except foot'], 'hypertension': ['Unspecified essential hypertension'], 'elevated blood pressure': ['Unspecified essential hypertension'], 'demand ischemia': ['Other acute and subacute forms of ischemic heart disease'], 'ST/Twave changes': ['Other acute and subacute forms of ischemic heart disease'], 'troponin peaking': ['Other acute and subacute forms of ischemic heart disease'], 'hyponatremia': ['Hyposmolality and/or hyponatremia'], 'hypokalemia': ['Hypopotassemia'], 'hypophosphatemia': ['Disorders of phosphorus metabolism'], 'hypomagnesemia': ['Disorders of magnesium metabolism']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Prostate cancer, obstructive symptoms Major Surgical or Invasive Procedure: TURP, bipolar History of Present Illness: ___, who was seen in preparation today for his upcoming TUR prostate scheduled for ___. His TUR prostate is part of his ongoing treatment program set up for his stage T3A and B adenocarcinoma of the prostate, associated with high residual urine volumes in the 400s. He has been on Lupron therapy since ___ and his residual urine volume today is 234 mL. Indeed rectal exam reveals a tumor outside the capsule. A history and physical was done and I went over the operation with the patient and his wife including the fact that part of his obstructive problem is lack of dynamic voiding due to scarring and infiltration of the tumor into the bladder neck area. Therefore, removing the obstruction may not completely free up his voiding such that he may still have an elevated residual urine volume, but it should be better than it is today. In addition, I will leave a small amount of extra tissue at the apex to assure against incontinence as the entire prostatic area may be somewhat rigid and removing all of the prostatic tissue could result in incontinence. Putting all this together, the operation will be done carefully to open it up as much as possible without any incontinence problems. Past Medical History: - history of low-grade colitis diagnosed on colonoscopy at ___ in ___, started on Canasa suppository and was on them for about a month, but has not used them in over ___ years. He saw occasional trace blood in the stool, but nothing regularly. He has not had a colonoscopy since ___ - hypertension. Social History: ___ Family History: Father had coronary disease and his mother had ___ disease. Paternal uncle had stomach cancer and his maternal grandfather had stomach cancer. Physical Exam: AFVSS NAD, pleasant and conversive non-labored breathing soft, non-tender, non-distended 3-way catheter in place, draining clear yellow urine WWP grossly non-focal Brief Hospital Course: Mr. ___ was admitted to Dr. ___ service after bipolar transurethral resection of prostate. No concerning intraoperative events occurred; please see dictated operative note for details. He patient received ___ antibiotic prophylaxis. The patient's postoperative course was uncomplicated. He received intravenous antibiotics and continuous bladder irrigation overnight. On POD1 the CBI was discontinued and Foley catheter was kept in place with plans for follow up the following week in clinic for vodiding trial. His urine was clear and and without clots. He remained afebrile throughout his hospital stay. At discharge, the patient had pain well controlled with oral pain medications, was tolerating regular diet, ambulating without assistance. He was given pyridium and oral pain medications on discharge and a course of antibiotics along with explicit instructions to follow up in clinic with Dr. ___. Medications on Admission: Lisinopril 20 mg daily, hydrochlorothiazide 12.5 daily, Flomax 0.4 mg b.i.d. Discharge Medications: 1. bacitracin zinc 500 unit/gram Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for penile irritation: apply to tip of penis for pain relief. Disp:*1 tube* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain, fever>100. Disp:*60 Tablet(s)* Refills:*0* 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: to be taken until catheter removed. Disp:*20 Tablet(s)* Refills:*0* 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain: for pain not relieved with tylenol or ibuprofen. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Prostate cancer, obstructive symptoms Discharge Condition: Stable, Good A/Ox3 Functionally independent Discharge Instructions: INSTRUCTIONS: -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve MEDICATIONS: -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in followup AND your foley has been removed (if not already done) -Complete a course of antibiotics (Ciprofloxacin) -You will be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. Also, if the Foley catheter and Leg Bag are in place--Do NOT drive (you may be a passenger). Followup Instructions: ___

{'Prostate cancer': ['Malignant neoplasm of prostate'], 'obstructive symptoms': ['Malignant neoplasm of prostate', 'Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)'], 'high residual urine volumes': ['Malignant neoplasm of prostate', 'Incomplete bladder emptying'], 'tumor outside the capsule': ['Malignant neoplasm of prostate'], 'scarring and infiltration of the tumor into the bladder neck area': ['Malignant neoplasm of prostate', 'Bladder neck obstruction'], 'low-grade colitis': [], 'hypertension': ['Unspecified essential hypertension']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - Percutaneous coronary intervention with thrombectomy and no stent History of Present Illness: Mr. ___ is a healthy ___ year-old male who presented with back pain and chest pain following a crossfit work-out and was found to have a dissection of the abdominal aorta in addition to new q waves on EKG and a mildly elevated troponin. The patient reports that he had a strenuous work-out the morning of admission. At home, shortly following the work-out, he experienced acute onset back pain across his back below the clavicle. This was associated with a cold sweat. The pain did not subside and when the patient tried to climb his stairs at home, he felt extremely week and thus presented to the ___ at ___. Upon presentation his back pain began to subside but he did begin to experience some mild central chest pain. At the ___, he was hemodynamically stable. An EKG was obtained which demonstrated new inferior q waves and a troponin was measured at 0.04. A CTA was obtained which demonstrated an abdominal aortic dissection of the infrarenal aorta. He was therefore transferred to ___ for further care. Here CT repeated – still no ascending dissection. Overnight echocardiogram poor quality, no obvious WMA. This morning’s echo showed slight inferior HK. Cardiac biomarkers rising and pt noted to have Q waves with slight STEs inferiorly. He went to cath and was found to have a RCA lesion. He had a thrombectomy with no stent and has a 50% residual distal RCA stenosis. Admitted to the CCU for further monitoring. Vitals on transfer were: T 98.2, HR 63, BP 123/71, RR 21, 99% RA. On the floor, patient reports that he feels "great" with no chest pain, back pain, shoulder pain or SOB. Only complaint is of mild lower abdominal dull pain. Past Medical History: PCP ___ ___ EKG with first-degree heart block sinus bradycardia, pt is asymptomatic, no further actions GERD L4/L5 microdiscectomy Otherwise healthy Social History: ___ Family History: Father: angioplasty, afib Mother: afib ___ grandfather may have had MI Otherwise mainly history of cancer (lung) No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.2, HR 63, BP 123/71, RR 21, 99% RA Gen: Pleasant gentleman, NAD HEENT: MMM NECK: no JVP elevation CV: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes ABD: soft, +BS, mild tenderness in mid lower quadrant EXT: warm, well-perfused, +pulses SKIN: warm, dry, no rashes or lesions NEURO: A&Ox3, CNII-XII grossly intact DISCHARGE PHYSICAL EXAM: ======================== VS: T 98.2, HR 60-70s, BP 120s/70s, RR ___, 97-99% RA Gen: Pleasant gentleman, NAD HEENT: MMM NECK: no JVP elevation CV: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes ABD: soft, +BS, mild tenderness in mid lower quadrant EXT: warm, well-perfused, +pulses SKIN: warm, dry, no rashes or lesions NEURO: A&Ox3, CNII-XII grossly intact Pertinent Results: Admission Labs: =============== ___ 06:15PM BLOOD WBC-11.3* RBC-4.61 Hgb-13.4* Hct-40.5 MCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-41.2 Plt ___ ___ 06:15PM BLOOD Neuts-76.8* Lymphs-15.5* Monos-7.2 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.67* AbsLymp-1.75 AbsMono-0.81* AbsEos-0.00* AbsBaso-0.02 ___ 06:15PM BLOOD ___ PTT-27.9 ___ ___ 06:15PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-27 AnGap-12 ___ 12:19AM BLOOD CK(CPK)-2278* ___ 06:15PM BLOOD CK-MB-52* ___ 12:19AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0 Discharge Labs: =============== ___ 06:40AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.9* Hct-37.3* MCV-90 MCH-28.7 MCHC-31.9* RDW-12.8 RDWSD-42.0 Plt ___ ___ 06:40AM BLOOD ___ PTT-28.4 ___ ___ 06:40AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-101 HCO3-26 AnGap-15 ___ 10:45AM BLOOD CK(CPK)-713* ___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0 ___ 04:55AM BLOOD %HbA1c-5.2 eAG-103 ___ 11:26AM BLOOD Triglyc-627* HDL-65 CHOL/HD-2.6 LDLmeas-73 ___ 04:24AM BLOOD CRP-2.8 Troponin Trend: =============== ___ 06:15PM BLOOD cTropnT-0.21* ___ 12:19AM BLOOD CK-MB-157* MB Indx-6.9* cTropnT-0.70* ___ 03:58AM BLOOD CK-MB-178* MB Indx-7.3* cTropnT-1.37* ___ 09:58AM BLOOD CK-MB-171* MB Indx-6.7* cTropnT-1.82* ___ 04:24AM BLOOD cTropnT-2.77* ___ 11:26AM BLOOD CK-MB-3 cTropnT-<0.01 CK Trend: ========= ___ 12:19AM BLOOD CK(CPK)-2278* ___ 03:58AM BLOOD CK(CPK)-2432* ___ 09:58AM BLOOD CK(CPK)-2562* ___ 11:26AM BLOOD CK(CPK)-74 Micro: ======= RPR: Imaging: ========= CTA ___: 1. Infrarenal abdominal aortic aneurysm as detailed above originating at the level of the ___ and extending into the proximal right common iliac artery. No significant change compared to recent CT. 2. Normal thoracic aorta without dissection. CXR ___: Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. EKG (___): NSR, nl axis, no ST changes TTE (___): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. An aortic dissection cannot be excluded. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CARDIAC CATH (___): RCA occluded with thrombus in mid- to distal-vessel. LAD and circumflex free of disease. Brief Hospital Course: ___ y/o previously healthy gentleman presenting with a type B aortic dissection complicated by an NSTEMI in the context of a cross-fit workout. # CORONARIES: 50% distal RCA occlusion, LAD and circumflex clean # PUMP: EF > 55% # RHYTHM: normal #) TYPE B AORTIC DISSECTION: Mr. ___ is a healthy ___ year-old male who presented with back pain and chest pain following a crossfit work-out and was found to have a dissection of the abdominal aorta. The dissection was located just beneath the takeoff of the ___, and terminating at the proximal most aspect of the right common iliac artery. Although he is a male he has no other clear risk factors, including HTN, age, CAD, vasculitis, bicuspid aortic valve, family history, h/o AVR, or cocaine use. We continued tight BP control - SBP<140 with IV/PO BB. He had no evidence on exam or imaging of end-organ or lower extremity ischemia. Therefore, the is no indication for emergent vascular surgery intervention. He will need f/u imaging in 6 months and will follow up with ___. His ESR and CRP were within normal limits and his RPR was not reactive. #) ACUTE CORONARY SYNDROME: He went to cath and was found to have a RCA lesion. He had a thrombectomy with no stent and has a 50% residual distal RCA stenosis. Admitted to the CCU for further monitoring after thrombectomy and we continued heparin 24h after procedure (starting it 4 hours after procedure). The patient is a Killip Class I indicating 6% mortality based on an updated study in JAMA performed at ___ and ___ published in ___. We continued aspirin 81mg daily, ticagrelor 90 BID, atorvastatin 10mg daily. TRANSITIONAL ISSUES: ========================= [] f/u aortic imaging in 6 months Medications on Admission: None. Discharge Medications: 1. TiCAGRELOR 90 mg PO BID RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*6 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 4. Metoprolol Succinate XL 12.5 mg PO DAILY RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - TYPE B AORTIC DISSECTION - ACUTE CORONARY SYNDROME Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to the hospital because you were having chest pain. We found that you were having a heart attack and we broke down a clot from one of your hearts blood vessels to treat that. Other imaging found that the wall of your large blood vessel, the aorta had formed a slit called a dissection. The vascular surgeons and did not think you needed to have a surgical repair at this time. It will be very important for you to keep good control of your blood pressure, and follow-up with the vascular surgeons, your PCP, and your new cardiologist (Drs. ___ and ___. Should you have any chest pain, please use the nitroglycerin pills we have prescribed for you. Take up to three pills, spaced 5 minutes apart. If the pain does not go away after this, call ___. If your pain does go away, call either Dr. ___ Dr. ___ an appointment. Finally, we have started you on several new medications because of your heart attack. These are very important, and must be taken every day. They are: 1) Ticagrelor (Brillinta) 90 mg twice a day. This will be continued for at least 3 months, and potentially as long as 9 months. The duration of this will be decided in follow-up appointments with Dr. ___ 2) Aspirin 81 mg daily, likely for the forseeable future 3) Metoprolol succinate 12.5 mg daily, on an ongoing basis 4) Atorvastatin 80 mg daily, on an ongoing basis It was a pleasure taking care of you! Your ___ Team Followup Instructions: ___

