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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: ___: diagnostic cerebral angiogram (positive for p.comm aneurysm) ___: angiogram for coiling of pComm aneurysm History of Present Illness: ___ y/o ___ female transferred from OSH with WHOL and imaging showing SAH. She experienced a sudden onset WHOL at 7:30PM this evening while at a funeral. She headache was localized to the top of her head and at the base of her skull. She also noted a transient episode of hearing loss when the headache started. Her hearing has returned to normal. The headache continued and she was taken to ___ ___ for further evaluation. She underwent a CT without contrast at the CHA which showed a subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns. She was transferred to ___ for further evaluation. The patient continues with complaints of a headache which is located at the top of her head and at the base of her skull. She also reports bilateral lower facial, jaw, and tongue numbness and tingling which has improved since the onset of the headache. She denies numbness, tingling, pain, and weakness of the upper and lower extremities bilaterally. However, she does endorse chest pain within the upper portion of the left arm. She denies SOB, nausea, vomiting, fever, chills, diplopia, dizziness, blurred vision, or speech-language difficulties. Past Medical History: HTN Hyperlipidemia Depression Arthritis H Pylori Colon polyp Bilateral osteoarthritis of the knees s/p right total knee replacement Colon polyp Gastritis ___ esophagus Social History: ___ Family History: No family history of neurologic diease or aneurysms. Physical Exam: On Discharge: ___ speaking, limited ___ A&Ox3 PERRL Face symmetric No drift MAE ___ strength Pertinent Results: CTA HEAD W&W/O C & RECONS Study Date of ___ 2:25 AM IMPRESSION: 1. 3-mm aneurysm is seen directed laterally at the origin of the left posterior communicating artery and a 2 mm aneurysm is seen directed medially at the origin of left posterior communicating artery. 2. Diminutive left vertebral artery with ___ termination. Dominant right vertebral artery. Otherwise, the posterior circulation is unremarkable. 3. No significant interval change in the extent of the subarachnoid hemorrhage, compared to the prior exam from ___. Probable bi-frontal small subdural hematomas (3;17). 4. Hypoplastic left transverse sinus, likely congenital. The remainder the dural venous sinuses are patent. INTRACRANIAL COILING Study Date of ___ 2:25 ___ IMPRESSION: 1. Successful coiling of a left PCOM artery aneurysm compatible with ___ and ___ grade CTA HEAD W&W/O C & RECONS Study Date of ___ 8:55 ___ CT head: No definite subarachnoid blood identified. No new hemorrhage. CTA head: There is no definite evidence of vasospasm of the circle of ___ although of the left MCA is possibly slightly more narrow and irregular compared to study from ___. CT neck: The a neck vessels are patent without stenosis, occlusion, or dissection Brief Hospital Course: ___ year old female who experienced a sudden onset WHOL while at a funeral. She reported headache which was localized to the top of her head and at the base of her skull. She also noted a transient episode of hearing loss when the headache started. She was taken to an OSH where imaging demonstrated subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns. #___: On arrival to ___ a CT/CTA was performed and demonstrated a 3-mm aneurysm on the posterior communicating artery and a 2 mm aneurysm medially at the origin of left posterior communicating artery. She was started on Keppra and Nimodipine. She underwent a diagnostic angiogram which confirmed the PCOMM aneursm. The patient was taken back to the angio suite on ___ for a coiling of the aneurysm. She tolerated the procedure well and was transferred back to the NICU for postop care. She developed slight R pronator drift postop which improved. She was transferred to ___ on POD #1. TCDs were completed on ___ and were negative for vasospasm, howevever limited due to poor bone window. She remained stable and was transferred to the floor on ___. She was continued on Nimodipine and IVF. CTA was done for vasospasm watch on ___ which did not demonstrate vasospasm. She was evaluated by physical therapy and was cleared for safe discharge to home. On day of discharge (___) Patient was neurologically stable and discharged to home with services in good condition. She was set up for home ___ and ___ services. Family confirmed they would provide home supervision for the first few days after discharge. She was given prescription to continue her 21 day course of Nimodipine for vasospasm prevention. Medications on Admission: Unknown. Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Pain - Severe Do not exceed >4g of acetaminophen in 24 hours including from other sources RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth Q4-6H PRN headache Disp #*90 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*12 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth daily PRN constipation Disp #*60 Tablet Refills:*0 4. LevETIRAcetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 5. NiMODipine 60 mg PO Q4H RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours Disp #*144 Capsule Refills:*0 6. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*3 7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H PRN pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid Hemorrhage Posterior Communicating Artery Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery/ Procedures: •You had a cerebral angiogram to coil the aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). 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. ___ try to do too much all at once. •You make take a shower. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you must refrain from driving. Medications •Resume your normal medications and begin new medications as directed. •You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). •You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication until follow-up. It is important that you take this medication consistently and on time. •You have been discharged on a medication to lower your cholesterol levels. We recommend that you continue this medication indefinitely. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •Mild to moderate headaches that last several days to a few weeks. •Difficulty with short term memory. •Fatigue is very normal •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 or puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •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: ___

{'headache': ['Nontraumatic subarachnoid hemorrhage from left posterior communicating artery'], 'numbness': ['Nontraumatic subarachnoid hemorrhage from left posterior communicating artery'], 'tingling': ['Nontraumatic subarachnoid hemorrhage from left posterior communicating artery'], 'chest pain': ['Nontraumatic subarachnoid hemorrhage from left posterior communicating artery'], 'hypertension': ['Essential (primary) hypertension'], 'hyperlipidemia': ['Hyperlipidemia'], 'hearing loss': ['Nontraumatic subarachnoid hemorrhage from left posterior communicating artery']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cerebral aneurysm Major Surgical or Invasive Procedure: ___: Pipeline Embolization of Left ICA aneurysm History of Present Illness: ___ with recanalized P-Comm aneurysm. She is s/p SAH w coiling ___ Left P-comm. She presents today for pipeline embolization of left ICA aneurysm. Past Medical History: HTN Hyperlipidemia Depression Arthritis H Pylori Colon polyp Bilateral osteoarthritis of the knees s/p right total knee replacement Colon polyp Gastritis ___ esophagus Social History: ___ Family History: No family history of neurologic diease or aneurysms. Physical Exam: ON DISCHARGE ============ Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [x]Simple [x]Complex [ ]None Pupils: Right ___ Left ___ EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast Wound: CDI right groin, covered Angio Groin Site: [x]Soft, no hematoma [x]Palpable pulses Pertinent Results: Please see OMR for pertinent imaging & lab results. Brief Hospital Course: On ___, Ms. ___ was admitted for pipeline embolization of L ICA aneurysm. Her operative course was uncomplicated; please see OMR note for full details. #ICA Ms. ___ was transferred from the PACU to the ___. ___ her foley catheter was removed and she was encouraged to get out of bed as tolerated. She mobilized well and was discharge home. Medications on Admission: ASA 325, Plavix 75, HCTZ 25 qd, garlic, ___ 3 fatty acids. Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 4. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cerebral aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angioplasty and Stent Activity •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •Do not go swimming or submerge yourself in water for five (5) days after your procedure. •You make take a shower. Medications •Resume your normal medications and begin new medications as directed. •It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You ___ Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •The medication may make you bleed or bruise easily. •Fatigue is very normal. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting 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: ___