{'Chest pain': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Back pain': ['Dissection of abdominal aorta'], 'Cold sweat': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Extremely week': ['Non-ST elevation (NSTEMI) myocardial infarction', 'Dissection of abdominal aorta'], 'Mild lower abdominal dull pain': ['Dissection of abdominal aorta']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) History of Present Illness: Mr. ___ is a ___ year old male with lactose intolerance who presented to ED with abdominal pain and hematemesis since the night prior to admission. He reports that he ate ___ food and a slice of pizza on ___ at ~5pm. At ~10 pm he reports onset of crampy epigastric pain with occasional epigastric burning pain that was relieved only by laying on his side. He took peptobismol which improved the pain, and had a normal bowel movement. At ~1am he woke up and had an episode of forceful vomiting during which he vomited ___ times, the last time he vomited about ___ cup of bright red blood. He went back to bed and woke up hours later and drank water because he felt dehydrated, and this caused him to vomit again, this time his vomited had dried blood more similar to coffee grounds. At this time he also had a loose, brown, non-bloody bowel movement. Finally, at ~5am he again drank water which prompted a third episode of vomiting coffee ground material. Patient endorses drinking coffee, and having ___ drinks of alcohol approximately twice per week. He denies recent NSAID use, and reports using NSAIDs ___ month about 2 pills each time. In the ED, initial VS were 99.2 122 153/90 16. Received 2L NS with improvement noted in his tachycardia, NG lavage showed bright red blood and clots which did not clear after >300cc output. He additionally received a DRE which was heme negative. NG tube was removed while in the ED. Patient was started on IV PPI and GI was consulted. Patient was transferred to floor pending GI consult. Transfer VS 97.7 89 142/70 16 100%RA One review of systems, he endorsed abdominal pain, nausea, vomiting, hematemesis and diarrhea as detailed in HPI. He denied fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, cough, shortness of breath, chest pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. On arrival to the floor, patient reports mild ongoing abdominal pain. Denies lightheadedness or palpitations. No additional acute symptoms. Past Medical History: - Lactose intolerance (keeps a lactose free diet) - Tonsillectomy and arytenoidectomy ___ years old) - Wisdom tooth extraction ___ years old) Social History: ___ Family History: -Father, aged ___, suffers from Diverticular Disease for ___ years which has been refractory with well maintained diet and hydration. Gallbladder removed for unspecified reasons. -Mother, aged ___, suffers from GERD and "thyroid problems." Has had recurrence of breast cancer 3 times with 2x being treated with chemotherapy and radiation and the ___ recurrence being treated with full mastectomy, all in same breast. -Grandmother (maternal) Passed from stomach cancer in early ___ -Grandfather: died from myocardial infarction -2 Brothers, aged ___ and ___, no medical conditions No family history of bleeding disorders. Physical Exam: ADMISSION PHYSICAL EXAM: VS 98.9 130/80 96(up to 120s on tele when ambulatory) 18 97%RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions DISCHARGE PHYSICAL EXAM Tmax 100.0 Tc 99.0 BP 120/73 (117-160/63-80) HR 83 (83-97) RR 20 (___) O2sat 99%RA (97-99%RA) General: Alert, oriented, cooperative, in no acute distress HEENT: NCAT, MMM, PERRLA, EOMI, anicteric sclerae, OP clear Neck: supple, no JVD, no palpable lymphadenopathy Pulm: Good aeration, CTAB without wheezes, rales, or ronchi Cor: RRR, normal S1, S2, no MRG Abdomen: soft, non-tender, non-distended, no rebound or guarding, no palpable hepatosplenomegaly, positive bowel sounds Extremities: WWP, 2+ radial and dorsalis pedis pulses bilaterally, no C/C/E Skin: No ulcers or lesions noted Pertinent Results: ___ 07:25AM BLOOD WBC-6.1 RBC-4.70 Hgb-14.6 Hct-42.0 MCV-89 MCH-31.0 MCHC-34.7 RDW-12.5 Plt ___ ___ 03:35PM BLOOD WBC-9.0 RBC-4.39* Hgb-13.8* Hct-39.3* MCV-90 MCH-31.4 MCHC-35.1* RDW-12.4 Plt ___ ___ 10:00AM BLOOD WBC-13.4* RBC-4.90 Hgb-15.3 Hct-43.5 MCV-89 MCH-31.2 MCHC-35.1* RDW-12.6 Plt ___ ___ 06:00AM BLOOD WBC-12.2* RBC-5.08 Hgb-16.0 Hct-44.2 MCV-87 MCH-31.6 MCHC-36.2* RDW-12.3 Plt ___ ___ 06:00AM BLOOD Neuts-90.8* Lymphs-3.8* Monos-4.1 Eos-0.8 Baso-0.4 ___ 06:00AM BLOOD ___ PTT-27.7 ___ ___ 07:25AM BLOOD Glucose-94 UreaN-6 Creat-0.8 Na-139 K-3.6 Cl-102 HCO3-27 AnGap-14 ___ 06:00AM BLOOD Glucose-127* UreaN-15 Creat-0.9 Na-137 K-4.2 Cl-102 HCO3-25 AnGap-14 ___ 06:00AM GFR = >75 ___ 03:35PM BLOOD ALT-44* AST-23 LD(LDH)-130 AlkPhos-61 TotBili-1.1 ___ 07:25AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9 ___ 03:35PM BLOOD Albumin-3.9 ___ CHEST (PA & LAT): FINDINGS: PA and lateral radiographs of the chest demonstrate clear lungs without focal consolidation concerning for pneumonia, pleural effusion or pneumothorax. The pulmonary vasculature is not engorged. The cardiac silhouette is normal in size. The mediastinal and hilar contours are within normal limits. There is no evidence of pneumomediastinum. The trachea is midline. The visualized upper abdomen is unremarkable. IMPRESSION: No acute cardiopulmonary pathology, specifically no evidence of pneumomediastinum. ___ 11:30:00 AM EGD Report: IMPRESSION: Localized erythema in the gastroesophageal junction possibly consistent with healed erosion or MW tear(biopsy). Erythema in the fundus compatible with gastritis. Mild erythema in the antrum compatible with gastritis (biopsy). Normal mucosa in the whole duodenum. Otherwise normal EGD to third part of the duodenum. RECOMMENDATIONS: Follow up biopsy results from antrum and esophagus. Hematemesis most likely related to ___ tear from retching. Would recommend daily PPI, advancing diet as tolerated, and observation. Continue recs of inpatient consult team. ___ Pathology Tissue: GI BX'S (2 JARS): A. Gastroesophageal junction biopsy: Squamous epithelium, no diagnostic abnormalities recognized. Gastric type mucosa, no intestinal metaplasia identified. B. Antrum biopsy: No diagnostic abnormalities recognized. Brief Hospital Course: ___ male presents with acute onset of abdominal pain, nausea, vomiting, diarrhea and hematemesis. #Hematemesis: He does not have clear risk factors for upper GI bleed. He reports drinking normal amounts of coffee, denies recent or heavy NSAID use, although he does report drinking ___ drinks approximately twice a week. There was no history or symptoms consistent with PUD, GERD, or H. pylori as the presentation appears to have been acute over one to two days. He denies family history of bleeding or clotting disorders. Differential considered included bleeding ulcer ___ tear vs AVM. Given the extent of blood loss with evidence of early hemorrhagic shock including tachycardia on presentation, GI was consulted and performed an urgent EGD for evaluation which showed localized erythema in the gastroesophageal junction consistent with healed erosion or ___ tear, erythema consistent with gastritis in the antrum and fundus, and otherwise wnl to third part of duodenum. History and EGD findings were most consistent with ___ tear. Biopsies from antrum and GE junction returned grossly normal without diagnostic abnormalities. Patient received Pantoprazole 40 mg IV while in ED. He was kept on IV pantoprazole and switched to omeprazole 40 mg PO daily the evening after EGD. His diet was advanced following the procedure, and he tolerated a regular diet well prior to discharge. His vital signs remained normal and stable throughout his hospitalization, and he did not experience any further episodes of vomiting or hematemesis. Per GI recs, we discharged him on a two week course of omeprazole 40 mg PO daily. We set up follow-up with his PCP in two weeks. Patient was advised to avoid fatty foods, caffeine, alcohol, spicy foods and anything that could irritate his stomach. #Hemorrhagic shock - no hypotension He presented with tachycardia and orthostatic symptoms without blood pressure drop (headache, mild dizziness on rising from bed). He received 2L NS in ED with good heart rate response. Upon arrival to floor heart rate was trending back up and increased >120 with standing on several occassions. He underwent urgent EGD which did not reveal active bleeding. He received an additional 1L bolus of NS on transfer to the floor, and was maintained on ___ continuous at 75-125 ml/hr while he diet was advanced to a regular diet. He was maintained on telemetry, which was only notable for several non-sustained, asymptomatic episodes of tachycardia upon standing and walking. His vital signs were monitored throughout and he never developed hypotension, or other signs or symptoms of hypovolemia. Hematocrit was trended 44.2-->43.5-->39.3-->42.0 on ___, ___, and ___ respectively. Two 18 gauge peripheral IVs were maintained throughout his hospitalization, as well as active type and crossmatch. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Omeprazole 40 mg PO DAILY Duration: 14 Days RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*14 Capsule Refills:*0 2. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: ___ Tear Upper GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were treated in the hospital for bleeding your GI tract. You underwent endoscopy of your upper GI tract which showed evidence of irritation of the stomach lining. There was an area of irritation where the stomach and esophagus meet which was most likely the source of your bleeding. You have been placed on a medicine to suppress acid production in your stomach. You should continue to take this until your follow up appointment with your new primary care physician in two weeks. You had biopsies taken from your stomach during the endoscopy. The results of your biopsies were normal without diagnostic abnormalities. You can follow up with your primary care physician regarding the results. Followup Instructions: ___

{'Abdominal pain': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Hematemesis': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Nausea': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Vomiting': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Tachycardia': ['Other shock without mention of trauma'], 'Orthostatic symptoms': ['Other shock without mention of trauma'], 'Lactose intolerance': ['Intestinal disaccharidase deficiencies and disaccharide malabsorption'], 'Alcohol use': ['Tobacco use disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / fluconazole Attending: ___. Chief Complaint: Elevated WBC, malaise Major Surgical or Invasive Procedure: None History of Present Illness: ___ with ETOH hepatitis and pancreatitis episode ___ with prolonged hospitalization at ___ c/b PNA, sepsis, respiratory failure, and pancreatic pseudocyst s/p endoscopic cystogastrostomy ___ and ___ drainage of R flank collection ___ c/b infection of pseudocyst (___), ___ fungemia, & severe necrotizing pancreatitis s/p laparoscopic drainage and debridement ___, on home tube feeds and outpatient micafungin therapy, now presents at the behest of her outpatient caregiver due to an elevated WBC to 18 on routine outpatient labs. She does endorse some malaise, myalgias, and mild SOB for the past ___s a change in character of her drain output from a purulent yellowish color to a purulent brown/tan color, however drain quantity has remained unchanged at about 40cc per day. Has had some non-radiating LLQ pain around her ostomy for the past couple weeks that is dull and not exacerbated by palpation or tube feeds (via dobhoff) and has been stable, but she does feel that oral intake occasionally makes this pain increase. Denies nausea or emesis and continues to pass stool and gas from her ostomy, has lost ___ lbs over the past month. She continues to have intermittent low-grade fevers at home, but no fevers of 101 or higher, no chills or sweats. RUE ___ site is cared for by home RN's and the cap is changed weekly, last changed today, and she has not noticed any swelling or redness or drainage from this site. No pain with urination, urinary frequency, or discharge. No dizziness, lightheadedness, chest pain, cough. Surgery is now consulted regarding her elevated WBC and generalized malaise. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: Discharge physical exam: Vital signs afebrile and stable Gen: Alert and oriented, no acute distress CV: RRR Pulm: No respiratory distress Abdomen: Soft, non-distended, mildly tender, ostomy with foul smelling brown stool, R flank drainage with small amount of brown liquid Extremities: warm and well perfused Pertinent Results: ___ 09:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-LG ___ 09:20PM URINE RBC-7* WBC-50* BACTERIA-FEW YEAST-NONE EPI-11 TRANS EPI-<1 ___ 09:20PM URINE MUCOUS-MANY ___ 05:20PM GLUCOSE-107* UREA N-12 CREAT-0.5 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19 ___ 05:20PM estGFR-Using this ___ 05:20PM ALT(SGPT)-28 AST(SGOT)-22 ALK PHOS-129* TOT BILI-0.3 ___ 05:20PM LIPASE-11 ___ 05:20PM ALBUMIN-4.3 ___ 05:20PM WBC-20.4*# RBC-4.78 HGB-13.2 HCT-40.1 MCV-84 MCH-27.6 MCHC-32.8 RDW-15.6* ___ 05:20PM NEUTS-82.5* LYMPHS-9.3* MONOS-6.8 EOS-1.1 BASOS-0.4 ___ 05:20PM PLT COUNT-295 US from ___: Nonocclusive thrombus extending from the right subclavian vein into the axillary and central portion of the basilic vein. There is no DVT in the distal basilic vein, cephalic vein or paired brachial veins. Brief Hospital Course: Ms. ___ was admitted on ___ after being found to have an elevated WBC in combination with malaise and some abdominal pain. She was pan-cultured on admission. Her blood cultures revealed negative cultures in those drawn from peripheral IV's, however in the blood culture from the PICC, viridans strep, coag-neg staph, and micrococcus grew. Her clostridium difficile PCR test at the same time was positive. The infectious disease service was then consulted. They recommended that she be on IV vancomycin for 14 days for her gram positive bacteremia and po vancomycin for 2 months. They planned to follow her in clinic to gradually wean the dose of po vanc. On HOD1, she did note some blood from her R flank drain however this never occurred again during her hospitalization. On ___, IV nurse attempted to place a R sided PICC line however follow chest xray revealed it was curled up in the arm. She then went to interventional radiology for placement of a PICC on ___. The radiology placement was unsuccessful and it prompted for RUE US. US revealed right subclavian vein thrombosis. Patient was started on SC Lovenox. Her antibiotics were changed to Linezolid per ID. Also per ID, her micafungin was stopped on ___. During her hospitalization, her WBC was trended and was normalized at the time of her discharge. Her electrolytes were also monitored and repleted as necessary. At the time of discharge, she was voiding, ambulatory, and mentating well. Her ostomy output was brown and foul smelling. The output from the drain on the R flank was decreasing in quantity and mostly liquid brown. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Duloxetine 60 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Gemfibrozil 600 mg PO BID 4. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain 5. Pancrelipase 5000 2 CAP PO TID W/MEALS 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Micafungin 100 mg IV Q24H 8. Pantoprazole 40 mg PO Q24H 9. Tamoxifen Citrate 20 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Milk of Magnesia 30 mL PO HS:PRN constipation 12. Multivitamins 1 TAB PO DAILY 13. Senna 2 TAB PO HS:PRN constipation Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Gemfibrozil 600 mg PO BID 5. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Micafungin 100 mg IV Q24H 8. Milk of Magnesia 30 mL PO Q6H:PRN constipation 9. Multivitamins 1 TAB PO DAILY 10. Pancrelipase 5000 2 CAP PO TID W/MEALS 11. Pantoprazole 40 mg PO Q12H 12. Senna 1 TAB PO BID:PRN constipation 13. Tamoxifen Citrate 20 mg PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Clostridium difficile colitis 2. Gram positive bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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 follow-up with your surgeon and Primary Care Provider (PCP) as advised. 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. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PICC Line: *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 or proceed 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. What to watch out for when you have a Dobhoff Feeding Tube: 1. Blocked tube: If the tube won't flush, try using 15 mL carbonated cola or warm water. If it still will not flush, ___ your nurse or doctor. Always be sure to flush the tube with at least 60 mL water after giving medicine or feedings. 2.Vomiting: ___ doctor if vomiting persists. Vomiting causes the loss of body fluids, salts and nutrients. *Give the feeding in an upright position. *Try smaller, more frequent feedings. Be sure the total amount for the day is the same though. *Infection may cause vomiting. Clean and rinse equipment well between feedings. *Do not let formula in the feeding bag hang longer than 6 hours unrefrigerated. After the formula can is opened, it should be stored in refrigerator until used. 3. Diarrhea: *This is frequent loose, watery stools. *Can be caused by: giving too much feeding at once or running it too quickly, decreased fiber in diet, impacted stool or infection. Some medicines also cause diarrhea. *Avoid hanging formula for longer than 6 hours. *Give more water after each feeding to replace water lost in diarrhea. ___ doctor if diarrhea does not stop after ___ days. 4. Dehydration: *Due to diarrhea, vomiting, fever, sweating. (Loss of water and fluids) *Signs include: decreased or concentrated (dark) urine, crying with no tears, dry skin, fatigue, irritability, dizziness, dry mouth, weight loss, or headache. *Give more water after each feeding to replace the water lost. ___ your doctor. 5. Constipation: ___ be caused by too little fiber in diet, not enough water or side effects of some medicines. *Take extra fruit juice or water between feedings. *If constipation becomes chronic, ___ the doctor. 6. Gas, bloating or cramping: Be sure there is no air in the tubing before attaching the feeding tube. 7.Tube is out of place: If the tube is no longer in your stomach, tape it down and ___ your doctor or home health nurse. Do not use the tube. You will need to have a new tube placed. 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. *Try to maintain ostomy output between 1000mL to 1500mL per day. Followup Instructions: ___