{'Cerebral aneurysm': ['Cerebral aneurysm'], 'HTN': ['Essential (primary) hypertension'], 'Hyperlipidemia': ['Hyperlipidemia'], 'Depression': [], 'Arthritis': ['Unilateral primary osteoarthritis'], 'H Pylori': [], 'Colon polyp': [], 'Bilateral osteoarthritis of the knees': [], 's/p right total knee replacement': ['Presence of right artificial knee joint'], 'Gastritis': [], '___ esophagus': ["Barrett's esophagus without dysplasia"]}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest discomfort, DOE Major Surgical or Invasive Procedure: Thrombolysis History of Present Illness: ___ year old woman with a history of PE in ___ now 5 weeks s/p recent ORIF for L medial malleolus fx p/w with worsening SOB and chest discomfort since ___. Pt stated that prior to onset of SOB, she experienced dizziness, lightheadedness and nausea on exertion on ___. Also notes sweating but was outside on a hot day. On ___ morning she developed sudden onset chest pain and shortness of breath after attempting to climb a hill on the scooter she is using for transportation(she is ___ LLE). She fell off the scooter, injuring her knee, elbow, and hand and reports being SOB with central chest pressure when she reached the top of the hill. She used her inhaler and these sx improved with rest. She also reports that a bilateral headache started at this time and has persisted. She denies striking her head or losing consciousness. Her chest discomfort and SOB have been present with minimal activity since this episode on ___, always resolving after 5min of rest. Pt localizes her pain to ___ chest, it does not radiate, describes the pain as "pressure" and discomfort. There was pressure with moderate exertion which intensified to pain when she was SOB. She remained sedentary all day ___ with continued SOB and chest discomfort crutching on flat ground ___ within her house. ___ morning she awoke and noted tachycardia upon going downstairs from her apartment. She called her PCP office and was told to go to ED for HR > 100. She went to ___ Ed at 3pm. She is s/p ORIF L medial malleolus fx (___) following MVA (___). She was started on prophylactic enoxaparin after her ankle surgery (40 mg daily) and reports good compliance, missing only 2 doses and not in succession. Prior history of DVT/PE in ___. Presenting symptoms included L flank pain and productive cough. CTA demonstrated segmental left lower lobe pulmonary emboli. Hospital course complicated by C. Diff infxn. Her PE was considered provoked based on smoking and OCP. She was discharged on ___ year Warfarin therapy, Flagyl, and Zofran PRN in addition to her home medications. OCPs discontinued, she has not taken them since. In the ED initial vitals were: ___ 78 145/92 20No chest pain while at rest in ED on floor, but she did report having mild SOB and lightheadedness when talking. Pt also reports having a headache. She was given Percocet and ibuprofen for the headache. - Labs were significant for WBC 12, d-dimer 4640. - Patient was given IV heparin 6500 units bolus and started on an infusion of 1620 at 11 pm. Vitals prior to transfer were: 00:43 (___) 98.3 79 143/86 18 99% RA. On the floor, she reports tolerating warfarin well in the past. She has been much less mobile since having her surgery given that she was previously employed as a ___ and is now ___ LLE. She received Warfarin 5mg at 0300 with coags 11.2 70.5* 1.0 at 0630. She is comfortable but tired, not SOB at rest. Past Medical History: PCOS c/b menorrhagia Depression Anxiety Fatty liver Borderline personality disorder gastroparesis, bacterial overgrowth, and pelvic floor dyssynergy Asthma GERD Ankle fracture s/p surgery x2 with pins Finger surgery ___ C. diff infection ___ (hospital-acquired) Social History: ___ Family History: Dad died of a brain aneurysm. No history of VTE in any family member. Physical Exam: ADMISSION: Vitals: 97.9 - 138/98 - 76 - 18 - 98RA, standing weight 124.9kg GENERAL: well nourished tan young lady with several piercings and LLE cast on, sitting in bed, comfortable, no respiratory distress HEENT: AT/NC, EOMI, anicteric sclera, MMM, good dentition, several facial piercings NECK: not assessed. CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: (not assessed yet); bruising LLQ EXTREMITIES: moving all extremities well, no edema, unable to examine LLE which is in a hard ankle cast, no erythema, swelling, eccyhmoses. NEURO: face