{'malaise': ['Intestinal infection due to Clostridium difficile', 'Bacteremia', 'Dehydration'], 'myalgias': ['Intestinal infection due to Clostridium difficile', 'Bacteremia', 'Dehydration'], 'mild SOB': ['Intestinal infection due to Clostridium difficile', 'Bacteremia', 'Dehydration'], 'elevated WBC': ['Intestinal infection due to Clostridium difficile', 'Bacteremia'], 'non-radiating LLQ pain': ['Cyst and pseudocyst of pancreas'], 'fevers': ['Intestinal infection due to Clostridium difficile', 'Bacteremia'], 'malaise and some abdominal pain': ['Intestinal infection due to Clostridium difficile', 'Bacteremia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / fluconazole Attending: ___. Chief Complaint: dehydration, abdominal pain, and tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: Ms ___ is a ___ with ETOH hepatitis and pancreatitis on ___ with a prolonged hospitalization at ___ c/b PNA, sepsis, respiratory failure, and pancreatic pseudocyst, s/p endoscopic cystogastrostomy ___ and ___ drainage of R flank collection ___ c/b infection of pseudocyst ___ fungemia, & severe necrotizing pancreatitis s/p laparoscopic drainage and debridement ___. She was most recently readmitted to ___ on ___ for increased WBCs and malaise, and a work up was notable for blood cultures from her PICC which grew viridans strep, coag-neg staph, and micrococcus grew and clostridium difficile PCR test at the same time was positive. She was treated with Vancomycin and transitioned to Linezolid and started on Micafungin per ID recomendations. She was ultimately discharged to a rehab on ___ in stable condition. Since discharge, the patient has been doing well, went from rehab to home two weeks prior to presenting and has been tolerating a regular diet. One week prior to presentation, however, she noticed a sharp burning pain at the site of her RLQ drain that she reported was ___ in severity and has persisted. She also noted that during this time, her RLQ drain, which had been working its way out over the past few weeks, had withdrawn back into her wound. Over the past few days, her RLQ pain has persisted and radiates across her epigastrum and along her back and increases to ___ in severity. Given the persistent abdominal and back pain, she presented to clinic today for evaluation. In addition to pain, she endorses poor po intake, dark urine, and feeling dehdraded. She denies emesis or fevers during this time, but does endorse having some nausea and night sweats. She also reports feeling depressed and is upset that she continues to return to the hospital. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: Pertinent Results: ___ 09:15PM URINE HOURS-RANDOM ___ 09:15PM URINE UCG-NEGATIVE ___ 09:15PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 09:15PM URINE RBC-4* WBC-14* BACTERIA-FEW YEAST-NONE EPI-4 TRANS EPI-<1 ___ 09:15PM URINE MUCOUS-RARE ___ 06:36PM LACTATE-1.1 ___ 06:30PM GLUCOSE-78 UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15 ___ 06:30PM estGFR-Using this ___ 06:30PM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-116* TOT BILI-0.2 ___ 06:30PM LIPASE-14 ___ 06:30PM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 06:30PM WBC-14.6*# RBC-4.97# HGB-13.7# HCT-42.3# MCV-85 MCH-27.6 MCHC-32.3 RDW-14.2 ___ 06:30PM NEUTS-81.4* LYMPHS-11.5* MONOS-4.3 EOS-2.2 BASOS-0.5 ___ 06:30PM PLT COUNT-285 ___ 06:30PM ___ PTT-31.8 ___ Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ from clinic where she had presented with left abdominal pain and tachycardia. Her drain had been removed in clinic and silver nitrate was applied due to some bloody drainage at the site. On admission, she was made NPO, put on IV pain medication, and received IV fluid hydration. CT scan of her abdomen showed an interval decrease in size of a prior peripancreatic fluid collection with question of superinfection of the collection. CT also showed question of a new splenic infarct, a high density in the subcutaneous tissue of the right posterolateral drain tract (which was correlated with the application of silver nitrate at that site), and a destructive appearing right iliac lucency concerning for a metastatic focus (given history of breast cancer). Infectious work up was done that was unremarkable - chest x-ray showed mild atelectasis and urinalaysis was negative. Her labs were also within normal limits with no leukocytosis. On HD2, the patient showed improvement in her abdominal pain and was advanced to a regular diet, which she tolerated well with no nausea and vomiting. Her home medications were restarted, and she was transitioned to PO pain control. Her wound remained covered, and her ostomy was viable. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. We discussed with her the CT finding of possible metastatic disease for which she was follow up with oncology. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Duloxetine 60 mg PO DAILY 3. Gemfibrozil 600 mg PO BID 4. Pancrelipase 5000 3 CAP PO TID W/MEALS 5. Lorazepam 1 mg PO Q8H:PRN anxiety 6. Pantoprazole 40 mg PO Q24H 7. Pregabalin 50 mg PO TID 8. Tamoxifen Citrate 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Senna 1 TAB PO BID:PRN constipation 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Gemfibrozil 600 mg PO BID 5. Lorazepam 1 mg PO Q8H:PRN anxiety 6. Multivitamins 1 TAB PO DAILY 7. Pancrelipase 5000 3 CAP PO TID W/MEALS 8. Pantoprazole 40 mg PO Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Tamoxifen Citrate 20 mg PO DAILY 11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 12. Pregabalin 50 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Dehydration 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: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . 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 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. *Please change your dressing to your right abdomen wound daily and as needed with dry gauze Followup Instructions: ___

{'dehydration': ['Dehydration'], 'abdominal pain': ['Other acute pain', 'Abdominal pain'], 'tachycardia': ['Other chronic pain'], 'poor po intake': ['Secondary diabetes mellitus without mention of complication', 'not stated as uncontrolled', 'or unspecified'], 'dark urine': ['Pure hypercholesterolemia'], 'feeling dehydrated': ['Dehydration'], 'nausea': ['Other chronic pain'], 'night sweats': ['Depressive disorder', 'not elsewhere classified'], 'feeling depressed': ['Depressive disorder', 'not elsewhere classified'], 'history of ETOH hepatitis and pancreatitis': ['Alcohol abuse', 'unspecified'], 'history of breast cancer': ['Personal history of malignant neoplasm of breast'], 'history of chemotherapy': ['Personal history of antineoplastic chemotherapy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Cipro / ciprofloxacin / fluconazole Attending: ___. Chief Complaint: Pancreatic necrosis Major Surgical or Invasive Procedure: ___ - Pancreatic washout and upsizing of pancreatic drain History of Present Illness: ___ with pancreatitis c/b necrosis and pseudocyst s/p multiple drainage procedures and drain placements. Currently has ___ Fr drain in draining thick pancreatic necrotic debris. Concern is that the drain is too small to handle such thick output and should be upsized. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: On discharge: afebrile at 99.2, ___ 121/62 18 99% on RA NAD, A+OX3 no scleral icterus RRR CTAB Soft, TTP around drain site, ND, ostomy appears normal and functioning Right pancreatic drain site draining pancreatic debris. Drain is put in ostomy bag to collect debris. 1+ pitting edema b/l Right thigh has some minimal redness, no fluctuance, no induration Pertinent Results: ___ 06:00AM BLOOD WBC-17.6* RBC-2.92* Hgb-7.5* Hct-24.5* MCV-84 MCH-25.5* MCHC-30.4* RDW-15.9* Plt ___ ___ 08:15AM BLOOD WBC-27.7*# RBC-3.32* Hgb-8.9* Hct-28.7* MCV-86 MCH-26.8* MCHC-31.0 RDW-15.8* Plt ___ ___ 07:30AM BLOOD WBC-19.0* RBC-2.97* Hgb-7.9* Hct-25.2* MCV-85 MCH-26.7* MCHC-31.5 RDW-16.0* Plt ___ ___ 06:00AM BLOOD ___ PTT-27.8 ___ ___ 07:30AM BLOOD Glucose-185* UreaN-5* Creat-0.6 Na-135 K-3.9 Cl-99 HCO3-27 AnGap-13 ___ 06:00AM BLOOD ALT-13 AST-12 LD(LDH)-109 AlkPhos-152* Amylase-17 TotBili-0.2 ___ 06:00AM BLOOD Lipase-18 ___ 11:00 am ABSCESS RETROPERITONEAL FLUID FROM PANCREATIC ABSCESS. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): ___ ALBICANS. ___ blood cultures are pending as of this discharge summary Brief Hospital Course: Mrs. ___ was admitted and underwent drain upsizing and pancreatic washout on ___. She did well afterwards with excellent pain control on oral medications. Her post-operative course was uncomplicated. She was pancultured for a low grade temperature. CXR was normal. UA was negative. Her OR cultures grew back ___ and she was started on Micafungin. A PICC line was placed for long term antibiotics. At the time of discharge she is afebrile. She was started on clears and advanced to fulls while supplementing her nutrition with tube feeds at goal. She has taken enough fulls and her tube feeds were stopped. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nicotine Patch 14 mg TD DAILY 2. Tamoxifen Citrate 20 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Duloxetine 60 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 7. Morphine SR (MS ___ 15 mg PO Q8H 8. Pantoprazole 40 mg PO Q12H 9. Gemfibrozil 600 mg PO BID 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Gemfibrozil 600 mg PO BID 5. Tamoxifen Citrate 20 mg PO DAILY 6. Nicotine Patch 14 mg TD DAILY 7. Morphine SR (MS ___ 15 mg PO Q8H 8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 9. Multivitamins 1 TAB PO DAILY 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 11. Micafungin 100 mg IV Q24H 12. Pantoprazole 40 mg PO Q12H 13. Heparin 5000 UNIT SC TID to be administered if patient is non-ambulatory Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pancreatitis, pancreatic pseudocyst, pancreatic necrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for debridement and upsizing of your pancreatic drain. You have done well and are now safe to return in Nursing Home to complete your recovery with the following instructions: . Please call Dr. ___ office at ___ if you have questions or concerns. . 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. . Pancreatic 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). * The pancreatic drain is placed in an ostomy bag and left to drain via gravity. The nurses ___ flush the drain (20 cc of NS q8hours) and fluid will drain from the tube and around the incision. This is normal and indicates that the drain is working by keeping the pancreatic tract open. * Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . Ostomy care: Please continue current care. Followup Instructions: ___

{'Pancreatitis': ['Acute pancreatitis', 'Cyst and pseudocyst of pancreas', 'Other specified diseases of pancreas'], 'Drain site care': [], 'Ostomy care': [], 'Fever': [], 'Pain': ['Acute pancreatitis'], 'Infection': ['Other and unspecified mycoses'], 'Anemia': ['Anemia', 'unspecified'], 'Diabetes': ['Secondary diabetes mellitus without mention of complication', 'not stated as uncontrolled', 'or unspecified'], 'Hypertension': ['Unspecified essential hypertension'], 'Hypercholesterolemia': ['Pure hypercholesterolemia'], 'Substance abuse': ['Alcohol abuse', 'unspecified'], 'Cancer': ['Personal history of malignant neoplasm of breast', 'Acquired absence of breast and nipple', 'Personal history of antineoplastic chemotherapy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / fluconazole Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ h/o EtOH pancreatitis c/b multiple infected pseudocysts s/p transgastric endoscopic cyst gastrostomy and percutaneous drainage of R flank fluid collection, p/w new LUQ pain x ___ weeks, increasing over the past week (especially yesterday). She was previously taking 6 mg Dilaudid q8h, but now is up to 8mg q8h. No f/c, no n/v. No diarrhea; +constipation. Her TF were decreased in an attempt to encourage PO intake, but eating caused her pain. She reports she takes 2 Ensures and 1 serving of clear liquid per day. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: Prior Discharge: VSS, Afebrile GEN: Pleasant with NAD CV: RRR, no m/r/g PULM: CTAB ABD: Soft, tender for deep palpations around ostomy site. LLQ ostomy with ostomy appliance and brown liquid stool, RUQ ___ drain to gravity drainage into ostomy bag with purulent fluid. EXTR: warm, no c/c/e Pertinent Results: ___ 08:00PM BLOOD WBC-14.1* RBC-4.43# Hgb-12.4# Hct-36.9# MCV-83 MCH-28.1 MCHC-33.7 RDW-16.3* Plt ___ ___ 08:40AM BLOOD WBC-9.1 RBC-4.34 Hgb-12.1 Hct-37.0 MCV-85 MCH-27.9 MCHC-32.8 RDW-16.2* Plt ___ ___ 08:00PM BLOOD Glucose-101* UreaN-7 Creat-0.4 Na-138 K-3.8 Cl-103 HCO3-23 AnGap-16 ___ 08:00PM BLOOD ALT-15 AST-19 AlkPhos-111* TotBili-0.2 ___ 08:00PM BLOOD Albumin-4.0 Calcium-9.6 Phos-3.0 Mg-1.6 ___ 08:00PM BLOOD Lipase-14 ___ ABD CT: IMPRESSION: Decrease in peripancreatic and right posterolateral fluid collections compared to ___. No new fluid collections. Brief Hospital Course: The patient well known for Dr. ___ was admitted to the General Surgical Service for evaluation of increased abdominal pain. On admission, the patient underwent abdominal CT scan which demonstrated multiple multiloculated rim-enhancing fluid collections surrounding the pancreas, but all smaller compare to CT scan from ___, no new collections were identified. Patient remained afebrile with elevated WBC on admission. Patient was made NPO with IV fluids, continued on home dose Micafungin and her pain was well controlled with Dilaudid PCA. On HD # 2, patient's diet was advanced to clears and she was restarted on TF at goal, PCA was converted to PO Dilaudid. Patient was started on aggressive bowel regiment with Colace, Senna and Milk of Magnesia. Patient's abdominal pain improved on clears, and she tolerated tubefeeds at goal. WBC returned to normal on HD # 3. During hospitalization, patient's stoma was evaluated by Ostomy nurse and their recommendations were followed. Patient was discharged home on HD # 4 in stable condition. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Duloxetine 60 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Gemfibrozil 600 mg PO BID 4. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain 5. Pancrelipase 5000 2 CAP PO TID W/MEALS 6. Lorazepam 0.5 mg PO Q8H:PRN anxiety 7. Micafungin 100 mg IV Q24H 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Pantoprazole 40 mg PO Q24H 10. Prochlorperazine 5 mg PO Q6H:PRN nausea 11. Tamoxifen Citrate 20 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Senna 2 TAB PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO Q8H 4. Gemfibrozil 600 mg PO BID 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 6. Micafungin 100 mg IV Q24H 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 20 mL by mouth three times a day:PRN Disp #*200 Fluid Ounce Refills:*3 8. Pancrelipase 5000 2 CAP PO Q 8H 9. Senna 1 TAB PO BID 10. Tamoxifen Citrate 20 mg PO DAILY 11. Florastor (saccharomyces boulardii) 250 mg Oral BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Infected pancreatic pseudocyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at ___ for evaluation of your abdominal pain. You now feel better and are now safe to return home to complete your recovery with the following instructions: . Please ___ Dr. ___ office at ___ if you have any questions or concerns. . 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. . RUQ ___ drain: *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). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *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. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. . PICC Line: *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 or proceed 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. Followup Instructions: ___

{'Abdominal pain': ['Cyst and pseudocyst of pancreas'], 'Constipation': ['Constipation'], 'Diarrhea': [], 'Nausea': [], 'Ostomy': ['Colostomy status'], 'Pain': ['Cyst and pseudocyst of pancreas'], 'Weight loss': ['Loss of weight']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Abacavir / baclofen Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ HIV cirrhosis alcoholism who presents after being discharged from ___ earlier today. He was requesting detox. Soon after discharge, he states that he went home and drank small amount of liquor and believes that he has some pancreatitis. He comes in complaining of epigastric pain that started immediately after consuming alcohol. Some Nausea with emesis. ___ pain. He does not report f/c, chest pain shortness of breath prior or constipation, or diarrhea, weight loss, neuro sx, cough, sudden blindness, rhinorrhea, sore throat, dysuria, He had been sober for ___ years up until ___ but then had flash backs from his PSTD. He then relapsed drinking. His last drink was midnight ___. . In ER: VS: 00:51 8 97.1 100 130/98 18 98% RA . Meds Given: Ondansetron 4 mg 1000 mL NS Morphine Sulfate 2 mg Potassium Chloride 40 mEq Morphine Sulfate 2 mg Potassium Chloride 40 meq Potassium Chloride 40 mEq Fluids given: 1L NS Radiology Studies: none Consults called: none ________________________________________________________________ ROS: SKIN: [] All Normal [+ ] Rash- psoriasis controlled [ ] Pruritus Headache HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [] All Normal [+ ] Mood change- depressed - in the process of changing therapist, his old therapist left and he could not get a referral until ___. [-]Suicidal/Homicidal Ideation [ ] Other: ALLERGY: [ +]Medication allergies: PCN - hives, abacavir -> flu like sx. [ ] Seasonal allergies [X]all other systems negative except as noted above Past Medical History: - HIV - ? Schizoaffective disorder - Alcoholism - Psoriasis - Hypertension - Hepatitis B, resolved per patient report - Peyronie's disease - Hyperlipidemia - Obesity - Gout - LSIL in anal PAP - ___ cyst Social History: ___ Family History: Mother died of pancreatic cancer at age ___. Father died of old age at ___. He was diagnosed with prostate cancer ___ years earlier. Physical Exam: 1. VS: T = 98.7 P = 92 BP = 130/78 RR = 20 O2Sat on _92% on RA GENERAL: Elderly male who looks older than his stated age. Nourishment:OK Grooming:OK Mentation: alert, speaks in full sentences. 2. Eyes: [X] WNL EOMI without nystagmus, Conjunctiva: clear 3. ENT [] WNL [X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [X] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [] WNL [X] Regular [] Tachy [X] S1 [X] S2 [+] Systolic Murmur ___, Location: LUSB [X] Edema RLE None [X] Edema LLE None 2+ DPP b/l [X] Vascular access [X] Peripheral [] Central site: 5. Respiratory [X]WNL [X] CTA bilaterally [ ] Rales [ ] Diminshed [X] Comfortable [ ] Rhonchi [ ] Dullness 6. Gastrointestinal [ X] WNL - NABS [X] Soft [] Rebound [] No hepatomegaly [] Non-tender [+]epigastric tendernes [] No splenomegaly [] Non distended [] distended [+] bowel sounds Yes [] guiac: positive/negative 7. Musculoskeletal-Extremities [X] WNL [ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica [ ] Other: [X] Normal gait []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [X] WNL [X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [X] WNL [X] Warm [X] Dry [] Cyanotic [] Rash: I didn't appreciate any psoriatic lesions 10. Psychiatric [X] WNL [x] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic Pertinent Results: Admission Labs: ___ 01:30AM BLOOD WBC-10.9 RBC-3.88* Hgb-13.5* Hct-37.5* MCV-97 MCH-34.7* MCHC-35.9* RDW-14.6 Plt ___ ___ 01:30AM BLOOD ___ PTT-23.3* ___ ___ 01:30AM BLOOD Glucose-233* UreaN-20 Creat-1.1 Na-140 K-2.5* Cl-102 HCO3-16* AnGap-25* ___ 01:30AM BLOOD ALT-37 AST-56* AlkPhos-108 TotBili-0.3 ___ 01:30AM BLOOD Albumin-4.0 Calcium-8.0* Phos-1.5*# Mg-1.0* ___ 08:00AM BLOOD pH-7.47* Comment-GREEN TOP ___ 08:00AM BLOOD freeCa-0.94* Discharge Labs: ___ 07:37AM BLOOD WBC-6.1 RBC-3.72* Hgb-13.2* Hct-37.4* MCV-101* MCH-35.6* MCHC-35.4* RDW-16.0* Plt Ct-83* ___ 07:37AM BLOOD Glucose-109* UreaN-10 Creat-0.9 Na-141 K-4.1 Cl-105 HCO3-22 AnGap-18 ___ 09:05AM BLOOD ALT-26 AST-39 AlkPhos-93 TotBili-1.1 ___ 07:37AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.4* RUQ Ultrasound: FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. Main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well evaluated due to overlying bowel gas. SPLEEN: Normal echogenicity, measuring 11.2 cm. KIDNEYS: The right kidney measures 11.2 cm. The left kidney measures 10.7 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Brief Hospital Course: ___ year old male with h/o HIV absolute CD4 = 571, HIV viral load undetectable, ETOH who presents with acute pancreatitis, EtOH withdrawal. ACUTE PANCREATITIS: Lipase elevated to 500 on admission. Unclear if he truly had pancreatitis. His presentation was mild as abdominal exam was benign throughout and never tender to palpation. He was initially on bowel rest and then advanced to regular diet. ETOH with withdrawal: Treated for withdrawal on CIWA and scored for approximately 36 hours requiring valium. Symptoms improved over the course of hospitalization. Social work consulted and discussed a plan for treatment as an outpatient. Thrombocytopenia: Drop in platelets on admission. Prior values as low as ~100. This was likely due to a combination of alcohol toxicity, bone marrow suppression and under production of thrombopoeitin from liver disease. Possible sequestration as well. No signs of overt cirrhosis on RUQ. Smear without schistocytes. His platelets had a nadir of 65 and on day of discharge were increased to 81. Hypomag/hypoK/hypocalcemia: He had severe depletion of calcium, magnesium and potassium. This was repeleted aggressively throughout his admission. GOUT: Podagra of the right great toe developed. History of this in the past, treated with colchicine. Diarrhea: Ruled out C diff and this improved during his admission. Chronic issues: HTN: continued atenolol. HIV:well controlled, continued HAART PSORIASIS: Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY GERD: Pantoprazole 40 mg PO Q24H Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 75 mg PO DAILY 2. Acamprosate 333 mg PO TID 3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 4. Multivitamins 1 TAB PO DAILY 5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral QHS 6. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Acamprosate 333 mg PO TID 2. Atenolol 75 mg PO DAILY 3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 4. Multivitamins 1 TAB PO DAILY 5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral QHS 6. Pantoprazole 40 mg PO Q24H 7. FoLIC Acid 1 mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Alcohol withdrawal pancreatitis thrombocytopenia schizoaffective HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, you were admitted to ___ with abdominal pain and alcohol withdrawal. Due to the alcohol abuse you had low calcium, magnesium, and potassium which were all treated aggressively. You were treated for alcohol withdrawal and you met with our social worker to develop a plan for you to help quit alcohol use. Followup Instructions: ___

{'Abdominal Pain': ['Acute pancreatitis'], 'Nausea with emesis': ['Acute pancreatitis'], 'Epigastric tenderness': ['Acute pancreatitis'], 'Mood change- depressed': ['Depressive disorder, not elsewhere classified'], 'Rash- psoriasis controlled': ['Other psoriasis'], 'Headache': [], 'Pruritus': [], 'Easy bruising': [], 'Easy bleeding': [], 'Adenopathy': [], 'Mood change- in the process of changing therapist': [], 'Suicidal/Homicidal Ideation': [], 'Other:': ['Schizoaffective disorder, unspecified', 'Hypopotassemia', 'Esophageal reflux', 'Diarrhea', 'Alcohol abuse, unspecified', 'Body Mass Index 32.0-32.9, adult']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Morphine And Related Attending: ___. Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: none History of Present Illness: ___ h/o chronic LBP s/p spinal cord stimulator with pulse generator revision ___ p/w nausea and vomiting since 5am this morning. . Was in USOH the night prior then awoke feeling unwell, began to have nausea and vomiting (non-bloody, non-bilious). Has been having band-like burning abdominal ___ in-between incision sites since stimulator revision but no new abdominal ___ and no change with PO intake. Denies fevers, chills, or sweats, diarrhea, dysuria, CP, SOB, palpitations. Back ___ is same as baseline but notes that as unable to tolerate POs and take oral ___ meds it has become worse during the day. Denies sick contacts although later found out that her daughter developed nausea and vomiting today. No known ingestion spoiled or questionable food products. Presented initially to ___ ___ where she was afebrile and labs notable for WBC 11.4, normal LFTs and lipase, negative U/A and urine hCG, normal ECG, and KUB with ? air-fluid levels and distended stomach. Transferred to ___ out of concern for possible problem with stimulator and for continuity of care with ___ ___ service. . Regarding spinal cord stimulator, she is f/b Dr. ___ the ___ Service and has responded well but required multiple revisions due to battery failure and possible foreign body reaction at initial site. On ___ the pacemaker generator was moved from the right to left abdominal wall ___ poor wound healing. Since this time she reports occasional lightheadedness. Last seen by Dr. ___ ___ for dermatitis at ___ site and monitoring of post-operative seroma which was improving. . In the ___ ED, afebrile with stable vitals. Labs notable for WBC 8.1 w/ PMN predominance but no bands, normal LFTs and lipase, lactate 1.3. KUB from OSH reviewed and deemed not to have air-fluid levels and no concern for obstruction (passing gas and stool) so therefore not repeated. Dr. ___ ___ regarding stimulator but thought unlikely to be attributed to symtoms. ___ and nausea improved with dilaudid and zofran but remained unable to tolerate POs. Admitted to medicine. Past Medical History: 1. Longstanding LBP and associated multifocal burning ___, numbness, and weakness in both legs since ___ that began during nursing school after lifting a heavy patient, s/p intra-disc electro-thermo therapy which improved the leg weakness and numbnesss, s/p spinal cord stimulator since ___, replaced on several occasions due to battery failure and FB reaction, last ___ (Dr. ___ 2. S/P L5/S1 fusion ___ 3. S/P CCY 4. Undergoing work-up for ?MS with Dr. ___ Social History: ___ Family History: Mother with HTN, hypercholesterolemia. Father alive and well. Physical Exam: Afebrile, VSS General: NAD HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple Cardiac: RRR, s1s2 normal, no m/r/g, no JVD Pulmonary: CTAB Abdomen: +BS, soft, abdominal binder present Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: Admission: ___ 06:00PM BLOOD WBC-8.1 RBC-4.16* Hgb-12.5 Hct-37.5 MCV-90 MCH-30.0 MCHC-33.2 RDW-12.7 Plt ___ ___ 06:00PM BLOOD Glucose-109* UreaN-9 Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-23 AnGap-16 ___ 06:00PM BLOOD ALT-14 AST-22 AlkPhos-55 TotBili-1.0 ___ 06:00PM BLOOD Lipase-24 ___ 08:00AM BLOOD Calcium-7.4* Phos-2.7 Mg-1.7 ___ 06:04PM BLOOD Lactate-1.3 ----------- Discharge: ___ 08:00AM BLOOD WBC-3.4*# RBC-3.60* Hgb-11.0* Hct-32.2* MCV-90 MCH-30.7 MCHC-34.2 RDW-12.3 Plt ___ ___ 08:00AM BLOOD Glucose-104 UreaN-7 Creat-0.8 Na-141 K-3.5 Cl-108 HCO3-23 AnGap-14 ___ 08:00AM BLOOD ALT-13 AST-24 AlkPhos-44 TotBili-0.___ h/o chronic LBP s/p spinal cord stimulator p/w nausea and vomiting. . # Nausea, vomiting: Likely viral gastroenteritis, improved with supportive care and antiemetics. She was tolerating a bland diet on discharge. . # Acute on chronic radiculopathy: No change in chronic symptoms. Chronic ___ service came by to offer reassurance, and felt stimulator change was unlikely to be causing nausea/vomiting. She will follow up with them as an outpatient. Medications on Admission: Neurontin 600 mg QAM, 600 mg Qafternoon, 1800 mg QHS Vicodin ___ mg ___ tabs Q6H prn Valium 5 mg QHS prn leg cramping Motrin prn Discharge Disposition: Home Discharge Diagnosis: 1. viral gastroenteritis 2. chronic back ___ with spinal cord stimulator Discharge Condition: stable, nausea improved, tolerating bland diet. Discharge Instructions: You were hospitalized with nausea and vomiting, which was probably viral gastroenteritis ("stomach bug"). Please call your primary care doctor for questions and concerns, and return to the emergency department with recurrent nausea, vomiting, fever greater than 101, blood in your stool, increased ___ or any other alarming symptoms. Followup Instructions: ___