symmetric, speech fluent, mores all extremities equally SKIN: warm and well perfused, no excoriations or lesions, several tattoos DISCHARGE: Vital signs: VS: T=97.6 BP=112/99 HR= ___ O2 sat=95% on RA General Appearance: NAD, sitting up in bed Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: S1 and S2 normal, No M/R/G. Respiratory: Clear to auscultation Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: LLE in cast, left wrist in brace Skin: Warm Neurologic: Oriented: person, place and time Pertinent Results: ADMISSION: ___ 03:37PM BLOOD WBC-12.0* RBC-4.42 Hgb-15.5 Hct-43.3 MCV-98# MCH-35.1* MCHC-35.7* RDW-12.6 Plt ___ ___ 03:37PM BLOOD Neuts-59.4 ___ Monos-3.7 Eos-7.5* Baso-0.8 ___ 03:37PM BLOOD ___ PTT-27.7 ___ ___ 03:20PM BLOOD ___ 03:37PM BLOOD Glucose-92 UreaN-9 Creat-0.9 Na-138 K-3.7 Cl-106 HCO3-23 AnGap-13 ___ 03:37PM BLOOD proBNP-692* ___ 03:37PM BLOOD cTropnT-0.02* ___ 06:50AM BLOOD Calcium-9.1 Phos-5.3* Mg-1.9 ___ 03:41PM BLOOD D-Dimer-4640* ___ 05:00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:00PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 ___ 05:00PM URINE CastHy-9* ___ 05:00PM URINE UCG-NEGATIVE CXR ___: No acute cardiopulmonary process. No significant interval change. CTA ___: Saddle pulmonary embolism in the bifurcation of the main pulmonary artery which is not completely occlusive, but which extends into multiple lobar and segmental pulmonary arteries bilaterally. No evidence of acute pulmonary infarct or right heart strain at this time. ECHO ___: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. Tricuspid annular plane systolic excursion is normal (1.9 cm; nl>1.6cm) consistent with normal right ventricular systolic function. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal right ventricular chamber size and systolic function by ___. Mild to moderate pulmonary artery hypertension. BILATERAL LENIS ___: 1. Nearly occlusive DVT in the distal left popliteal vein. Left calf veins could not be assessed due to overlying cast. 2. No DVT in the right leg. Discharge Labs: ___ 07:42AM BLOOD WBC-7.6 RBC-3.86* Hgb-13.2 Hct-37.8 MCV-98 MCH-34.2* MCHC-35.0 RDW-12.6 Plt ___ ___ 03:10PM BLOOD PTT-74.9* ___ 07:42AM BLOOD Plt ___ ___ 07:42AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142 K-4.0 Cl-106 HCO3-29 AnGap-11 Brief Hospital Course: HOSPITAL COURSE: ___ year female with history of PE and recent L ankle ORIF presenting with worsening SOB and chest pain, saddle PE on CT, DVT in LLE s/p heparin with evidence of mild PAH on echo transferred to CCU for systemic lysis who did well with improvement in dyspnea. ACTIVE ISSUES: # Acute saddle PE: Patient presented with her second "provoked" PE after immobilization from fracture. Though she was on prophylactive enoxaparin after ankle surgery, she may have been underdosed, given her severe obesity. PESI score (Predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria) is 29, Class I, Very Low Risk: ___ 30-day mortality in this group. Elevated BNP/trop associated with higher mortality in PE patients. BNP >600 with 16X increased risk of mortality (pt BNP 692). However she was hemodynamically stable inspite of a large clot burden on her CTA. RV function was preserved but had trop leak and given youg age and saddle embolus, high risk of developing pulmonary hypertension. Cardiology was consulted who recommended transfer to CCU for intra vascular TPA thrombolysis. Remained hemodynamically stable with good O2 saturation on room air. There was no evidence of right heart strain on EKG or CT though is evidence of pulmonary hypertension on TTE. Started rivaroxaban 15 BID x3 weeks then 20 daiy (dose appropriately for BMI) #?Hypercoagulability: Heme has seen patient and concerned about possible malignancy so recommended age appropriate cancer screening as well as hypercoaguability work-up as outpatient. Pt was transitioned to rivaroxaban. Hypercoagulability work up should be done on an outpatient basis including: Factor V Leiden, prothrombin gene mutation, ACA and b2 glycoprotein Abs, protein C & S, ATIII. Patient will need pap smear/pelvic exam to exclude malignancy. We encourage weight loss and smoking cessation. We arranged for follow up in the coagulation clinic upon discharge. At the present time, we would recommend longterm anticoagulation, but this can be readdressed in the future based on the presence or absence of chronic risk factors, as discussed above. # BRBPR – s/p 1 bloody bowel movement. Patient hemodynamically stable. No other bloody bowel movements reported. INACTIVE ISSUES: # Hypertension: Will monitor for return to baseline in next