{'nausea': ['viral gastroenteritis'], 'vomiting': ['viral gastroenteritis'], 'abdominal ___': ['thoracic or lumbosacral neuritis or radiculitis'], 'back ___': ['chronic back ___ with spinal cord stimulator']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: S/P MVC Right leg and chest pain Major Surgical or Invasive Procedure: ___ 1. Irrigation debridement skin to bone right femur. 2. Open reduction internal fixation with intramedullary nail right open femur fracture. History of Present Illness: ___ year old female who unrestrained driver in a high-speed MVC with intrusion to the dashboard noted to have open R femur fx and R rib fx's Past Medical History: PMH none PSH none Social History: ___ Family History: non contributory Physical Exam: Constitutional: uncomfortable HEENT: Normocephalic, atraumatic Trachea midline Chest: Clear to auscultation equal breath sound tender along right chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Extr/Back: Open wound with swelling to right thigh Skin: No rash pulses intact distally Neuro: Speech fluent Psych: Normal mood, Normal mentation Cranial nerves II through XII grossly intact, Motor ___ in all extremities, sensory without focal deficits Pertinent Results: ___ 05:00AM WBC-21.2* RBC-4.83 HGB-14.2 HCT-40.9 MCV-85 MCH-29.5 MCHC-34.8 RDW-13.7 ___ 05:00AM PLT COUNT-337 ___ 05:00AM ___ PTT-21.3* ___ ___ 05:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:07AM GLUCOSE-247* LACTATE-3.3* NA+-140 K+-3.6 CL--102 TCO2-24 ___ 05:00AM UREA N-15 CREAT-0.9 ___ CXR : Minimally displaced rib fractures, left first through third ribs. ___ CTA Chest : 1. Traumatic focal dissection in the proximal descending aorta with expanding contained thrombus since ___. 2. No central pulmonary embolism. 3. Mild pulmonary edema. 4. Small bilateral pleural effusions and adjacent atelectasis. 5. Stable anterior proximal left rib fractures. 6. Fatty liver. ___ MRI Left knee : 1. No evidence of injury to the menisci, ligaments, or tendons. 2. Medial femoral condyle osseous contusion. 3. Full thickness chondral fissure in the lateral tibial plateau. 4. Diffuse subcutaneous soft tissue and vastus muscle edema. ___ CTA Chest : 1. Focal contained, post-traumatic aortic dissection in the proximal descending aorta is unchanged since previous CT dated ___. 2. Stable fractures involving the anterior ends of first and second ribs on left side. Brief Hospital Course: On ___, the patient went to the OR for femur fx repair, she had low O2 sats postoperatively, requiring a non rebreather. On ___, the patient's C-spine was cleared and her diet was slowly advanced. Logroll precautions were d/c'd and patient was started on dilaudid PCA. ON ___, the patient had an acute drop in her HCT down to 23.7, she received a unit of blood and responded appropriately. She continued to have some desaturation with turning/sleeping, but she was able to be transitioned from NRB to NC. On ___, the patient underwent CTA to rule out PE, which showed dissection of the descending aorta. Cardiac surgery was consulted and recommended no surgery, but instead strict blood pressure control. On ___, patient was started on labetalol gtt for better HR and BP control, and this was transitioned to po Lopressor and labetalol gtt was discontinued. Otherwise, patient was doing well, tolerating regular diet. Ortho recommended 50% weight bearing on right leg and full wt bearing on the left leg. The patient was transferred to the floor on ___. Following transfer to the Trauma floor she continued to make good progress. Vascular surgery was consulted regarding her descending thoracic aortic dissection and they recommended Coumadin, aspirin and keeping SBP < 140 mmHg. Her Coumadin was started on ___ at 5mg followed by 7.5 mg on ___ and ___. Her INR on ___ is 1.7 and she will take 5mg daily with an INR check on ___. Dr. ___ PCP ___ dose her Coumadin starting on ___. Her last CTA chest was on ___ which showed no progression of her dissection. Blood pressure control was successful with Lopressor and hydralazine with SBP 95-120/70 and heart rates in the 70's. She will be discharged on Labetolol alone at 100 mg BID and the ___ will follow up with blood pressure checks for the first few days. Her blood sugars have been elevated since admission in the high 100-240 range. She was encouraged to follow up with Dr. ___ ___ further management. From an Orthopedic standpoint she has done well post op. Her incision is healing well and after many Physical Therapy visits she is able to crutch walk safely. Her weight bearing status is partial (50%) on the right leg and full weight bearing on the left. Her staples will be removed by the ___ on ___. After a long recovery she was discharged home on ___ with ___ services for BP checks and Coumadin teaching and monitoring. Medications on Admission: none Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): thru ___. Disp:*4 Tablet(s)* Refills:*0* 9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR ___ to determine future. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: S/P MVC 1. Open right femur fracture 2. Proximal descending thoracic aortic dissection with contained thrombus 3. Left rib fractures ___. Right first rib fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital after your car accident with multiple injuries including a broken right leg, rib fractures and a small tear in your aorta which sealed over. * Your orthopedic surgery went well and your weight bearing status on the right leg is partial weight bearing with crutches. The ___ will take your staples out. * Your injury caused left rib fractures ___ and the right first rib which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * The aortic dissection was noted on your initial CT scan. You need to have good blood pressure control and also must stay on a blood thinner called Coumadin. You will need to have your blood tested frequently in the beginning of therapy but after you are regulated it should be once a month. Maintain safety precautions while on Coumadin so that you don't bleed. Be careful with sharp objects. Shave your legs with an electric razor to prevent cuts that will bleed excessively. Do not use ibuprofen or any product with Ibuprofen in it as it can increase your bleeding tendency. * Dr. ___ will regulate your Coumadin dose. * Your blood sugars have been on the high side since your admission and you should talk to your PCP about further testing for diabetes. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ), chest pain, or increased leg pain. Followup Instructions: ___

{'Right leg and chest pain': ['Open fracture of shaft of femur', 'Injury to thoracic aorta'], 'Minimally displaced rib fractures': ['Closed fracture of four ribs'], 'Traumatic focal dissection in the proximal descending aorta': ['Injury to thoracic aorta'], 'Mild pulmonary edema': ['Acute edema of lung'], 'Small bilateral pleural effusions and adjacent atelectasis': ['Acute edema of lung'], 'Fatty liver': ['unspecified'], 'No evidence of injury to the menisci, ligaments, or tendons': ['unspecified'], 'Medial femoral condyle osseous contusion': ['unspecified'], 'Full thickness chondral fissure in the lateral tibial plateau': ['unspecified'], 'Diffuse subcutaneous soft tissue and vastus muscle edema': ['unspecified'], 'Focal contained, post-traumatic aortic dissection in the proximal descending aorta': ['Injury to thoracic aorta'], 'Stable fractures involving the anterior ends of first and second ribs on left side': ['Closed fracture of four ribs'], 'Low O2 sats postoperatively': ['unspecified'], 'Acute drop in her HCT': ['unspecified'], 'Desaturation with turning/sleeping': ['unspecified'], 'Elevated blood sugars': ['unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Codeine Attending: ___. Chief Complaint: Recurrent effusions Major Surgical or Invasive Procedure: ___ Left video-assisted thoracoscopic surgery parietal pleural biopsy, effusion evacuation, and bronchoscopy. History of Present Illness: Mrs. ___ is an ___ woman with a history of breast cancer and newly diagnosed thyroid nodule suspicious for papillary cancer who has now presented with mediastinal lymphadenopathy which has grown very quickly. She has had workup with an EBUS with biopsy of level VII lymph node which showed suspicion for lymphoma. Past Medical History: - HTN - Hypothyroidism - Breast cancer x2, status post lumpectomy x2, status post XRT. Social History: ___ Family History: Mother: deceased breast cancer. Father ___: Sister deceased MM, Brother deceased lymphoma ___ Other Physical Exam: PHYSICAL EXAM: Height: Weight: Temp: 96.8 HR: 107 BP: 140/70 RR: 22 O2 Sat: 94% RA GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [ ] All findings normal [x] CTA/P [x] Excursion normal [x] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: Decrease breath CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect Pertinent Results: ___ 04:22PM POTASSIUM-3.4 ___ 04:22PM MAGNESIUM-1.7 ___ 04:22PM WBC-6.0 RBC-3.71* HGB-12.0 HCT-35.6* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.0 ___ 04:22PM PLT COUNT-341 ___ 12:50PM OTHER BODY FLUID CD23-D CD45-D ___ ___ KAPPA-D CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D CD5-D ___ 12:50PM OTHER BODY FLUID CD3-D ___ 12:50PM OTHER BODY FLUID IPT-D Brief Hospital Course: Mrs. ___ is an ___ woman with a history of breast cancer and newly diagnosed thyroid nodule suspicious for papillary cancer who has now presented with mediastinal lymphadenopathy which has grown very quickly. She has had workup with an EBUS with biopsy of level VII lymph node which showed suspicion for lymphoma. Patient was brought to the OR for Left video-assisted thoracoscopic surgery parietal pleural biopsy, effusion evacuation, and bronchoscopy. Post-Op: Patient was stable with little pain on exam. CT was placed on suction and diet was advanced as tolerated. POD 1: Patient complained of mild incisional site pain with positive response to Dilaudid. She was started on Colace and maintained oxygen sat at 93-95% on 4L NC. She was subsequently weaned down to 2L NC. She continued to tolerated her diet and IVF were decreased. CXR: In comparison with prior study, there is little change in the appearance of the left chest tube and extensive opacification involving the lower half of the left lung. Dilatation of a gas-filled stomach, for which nasogastric tube might prove helpful. POD 2: Patient re-mained on telemetry w/o events. CT remained to suction with serosanguinous outputs. No leak was observed and no crepitus in the chest wall was appreciable. Patient was weaned to 1.5L NC and reported 1 BM. CXR: Unchanged left lower lobe and middle lobe opacity, consistent with post-surgical changes, or residual lung mass. Pneumonia cannot be ruled out, but is less likely. POD 3: CT placed to water seal. Patient was weaned of 02 and maintained sat's at 93% on RA. Pain was well controlled with Tylenol. Discharge planning was initiated and patient was thought to be fit for discharge home with services. Follow-up CXR showed findings listed below. CXR: Again seen is a left-sided chest tube. There is a new loculated pneumothorax in the left upper lung laterally. POD 4: Patient continued to be stable with good PO-intake, adequate UOP and minimal pain. Given recent CXR patient was kept for a day and Patient CT was clamped at 9:00pm. Repeat CXR showed stable loculation with no new pneumothorax. POD 5: Patient continued to be stable. CT was removed uneventfully and post-pull CXR was ordered. Patient continued to be stable with stable vital prior to discharge. Medications on Admission: Medications - Prescription AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - Dosage uncertain ANASTROZOLE [ARIMIDEX] - 1 mg Tablet - one Tablet(s) by mouth daily LATANOPROST [XALATAN] - (Prescribed by Other Provider) - Dosage uncertain LEVOTHYROXINE - (Prescribed by Other Provider) - Dosage uncertain METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other Provider) - Dosage uncertain PERSERVISION - (Prescribed by Other Provider) - Dosage uncertain TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for prn pain. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left pleural effusion Discharge Condition: stable Discharge Instructions: Call Dr. ___ ___ if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develop drain: steri-strips remove if start to come off. Followup Instructions: ___

{'Recurrent effusions': ['Other malignant lymphomas', 'Unspecified pleural effusion'], 'Mediastinal lymphadenopathy': ['Other malignant lymphomas', 'Intrathoracic lymph nodes'], 'Decrease breath': ['Iatrogenic pneumothorax', 'Pulmonary collapse'], 'Pain': ['Other acute postoperative pain'], 'Hypothyroidism': ['Unspecified acquired hypothyroidism'], 'Breast cancer': ['Personal history of malignant neoplasm of breast'], 'Thyroid nodule': ['Malignant neoplasm of thyroid gland']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Transfer with ? splenic laceration Major Surgical or Invasive Procedure: Diagnostic paracentesis Therapeutic paracentesis of 9 Liters of ascitic fluid History of Present Illness: Mrs. ___ is a ___ woman with alcoholic cirrhosis, continued alcohol abuse, intermittent acute renal failure who presented to an outside hospital after her sister found her on the ground after a fall. At the OSH, she underwent trauma evaluation, which demonstrated a ? splenic laceration, so she was transferred to ___. Upon arrival, she reports abdominal fullness and reports feelign cold, but she has no frank abdominal pain. She denies lower extermity edema, shortness of breath, orthopnea. She denies hematemesis, coffee ground emesis or hematochezia or melena. She reports that her right orbit is mildly painful, but this is improving. All other review of systems negative. Of note, there is some mention in the OSH records of low-grade temps, but it is not apparent that attempts at paracentesis were made. Past Medical History: - EtOH cirrhosis complicated by recurrent ascites and hx of hepatic encephalopathy. Known portal gastropathy. - EtOH abuse/dependence. Denies a history of alcohol withdrawal. - Multiple epsisodes of ARF due to prerenal azotemia versus HRS type II - Anemia - s/p umbilical hernia repair on ___ - Psoriasis Social History: ___ Family History: Negative for family history of liver disease Physical Exam: Vitals: 98.8, 152/78, 73, 18, 95%RA General: Alert, oriented x3, NAD, R eye with surrounding echymossis, jaundiced, HEENT: NCAT, PERRL, EOMI, + scleral icterus, MM dry, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Decreased BS at both bases, R>L Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: Distended, positive fluid wave, shifting dullness Extremities: Trace bilateral edema, 2+ radial, DP pulses b/l Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Pertinent Results: ___ 07:15AM WBC-6.5 RBC-3.39* HGB-10.3* HCT-31.2* MCV-92# MCH-30.4 MCHC-33.1 RDW-19.7* ___ 07:15AM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.1* ___ 07:15AM ALT(SGPT)-25 AST(SGOT)-98* ALK PHOS-142* TOT BILI-4.6* ___ 07:15AM GLUCOSE-77 UREA N-19 CREAT-1.8* SODIUM-136 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16 ___ 09:00AM ___ PTT-53.0* ___ ___ 10:10AM ASCITES WBC-30* ___ POLYS-5* LYMPHS-54* ___ MESOTHELI-2* MACROPHAG-39* ___ 10:10AM ASCITES TOT PROT-2.6 GLUCOSE-97 LD(LDH)-67 ALBUMIN-1.4 ___ 12:35PM HCT-31.2* ___ 10:05PM BLOOD Hct-30.2* ___ 07:10AM BLOOD Hct-31.9* ___ 06:45AM BLOOD Hct-28.9* Imaging: OSH: CT abdomen: massive ascites, wedge-shaped density in the upper aspect of the spleen, splenic laceration cannot be excluded. CT head: soft tissue swelling adjacent to right orbit, no intracranial pathology. CT abd/pelvis ___ at ___: IMPRESSION: 1. Splenic laceration. Unable to evaluate for active extravasation due to lack of IV contrast. 2. Cirrhotic liver with splenomegaly and large ascites. Amount of ascites has increased. 3. Interval decrease in size of left rectus sheath hematoma, almost resolved. 4. Distended gallbladder with appearance of adenomyomatosis at the fundus and possible small gallstone. Brief Hospital Course: Ms ___ is a ___ year-old female with alcoholic cirrhosis who presented to an OSH s/p fall, found to have a splenic laceration and transferred here for further care. # Splenic laceration: Upon arrival she was hemodynamically stable. Radiology was unable to open the imaging on the OSH CD, so a non-contrast abdominal/pelvis CT was completed which showed a moderate-sized splenic laceration (although radiology was unable to tell if it was actively bleeding due to lack of contrast). Her Hct was trended and remained stable in the low 30' to high 20's. Transplant surgery was consulted and recommended conservative management. On discharge her Hct was 28.9. # Alcoholic Cirrhosis: The patient has a history of ESLD with history of encephalopathy and HRS. A diagnostic para was negative for SBP. She had ascites on exam and her diuretics were initially held in anticipation of a large volume paracentesis. She was given 50 gm albumin the day prior to discharge and the day of discharge had a large-volume paracentesis of 9 L of ascitic fluid and received an additional 50 gm of albumin. She will follow up with her hepatologist as an outpatient next week. She was continued on nadolol, a PPI, lactulose, rifaximin, and bactrim (for SBP prophylaxis). # Continued alcohol use: She was monitored on a CIWA scale, however did not display symptoms of withdrawal. She was continued on thiamine, folic acid, and a multivitamin. She was strongly encouraged to stop drinking do to alcohol's negative effects on her health. # Chronic kidney disease: The patient recently had HRS and has chronic renal insufficiency. Her creatinine on admission was 1.8 (the lowest value recorded in OMR for her recently). Her diuretics were held and she received albumin as described above and her Cr trended down to 1.3 the day of discharge. She was asked to restart her diuretics the day after discharge. # Code: She is full code. Medications on Admission: Folic acid 1 mg po daily Thiamine 100 mg po daily Multivitamin daily Omeprazole 40 mg po daily Nadolol 40 mg po daily Lasix 20 mg po daily Aldactone 25 mg po daily Lactulose 15 mL twice daily, titrating to ___ bowel movements per day Rifaximin 400 mg po tid Bactrim DS 1 tab 5 times per week Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ML PO BID (2 times a day): Titrate to ___ bowel movements per day. 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 5X/WEEK (___). 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Splenic laceration Secondary: Alcoholic cirrhosis Hyponatremia Chronic kidney disease Chronic anemia Discharge Condition: Mental Status: Patient was oriented to person and place, but was slightly confused about the date. Otherwise she answered questions appropriately. No asterixis. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to ___ due to concern for damage to your spleen. You had fallen and been taken to another hospital where there was concern for bleeding from the spleen. You underwent an abdominal/pelvis CT here which showed the damage to the spleen. Your blood counts were monitored and remained stable. You underwent a diagnostic paracentesis to check for infection in the fluid in your stomach. There was no evidence of infection. The liver doctors saw ___ and recommended draining fluid from your abdomen to improve your abdominal distenion so you underwent a therapeutic paracentesis the day of your discharge. It is very important that you stop drinking alcohol to prevent further damage to your liver. No changes were made to your medications. Continue your medications as previously prescribed. Followup Instructions: ___

{'abdominal fullness': ['Alcoholic cirrhosis of liver', 'Other ascites'], 'cold': [], 'right orbit mildly painful': [], 'lower extremity edema': ['Chronic kidney disease'], 'shortness of breath': [], 'orthopnea': [], 'hematemesis': [], 'coffee ground emesis': [], 'hematochezia': [], 'melena': [], 'anemia': ['Chronic anemia'], 'splenic laceration': ['Other injury into spleen without mention of open wound into cavity'], 'alcoholic cirrhosis': ['Alcoholic cirrhosis of liver'], 'portal gastropathy': ['Alcoholic cirrhosis of liver'], 'hepatic encephalopathy': ['Alcoholic cirrhosis of liver'], 'acute renal failure': ['Chronic kidney disease'], 'prerenal azotemia': ['Chronic kidney disease'], 'umbilical hernia repair': [], 'psoriasis': [], 'low-grade temps': [], 'ARF': ['Chronic kidney disease'], 'HRS type II': ['Chronic kidney disease'], 'scleral icterus': ['Alcoholic cirrhosis of liver'], 'jaundiced': ['Alcoholic cirrhosis of liver'], 'Decreased BS at both bases': [], 'R>L': [], 'Distended': ['Other ascites'], 'positive fluid wave': ['Other ascites'], 'shifting dullness': ['Other ascites'], 'Trace bilateral edema': ['Chronic kidney disease'], '2+ radial': ['Chronic kidney disease'], 'DP pulses b/l': ['Chronic kidney disease'], 'Alert, oriented x 3': [], 'Able to relate history without difficulty': [], 'Negative for family history of liver disease': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: R transscaphoid perilunate fracture dislocation Major Surgical or Invasive Procedure: ___ Dr. ___, MD 1. Open reduction internal fixation right scaphoid fracture. 2. Open reduction internal fixation triquetral fracture. 3. Open release of the right carpal tunnel. 4. Open reduction internal fixation of a wrist perilunate dislocation History of Present Illness: HPI: ___ yo RHD M who was skateboarding on ___ when he was struck from behind on the R side by a car. Pt was taken to ___ where trauma workup was negative except for a R transscaphoid perilunate fracture dislocation. Pt was transferred to ___ ED & orthopaedics was consulted. At time of initial eval pt had median nerve symptom w/ numbness at tingling of fingertips of the first 3 digits w/ associated slight diminished sensation in those digits. Closed reduction was performed under conscious sedation & pt was placed in a splint. Pt median nerve symptoms improved with resolution of paresthesias and only slight diminished sensation over the thumb. Pt was discharged home, and now returns for planned surgical fixation. Pt reports had some tingling in median nerve distribution upon waking this morning, but this has resolved. No other interval changes. ROS otherwise negative. Past Medical History: h/o B ankle fx h/o metacarpal fracture s/p tonsillectomy as a child Social History: ___ Family History: Noncontributory Physical Exam: PEX on admission A&O x 3 Calm and comfortable RUE: splint c/d/i Sensation to light touch slightly diminished thumb as compared to other side, otherwise SILT in R M U distibutions EPL FPL EIP EDC FDP fire Digits WWP Pertinent Results: N/A Brief Hospital Course: The patient was admitted to the Orthopaedic Service for repair of a R transscaphoid perilunate fracture dislocation & triquetral fracture. The patient was taken to the OR and underwent ORIFR transscaphoid perilunate fracture dislocation & triquetral fracture as well as carpal tunnel release. The patient tolerated all procedures without difficulty and was transferred to the PACU in stable condition. Please see operative report for full details. The patient transferred to the floor in the usual fashion. Postoperatively, pain was controlled with a PCA with a transition to PO pain meds as tolerated. Diet was advanced without complication. Pt noted persitent numbness in the median nerve distribution which was improved w/ strict hand elevation. At time of discharge states has mild slight residual "pins & needles" senstion involving the thumb. The hospitalization has otherwise been uneventful and the patient has done well. **** At discharge, vital signs are stable, the patient is alert and oriented, afebrile, tolerating pos, voiding qshift and pain is well controlled. Splint is c/d/i. Pt has very mild decreased senstion to light touch over the R thumb, similar to pre-operative exam. Digits are WWP. Fires EPL/FPL/FDP/EDC. The extremities are neurovascularly intact distally throughout. All incisions are clean, dry and intact without evidence of infection, hematoma or seroma. **** The patient is discharged to home in stable condition. Intructions given. Medications on Admission: 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 3. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice a ___: Take while on narcotic to prevent constipation. Discharge Medications: 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 3. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice a ___: Take while on narcotic to prevent constipation. Discharge Disposition: Home Discharge Diagnosis: R transscaphoid perilunate fracture dislocation s/p ORIF & carpal tunnel release Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify MD if you experience: increasing pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage at the incision site, chest pain, shortness of breath or other symptoms of concern. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your pre-hospitalization medications unless otherwise instructed. 4. You have been given medications for your pain control. As your pain improves, decrease your pain medication by taking fewer tablets and/or increasing the time interval between doses. Do not drink, drive or operate machinery while taking narcotics. Take a stool softener to prevent constipation. 5. Do not drive until cleared to do so by your surgeon or your primary MD. 6. Please keep splint clean and dry 7. WB Status: non-weightbearing right upper extremity 8. Please keep right upper extremity maximally elevated at all times to help w/ swelling and pain 9. Antibiotics: Physical Therapy: Non-weightbearing right upper extremity Treatments Frequency: Please continue splint. Keep clean and dry Followup Instructions: ___

{'numbness at tingling of fingertips': ['Injury to median nerve'], 'slight diminished sensation': ['Injury to median nerve'], 'paresthesias': ['Injury to median nerve'], 'R transscaphoid perilunate fracture dislocation': ['Closed fracture of navicular [scaphoid] bone of wrist', 'Closed fracture of other bone of wrist'], 'triquetral fracture': ['Closed fracture of other bone of wrist'], 'carpal tunnel release': ['Injury to median nerve']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: ibuprofen Attending: ___. Chief Complaint: L thumb near complete amputation Major Surgical or Invasive Procedure: ___ ___: 1. Irrigation and debridement down to necrotic bone. 2. Primary IP joint arthrodesis with autograft. 3. Repair of the radial digital nerve. 4. Repair of the ulnar digital nerve. 5. Repair of the ulnar digital artery with a 3 cm vein graft from the foot. 6. Full thickness skin graft measuring 5x1.5cm History of Present Illness: Mr. ___ is a ___ year old male with past medical history significant for HCV who presents from outside hospital with a near complete amputation of his left thumb at the interphalangeal joint. Patient states he was using a table saw at work and cut through his thumb. He denies any other injuries. He has no sensation distal to the cut. Past Medical History: Hepatitis C virus Social History: ___ Family History: NC Physical Exam: NAD No respiratory distress RRR splint c/d/i, decreased sensation in the distal thumb, some sensation over dorsal nailbed, cap refill ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic Hand surgery team. The patient was found to have L thumb near complete amputation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for: 1. Irrigation and debridement down to necrotic bone. 2. Primary IP joint arthrodesis with autograft. 3. Repair of the radial digital nerve. 4. Repair of the ulnar digital nerve. 5. Repair of the ulnar digital artery with a 3 cm vein graft from the foot. 6. Full thickness skin graft measuring 5x1.5cm , which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and was monitored for 24hours there w/ q1h NV exams to his L thumb. After 24h he was transferred to the floor. The patient was initially given IV fluids and IV pain medications including a supraclavicular nerve catheter. He was initially kept NPO in case there was a need to potentially take him back to the OR for a revision. He progressed to a regular diet and oral medications by POD#2. The patient was given ___ antibiotics and anticoagulation per routine and antibiotics were continued while he was in house. The patient's home medications were continued throughout this hospitalization. The patient was discharged home with followup in 1 week. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB on the LUE, and will be discharged on ASA 162mg for DVT prophylaxis. The patient will follow up in Hand Clinic per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Methadone Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 162 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 6. Senna 8.6 mg PO BID 7. Methadone (Concentrated Oral Solution) 10 mg/1 mL 63 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: L thumb near complete amputation Discharge Condition: Stable Discharge Instructions: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non weight bearing L upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin 162mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet Physical Therapy: NWB LUE Treatments Frequency: Wound monitoring Pin care: The initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed ___ days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use ___ strength Hydrogen Peroxide with a Q-tip to the site. Call your surgeon's office with any question Followup Instructions: ___

{'near complete amputation of left thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'decreased sensation in the distal thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'cut through thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'no sensation distal to the cut': ['Partial traumatic transphalangeal amputation of left thumb']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bloody bowel movement Major Surgical or Invasive Procedure: none History of Present Illness: ___ smoker w/ history of hyperlipidemia, BPH, GERD, DJD, osteoarthritis, and colon polyps presents today with one bloody BM, fever in AM and abdominal pain. Pt's last ___ was in ___ at which point he had some polyps that were benign. The patient woke up in the morning in his usual state of health. He went to work after eating a muffin and drinking a coffee. While at work, he experienced a band of pain along his abdomen, lasting for 45 minutes and was drenched in sweat. Had large blood BM at 11 AM (blood covered stool). Since then has had ___ belly pain in lower quadrants in a horizontal band. In the ED, initial vs at 14:22 were pain 6 t 98.6 64 133/78 16 99%. He was ound to have elevated WBC (19.2). CT shows colitis, patient given 0.5 mg IV dilaudid, 400mg IV cipro. Transfer VS 98.1po 59 16 126/81 100% RA ___. On arrival to the floor, patient reports continued abdominal pain, but is comfortable. He also reports continuing smoking and having a rash along his right axila. He denies any recent antibiotics, travel, changes in his diet, or sick contacts. REVIEW OF SYSTEMS: Recent headache over the weekend, twice, which is new for him.. Denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, melena, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: 1. Status post appendectomy. 2. Status post sebaceous cyst excision. 3. Status post arthroscopy, left knee. 4. Status post arthroscopy, right knee. Social History: ___ Family History: Positive for lung cancer, CAD, hypertension, and diabetes. No history of crohn disease or ulceraive colitis. Physical Exam: Admission: VS 98.7, 146/89, 56, 18, 98% GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft tender along left lower quadrant. ND normoactive bowel sounds, no hsm EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN small erythematous papular rash under right axila. Discharge: VS 98.4, 122/80, 65, 18, 96%RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft, mildly tender with soft and deep palpation in LLQ, no masses EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN small erythematous papular rash under right axila. Pertinent Results: Admission: ___ 02:32PM NEUTS-91.6* LYMPHS-5.7* MONOS-2.6 EOS-0 BASOS-0.1 ___ 02:32PM WBC-19.2*# RBC-5.14 HGB-15.6 HCT-46.2 MCV-90 MCH-30.4 MCHC-33.8 RDW-13.1 ___ 02:32PM LIPASE-51 ___ 02:32PM PLT COUNT-346 ___ 02:32PM ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-187 ALK PHOS-73 TOT BILI-0.5 ___ 02:32PM LIPASE-51 ___ 02:32PM GLUCOSE-120* UREA N-14 CREAT-0.7 SODIUM-137 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 ___ 02:40PM LACTATE-1.1 ___ 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07:52PM URINE COLOR-Yellow APPEAR-Clear SP ___ Discharge: ___ 07:00AM BLOOD WBC-12.2* RBC-4.90 Hgb-14.3 Hct-43.5 MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-106 HCO3-25 AnGap-11 ___ 07:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2 Micro: ___ 9:00 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. ___ 2:52 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___BD & PELVIS WITH CO IMPRESSION: 1. Acute colitis involving the descending and sigmoid colon. Etiologies include infectious, inflammatory and less likely ischemic. 2. Enlarged prostate, correlate with PSA. 3. Bilateral small indeterminate adrenal nodules. 4. Mild compression of T11 and T12 vertebral bodies. Cardiovascular Report ECG Study Date of ___ 3:26:28 ___ Sinus rhythm. Normal tracing. No previous tracing available for comparison. Brief Hospital Course: # Colitis: Patient presented with one bloody bowel movement associated with crampy abdominal pain. CT showing acute colitis of descending colon. Differential diagnosis includes infectious (bacterial, viral, parasitic), ischemic, and inflammatory. Ischemic possible given high white count, acute nature and smoking history, however normal lactate. EKG with normal sinus rhythm. Infectious possible with high white count, however patient was afebrile and did not describe diarrhea or vomiting. Further, patient had no travel history, sick contacts or concerning food ingestion. First presentation of inflammatory bowel disease is possible, however less likely given acute nature and disease of only descending colon. Diverticuli seen on previous colonoscopy, however elevated white count and pain is not consistent with diverticular bleeding. The patient was started on ciprofloxacin for possible infectious etiology and given IV fluids. Gastroenterology was consulted due to concern for ischemic etiology. Stool studes were sent and were negative for salmonella, shigella, campylobacter, vibrio and yersinia. C. difficile testing was not done as sample was unsuitable for testing (solid). GI recommended discontinuing ciprofloxacin and outpatient follow up given resolving symptoms with stable hemodynamics and recent colonoscopy. The patient was scheduled for outpatient follow up with gastroenterology. Chronic Issues: # T11/ T12 vetebral compression: Compression seen on CT scan. Patient has no current back pain with normal neurological exam. # Enlarged prostate: BPH, mildly symptomatic with stable PSA, and a relatively recent prostate biopsy, which was negative for malignancy. Patient continued on finasteride and Flomax as prescribed. Transitional Issues: -follow up with GI for possible endoscopy as outpatient -follow up with PCP -___ cultures pending Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS Hold for SBP<100 Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS Hold for SBP<100 Discharge Disposition: Home Discharge Diagnosis: Primary: colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with an episode bloody bowel movement. CT scan showed colitis, which may have be infectious. You were seen by gastroenterology and will follow up with Dr. ___ in clinic. Medication changes: none Followup Instructions: ___

{'bloody bowel movement': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'fever in AM and abdominal pain': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'band of pain along his abdomen': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'elevated WBC': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'CT shows colitis': ['Other and unspecified noninfectious gastroenteritis and colitis'], 'rash along his right axila': [], 'recent headache': [], 'history of hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'BPH': ['Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'], 'GERD': ['Esophageal reflux'], 'DJD': ['Osteoarthrosis', 'unspecified whether generalized or localized', 'site unspecified'], 'colon polyps': ['Personal history of colonic polyps']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Morphine Attending: ___ Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy ___ laparoscopic cholecystectomy ___ History of Present Illness: ___ s/p C-section ___ presents to the ___ ER after experiencing an acute onset of RUQ pain after eating last night. Patient states she ate a steak dinner yesterday evening and approximately one hour after had an acute onset of sharp, severe RUQ pain. The pain was constant and associated with nausea but no vomiting. She went an OSH hospital where her pain resolved with pain medication and was told to follow up with her PCP. After returning home she had two more episodes of pain which resolved within an hour. She also reports having another episode of pain 2 weeks ago in a similar location, but less severe which resolved after an hour. She denies fevers, vomiting, BRBPR or melena. Past Medical History: - Hairy cell leukemia (now status post 1 cycle Cladribine) - History of diabetes mellitus, untreated /diet controlled . - S/p knee and ankle surgeries x ___ - S/p appendectomy Social History: ___ Family History: Her mother is ___ and has thyroid disease and elevated cholesterol. Her father is ___ and has coronary artery disease and hemochromatosis. Her brother is ___ and well. She has one paternal uncle who died in his ___ from an asbestos-related cancer. No other family members have cancers or blood disorders. Physical Exam: Physical Exam: Vitals: T 97.8 P 80 BP 130/90 RR 16 O2 100% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, negative ___ sign no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ WBC-6.4 RBC-3.96* HGB-11.7* HCT-35.0* MCV-89 MCH-29.7 MCHC-33.6 RDW-13.3 ___ ALT-366* AST-396* AlkPhos-173* Amylase-39 TotBili-2.6* DirBili-1.4* IndBili-1.2 ___ ALT-342* AST-206* AlkPhos-166* Amylase-34 TotBili-3.2* ___ ALT-249* AST-101* AlkPhos-170* TotBili-1.5 ___ ALT-158* AST-49* AlkPhos-144* TotBili-1.0 ___ Lipase-29 RUQ (___) 1. Slightly distended gallbladder, but no evidence of cholecystitis or cholelithiasis. 2. Echogenic liver consistent with fatty infiltration; other forms of liver disease, including more significant hepatic fibrosis or cirrhosis cannot be excluded on the basis of this examination. 3. Mildly enlarged spleen measuring 13.2 cm. ERCP ___ The major papilla was bulging proximal to the opening. There appeared to be two openings to the biliary orifice consistent with a possible fistula. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. There was no bleeding. The intrahepatics were normal. The CBD was around 7 mm. There was a distal CBD filling defect. The stone was extracted successfully using a 9-12 mm stone extraction balloon. An occlusion cholangiogram after the bile duct sweeps showed no filling defects. There was excellent flow of bile and contrast. Brief Hospital Course: The patient was admitted to the ___ service on ___ for right upper quadrant pain on elevated LFTs suggestive of choledocolithiasis. She was made NPO and started on maintainence IVFs. Her abdominal pain was well controlled on the floor. Her follow-up LFTs on HD#2 revealed an uptrending t-bili from admission (2.6->3.2). Interventional GI was consulted and the patient underwent successfully ERCP removal of a CBD stone with sphincterotomy on ___. The patient did not exhibit complications from the ERCP and her abdominal pain improved significantly following the procedure as well. On HD#3, the patient's LFTs downtrended, most notable for a t-bili of 1.5 (from 3.2), along with a decrease in her transaminitis. Given the patient's clinical improvement and downtrending LFTs, the decision was made to proceed to laparoscopic cholecystectomy, which was performed on ___. The procedure was without complication. The patient's diet was advanced on POD#1, and she was tolerating a regular diet upon discharge. She was instructed to follow-up in the ___ clinic in 2 weeks. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *Endocet 5 mg-325 mg ___ Tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: choledocolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the acute care surgery service with choledocolithiasis (a gallstone in you common bile duct). The gallstone was removed by a procedure called an ERCP. You then underwent a laparoscopic cholecystectomy to remove your gallbladder without complication. Below are instructions to follow post-operatively: Please resume all regular home medications unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___

{'RUQ pain': ['Calculus of bile duct without mention of cholecystitis'], 'nausea': ['Calculus of bile duct without mention of cholecystitis'], 'elevated LFTs': ['Calculus of bile duct without mention of cholecystitis'], 'hairy cell leukemia': ['Leukemic reticuloendotheliosis'], 'history of diabetes mellitus': ['unspecified site'], 'knee and ankle surgeries': ['extranodal and solid organ sites'], 'appendectomy': ['Personal history of tobacco use'], 'family history of thyroid disease': ['Personal history of antineoplastic chemotherapy'], 'family history of elevated cholesterol': ['Other acquired absence of organ']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine Attending: ___ Chief Complaint: Right arm tenderness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ woman who was diagnosed with hairy cell leukemia in late ___ after presenting with hepatosplenomegaly and thrombocytopenia to the emergency room. She had follow up with hematology/oncology and Dr. ___ diagnosis was confirmed. She underwent placement of a ___ line on ___ for initiation of continuous infusion cladribine at 0.7mg/kg weekly. Early the day prior to this admission she woke up with pain at the ___ entry site in her right arm. She had been lying on her right side while sleeping. Over the course of the day, the pain continued and was worse with movement of the arm. It radiated to the right hand and was accompanied by numbness and tingling of her fingertips. She felt that the arm was slightly more swollen than her left arm, and she sought evaluation in the Emergency Department. In the ED, a right upper extremity ultrasound revealed no DVT. While in the ED, she developed sharp, pressure-like, "tight" chest discomfort, substernal, non-radiating, not accompanied by nausea, vomiting, and diaphoresis. She does report mild dyspnea which she attributes to anxiety. EKG was performed and revealed no evidence of ischemia; in addition, a CT scan of the chest showed no pulmonary embolus. She was given Percocet for her pain, with resolution of her discomfort. She estimates that the pain lasted approximately an hour before stopping. . Past Medical History: - Hairy cell leukemia (now status post 1 cycle Cladribine) - History of diabetes mellitus, untreated /diet controlled . - S/p knee and ankle surgeries x ___ - S/p appendectomy Social History: ___ Family History: Her mother is ___ and has thyroid disease and elevated cholesterol. Her father is ___ and has coronary artery disease and hemochromatosis. Her brother is ___ and well. She has one paternal uncle who died in his ___ from an asbestos-related cancer. No other family members have cancers or blood disorders. Physical Exam: VITAL SIGNS: 98.2, 88, 125/87, 20, 98%RA ECOG performance status 0. Pain ___. GENERAL APPEARANCE: The patient is a pleasant woman, well-appearing. HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. The oropharynx is clear without lesions. Mucous membranes are moist. NECK: Supple, without lymphadenopathy. LUNGS: Clear bilaterally without crackles or wheezes. HEART: S1, S2, regular without murmurs. ABDOMEN: Soft, nontender, nondistended. There is marked hepatosplenomegaly. EXTREMITIES: The right upper extremity is mildly tender to palpation slightly proximal to the PICC insertion site. There is no erythema or edema. Distal pulses and sensory function are intact. SKIN: No bleeding, bruising, or rash. NEUROLOGIC: Alert and oriented x3. CN ___ intact. Strength ___ in proximal and distal muscle groups, upper and lower extremities. Sensation intact to light touch. Cerebellar function intact to finger nose finger testing. Pertinent Results: ADMISSION LABS: ___ 10:40PM GLUCOSE-101 UREA N-15 CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 ___ 10:40PM ALT(SGPT)-37 AST(SGOT)-33 LD(LDH)-255* CK(CPK)-45 ALK PHOS-55 TOT BILI-1.0 ___ 10:40PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-1.9 ___ 10:40PM WBC-4.9 RBC-4.19* HGB-13.4 HCT-37.5 MCV-90 MCH-32.1* MCHC-35.9* RDW-14.7, PLTs 116 ___ 10:40PM NEUTS-76.3* LYMPHS-17.7* MONOS-1.7* EOS-3.9 . CARDIAC ENZYMES: ___ 10:40PM CK-MB-NotDone cTropnT-<0.01 . ADDITIONAL IMAGING: ___ CTA: IMPRESSION: 1. No pulmonary embolism. 2. Massive splenomegaly, partially imaged. . ___ RIGHT UE ULTRASOUND: IMPRESSION: No evidence of DVT. . CARDIAC/EKGs: ___ EKG: Rate 78-80, NSR, normal intervals, normal axis, no ST changes to suggest ishcemia. . . URINE STUDIES: ___ 07:40AM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 07:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . MICROBIOLOGY: ___ 9:32 am CATHETER TIP-IV// Source: ___. **FINAL REPORT ___ WOUND CULTURE (Final ___: No significant growth. . DISCHARGE LABS: ___ 09:00AM BLOOD WBC-1.6* RBC-4.00* Hgb-13.0 Hct-36.4 MCV-91 MCH-32.5* MCHC-35.8* RDW-13.9 Plt ___ ___ 09:00AM BLOOD Neuts-85.6* Lymphs-8.8* Monos-0.5* Eos-4.7* Baso-0.3 ___ 09:00AM BLOOD Plt ___ ___ 09:00AM BLOOD Glucose-151* UreaN-12 Creat-0.6 Na-137 K-3.6 Cl-102 HCO3-25 AnGap-14 ___ 09:00AM BLOOD ALT-42* AST-37 LD(LDH)-251* AlkPhos-49 TotBili-2.2* ___ 09:00AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8 UricAcd-4.7 Brief Hospital Course: In summary, the patient is a ___ female with recent diagnosis of hairy cell leukemia in ___, who presented to ED towards the end of her Cladribine infusion cycle complaining of right arm pain at ___ insertion site. . # Right arm pain. The patient's presentation on physical exam was consistent with a superficial thrombophlebitis vs. early infection at ___ site. She had no fevers and no apparent discharge at site. Blood cultures were negative. Ultrasound of right upper extremity showed no abscesses and no evidence of any DVTs. The right PICC line was removed and a peripheral IV was placed in order to continue her scheduled continuous infusion of Cladribine therapy for her HCL. She was given some local warm packs, and percocet and then Tylenol for pain relief which she tolerated well. She had marked improvement by hospital day 2 with less erythema, less tenderness and less edema at her prior right arm ___ site. Given negative screen for infectious causes and unremarkable ultrasound she was daignosed with a phlebitis reaction at ___ site that can be a common side effect of Cladribine. Because she only had about ~50 hours of her therapy left she remained inpatient for ongoing monitoring for an extra day until completing her full scheduled dose (25 mg remaining). At time of discharge she had stable vital signs, and older ___ site had only a small, well-healing bruise, otherwise much improved from initial presentation. Erythema and tenderness had resolved. . # Hairy Cell Leukemia: Patient initially presented to ED several weeks ago at the beginning of ___ with chief complaint of abdominal pain at left upper quadrant and noted to have massive splenomegaly on CT. She also had thrombocytopenia so she was referred for hematology/oncology follow-up, and she is now being followed closely by Dr. ___. On this admission she was finishing up her planned Cladribine therapy. During her hospital stay she tolerated infusion very well with some occasional nausea which was treated with compazine initially and then some additional Zofran with good effects. No associated emesis, diarrhea or abdominal pains. On physical exam, enlarged spleen that was mildly tender to palpation. . She was set-up for a follow-up outpatient oncology appointment for about 1 week after her discharge. She was discharged with instructions to begin her prophylactic doses of Acyclovir and Bactrim DS. Of note, she was already vaccinated on ___ for pneumococcus, meningococcus,and hemophilus influenza. . #)Chest pain: Ms. ___ complained of some vague chest tightness upon arrival to the ED. The cause of the patient's chest pain was unclear per ED staff. Cardiac enzymes were negative and EKG showed no ischemic changes, normal axis and noraml rate and intervals. Symptoms were ___ severity and highly atypical for acute coronary syndrome. CTA scan results ruled her out for any pulmonary embolus. By the time she arrived on ___ floor she was asymptomatic and had no further complaints throughout her stay. Per patient, she endorsed that she felt her chest pains may have been stress and anxiety related as she had felt very concerned about a possible line infection upon arrival to ED. Will continue to monitor symptoms without further intervention at this time. . #)Prophylaxis: The patient was not given any additional antocoagulation given her thrombocytopenia history. She was encouraged to ambulation BID-TID. . #)Code Status: The patient was maintained as a full code status for the entirety of her hospital course. . Medications on Admission: Percocet prn Lorazepam 0.5mg tid prn Discharge Medications: 1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 2. Ativan 0.5 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for sleep,anxiety, nausea. 3. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 4. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO 3X WEEK: PLEASE TAKE ONE TABLET EVERY ___. . Discharge Disposition: Home Discharge Diagnosis: Primary: -Superficial Thrombophlebitis of right forearm -Hairy Cell Leukemia . Secondary: - History of diabetes mellitus, diet controlled - Anxiety . Other past medical history: - status post knee and ankle surgeries x 3 - status post appendectomy Discharge Condition: Good. At time of discharge the patient had stable vital signs and she was in no apparent distress. Discharge Instructions: It was a pleasure taking care of you here at ___ ___. . You were admitted with redness, irritation, local tenderness and swelling at the ___ IV line site in your right arm. An ultrasound was done to ensure you did not have any blood clots or abscesses. The PICC line was removed and the area seemed to recover well over a period of 2 days. Because you only had 2 days left for the rest of your cladribine infusion the ___ team decided to monitor your right arm and continue the rest of your therapy as an inpatient through a new peripheral IV line. After you completed your therapy this line was removed. Ultimately, it was felt that you did not have a skin infection and you were diagnosed with a condition called thrombophlebitis which is a local irritation of the blood vessels. This is a common side effect of cladribine therapy. . You were set up for a follow-up appointment with your primary oncologist as outlined below. . Lastly, please return to the emergency room or call your doctor if you develop any new rashes, swelling of your arm, fevers, chills, bleeding or discharge at the infusion site, worsening abdominal pains, or any other concerning symptoms. . MEDICATION INSTRUCTIONS: Please start your new Bactrim and Acyclovir medications as instruced by your primary oncologist. Otherwise, continue your usual home medications. Followup Instructions: ___

{'Right arm tenderness': ['Phlebitis and thrombophlebitis of superficial veins of upper extremities'], 'Chest discomfort': ['Other chest pain'], 'Hepatosplenomegaly': ['Leukemic reticuloendotheliosis'], 'Thrombocytopenia': ['Leukemic reticuloendotheliosis'], 'Numbness and tingling of fingertips': ['Leukemic reticuloendotheliosis'], 'Swollen arm': ['Phlebitis and thrombophlebitis of superficial veins of upper extremities'], 'Anxiety': ['Diabetes mellitus without mention of complication']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___ Chief Complaint: Fevers, chills, perianal pain Major Surgical or Invasive Procedure: Incision and drainage of rectal abscess History of Present Illness: ___ yo F s/p laser destruction of perineal and perianal condyulomata on ___ by Dr. ___. She had recovered well, and had returned both to work and school. She now returns with complaints of 3 days of intermittant fevers and chills, as well as some new L perianal pain. She reports night sweats as well. She has had a decreased appetite since the surgery and she has had some trouble moving her bowels since then, with her last BM being 3 days ago. She denies nausea or vomiting. She denies any melena or hematochezia. She denies any drainage of bleeding from the perianal region. Her L gluteus is tender when sitting, but she does not note any increase in pain when she moves her bowels. She does reports some dysuria and dark brown urine. Past Medical History: PMH: Depression, anxiety, perineal/perianal condylomata PSH: Microscopically-assisted biopsy and transanal laser destruction of anal, perineal, vulvar, and vaginal condylomata ___ Social History: ___ Family History: Non-contributory. Physical Exam: On day of admission: PE: 98.4 94 140/84 10 100RA NAD. A&Ox3. Anicteric. MMM. Supple. RRR. CTAB. Soft. NT. ND. +BS. Normal tone. No masses. No gross or occult blood. Erythema ~2 lateral to anal verge on L, occupying apex of gluteus. Tender to palpation. No induration or fluctuance at area of erythema. No tenderness in the anal canal. No masses, fullness or tenderness on digial rectal exam. No additional condylomata appreciated. Warm and well perfused. No peripheral edema. Pertinent Results: ___ 06:40AM BLOOD WBC-12.1* RBC-3.58* Hgb-11.4* Hct-32.9* MCV-92 MCH-31.8 MCHC-34.6 RDW-12.4 Plt ___ ___ 06:25AM BLOOD WBC-19.5* RBC-3.55* Hgb-11.2* Hct-32.9* MCV-93 MCH-31.5 MCHC-33.9 RDW-12.6 Plt ___ ___ 07:15AM BLOOD WBC-22.7* RBC-3.38* Hgb-10.9* Hct-31.1* MCV-92 MCH-32.3* MCHC-35.1* RDW-12.2 Plt ___ ___ 10:20AM BLOOD WBC-31.3* RBC-4.03* Hgb-13.3 Hct-37.1 MCV-92 MCH-33.1* MCHC-35.9* RDW-12.1 Plt ___ ___ 06:20PM BLOOD Neuts-69 Bands-21* Lymphs-5* Monos-5 Eos-0 Baso-0 ___ Myelos-0 ___ 10:20AM BLOOD Glucose-115* UreaN-5* Creat-0.6 Na-137 K-4.1 Cl-103 HCO3-21* AnGap-17 ___ 10:20AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7 . CT ABDOMEN W/CONTRAST Study Date of ___ IMPRESSION: Large anal fluid collection, which may represent multiple adjacent collections, or a single large collection with multiple compartments. It is highly suspicious for abscess in this clinical setting and would be amenable to percutaneous drainage. Brief Hospital Course: The patient was admitted from the emergency room on ___. She was empirically started on levo/flagyl. ___ - the patient had a CT confirming a deep multiloculated ___ abscess and was brought to the operating room for an incision and drainage of a ___ abscess. A foley catheter was placed due to difficulty voiding. ___ - the patient underwent a dressing change and second look in the operating room which revealed no undrained or new areas, she continued on antibiotics. The foley catheter was removed at midnight. Voiding adequate amounts. ___ - Tolerating a regular diet. Passing flatus. Ambulating independently. Perirectal wound packing changed at bedside. Two open sites, packed with kerlix gauze. Wound bed beefy red, no purulent exudate noted. Patient pre-medicated prior to dressing change. Tolerated well. WBC decreased 19.5 from 22. ___ - Discharge home with ___ for dressing changes. Continue with oral antibiotics for 7 more days. Medications on Admission: None Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: Do not exceed 4000mg in 24hours. 2. Tums 500 mg Tablet, Chewable Sig: ___ Tablet, Chewables PO four times a day as needed for heartburn. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with oxycodone. Disp:*60 Capsule(s)* Refills:*0* 4. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*42 Tablet(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days: Take with food. Disp:*21 Tablet(s)* Refills:*0* 6. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Take 2 tabs 30 minutes prior to dressing change and as needed. Disp:*45 Tablet(s)* Refills:*0* 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 2 weeks: Take with food . Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: ___ abscess . Secondary: perineal/perianal condylomas, Anxiety, depression Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * Your pain is not improving within ___ hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Perirectal Abscess wound care: -Pre-medicate yourself with Pain pills about ___ minutes prior to dressing change per Visting nurse. -___ should be changed once a day. -You may shower. Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: ___

{'fevers': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'chills': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'perianal pain': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'night sweats': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'decreased appetite': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'trouble moving bowels': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'tender gluteus': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'dysuria': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'dark brown urine': ['Abscess of anal and rectal regions', 'Other postoperative infection']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: perirectal abscess Major Surgical or Invasive Procedure: Exam under anesthesia Incision and drainage of complex ___ abscess History of Present Illness: Ms. ___ is a ___ woman who underwent incision and drainage of a perirectal abscess approximately ___ years ago. She now presents with recurrent perirectal abscess and on a CAT scan that was obtained in the emergency room before surgery consult; the patient was found to have a horseshoe type of perirectal abscess extending from the patient's left side and around the rectum on the dorsal aspect. The patient was then taken to the OR for examination under anesthesia and incision and drainage of the perirectal abscess. Past Medical History: PMH: Depression, anxiety, perineal/perianal condylomata PSH: Microscopically-assisted biopsy and transanal laser destruction of anal, perineal, vulvar, and vaginal condylomata ___ Social History: ___ Family History: Non-contributory. Physical Exam: Discharge Physical Exam VS: 98.9 73 115/76 18 100%ra Gen: alert and oriented x3 NAD CV: RRR Pulm: CTAB Abd: Soft NT ND Rectal: opened abscess cavity with some purulent drainage, packed loosely with plain packing material Pertinent Results: ___ 04:21PM LACTATE-0.9 ___ 02:25PM WBC-19.1*# RBC-3.82* HGB-11.7* HCT-36.0 MCV-94 MCH-30.6 MCHC-32.5 RDW-11.9 ___ 04:45AM BLOOD WBC-13.7* RBC-3.59* Hgb-11.2* Hct-33.4* MCV-93 MCH-31.1 MCHC-33.5 RDW-11.6 Plt ___ Brief Hospital Course: Ms. ___ has a history of prior perirectal abscesses, and presented to the ED with symptoms of a recurrent abscess. She was taken to the OR for incision and drainage of this large horseshoe type abscess; for full details please see the dictated operative summary. She tolerated the procedure well; a shortened chest tube was left in the cavity to allow for irrigation overnight. She was brought back to the floor in good condition. She was advanced to a regular diet and pain was controlled on oral medications. She ambulated and voided appropriately. She remained on cipro/flagyl for the duration of her hospital course. Prior to discharge, the tube was removed from the cavity and a loose packing was placed. She will remove the packing in one day and follow up with Dr. ___ in clinic later this week. She is discharged home in good condition on hospital day 2, POD#1. Medications on Admission: lamictal 100', dicyclomine 10' Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ___ abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the colorectal surgery service after drainage of a complex ___ abscess. You have done well postoperatively and you are now ready to go home. You will have a small wick inside the abscess. This should be removed tomorrow. After it is removed, please start taking ___ baths daily and after bowel movements. Continue to take pain medication as needed and also take stool softeners to prevent constipation. Followup Instructions: ___

{'perirectal abscess': ['Abscess of anal and rectal regions'], 'Depression': ['Depressive disorder'], 'Anxiety': ['Anxiety state']}