few days. Likely secondary to PE. Medication is not necessary at this time as blood pressure is currently well controlled. #Tobacco use: Likely a contributing factor to her past two DVTs. Will continue to encourage cessation. Continue nicotine patch # Ankle fracture s/p surgery x2 with pins: Continue NWB, mobilize w/ crutches. ___ order in place. # Depression/anxiety/borderline personality disorder: continue home psych meds. # GERD :omeprazole while in house as no dexilant on formulary #Anxiety: ativan qhs and if anxiety #Chronic headaches, no h/o head strike; tylenol with codeine prn, zofran for nausea. #Undiagnosed sleep apnea - will need sleep study as an outpatient TRANSITIONAL ISSUES: - Sleep study as outpatient - F/up re: headaches and ?further evaluation - Hypercoaguable work-up Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LaMOTrigine 300 mg PO HS 2. Mirtazapine 45 mg PO HS 3. CloniDINE 0.3 mg PO HS 4. Dexilant (dexlansoprazole) 60 mg oral daily 5. OxycoDONE (Immediate Release) 5 mg PO Q4H-Q6H:PRN pain 6. Ibuprofen 800 mg PO Q6H-Q8H:PRN pain Discharge Medications: 1. Rivaroxaban 15 mg PO BID Duration: 3 Weeks RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. Rivaroxaban 20 mg PO DAILY to begin after 3 weeks of 15 mg BID RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. CloniDINE 0.3 mg PO HS RX *clonidine 0.3 mg take one tablet(s) by mouth every night Disp #*30 Tablet Refills:*0 4. LaMOTrigine 300 mg PO HS 5. Mirtazapine 45 mg PO HS 6. Nicotine Patch 14 mg TD DAILY RX *nicotine [Nicoderm CQ] 7 mg/24 hour Please replace daily daily Disp #*30 Patch Refills:*3 RX *nicotine [Nicoderm CQ] 14 ___ on skin, replace daily daily Disp #*30 Patch Refills:*0 7. Dexilant (dexlansoprazole) 60 mg oral daily RX *dexlansoprazole [Dexilant] 60 mg 60 mg capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 8. OxycoDONE (Immediate Release) 5 mg PO Q4H-Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pulmonary Embolism Secondary Diagnosis: Hypertension 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 ___, It was a pleasure caring for you during your recent admission to the ___. You were admitted with shortness of breath and chest pain and found to have a blood clot in your lung. We treated you with medications to dissolve the blood clot and your symptoms improved. You must remain on medications to keep your blood thin. You should follow up with Dr. ___ in ___ weeks and have a repeat echocardiogram (ultrasound) of your heart in 6 weeks. Additionally, It is very important that you stop smoking, we provided you with information on smoking cessation. You should follow up with your primary care doctor within the next week to discuss treatment options. Be Well, Your ___ Doctors ___ 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: left flank pain Major Surgical or Invasive Procedure: none History of Present Illness: History of Present Illness: ___ with PCOS on OCP admitted with left flank pain. Felt well until 3 weeks ago when she developed loose watery stools after eating any food (not just fatty or dairy). No associated fever, chills, sweats, weight loss, abdominal pain, nausea, melena, or hematochezia. One week ago developed cold symptoms - nasal congestion, runny nose, sore throat, and nonproductive cough. Had a fall last week onto her side while walking on slippery steps. No head trauma or LOC. Three days prior to admission felt left-sided intermittent flank pain for which she took ibuprofen without relief. Attributed pain to the recent fall. Pain exacerbated by deep inspiration. No dizziness, lightheadedness, chest pain, palpitations, shortness of breath, dysuria, urinary frequency, or calf pain or swelling. Pain worsened today so came to the ED. In the ED, initial vs 96.8 89 161/101 18 100% RA. WBC# 10.9 D-dimer 560. U/A showed trace blood rare bacteria. CTA showed left lower lobe segmental PE. Given heparin IV, morphine, and tylenol. V/S prior to transfer 75 132/99 16 98%RA. Past Medical History: PCOS c/b menorrhagia Depression Anxiety Fatty liver Social History: ___ Family History: Dad died of a brain aneurysm. No history of VTE Physical Exam: On admission: V/S: T 96.6 BP 125/74 HR 66 RR 16 O2sat 99%RA Wt 282.3 lbs GEN: Appears well NECK: JVD difficult to assess LUNGS: Clear CV: reg rate nl S1S2 no m/r/g ABD: soft NTND guaiac neg in ED EXT: warm, dry no calf tenderness or edema Pertinent Results: Labs on admission: ___ 08:20PM BLOOD WBC-10.9 RBC-4.17* Hgb-13.2 Hct-36.7 MCV-88 MCH-31.6 MCHC-35.9* RDW-13.4 Plt ___ ___ 08:20PM BLOOD Neuts-54.0 ___ Monos-4.0 Eos-5.9* Baso-0.8 ___ 08:20PM BLOOD Plt ___ ___ 08:20PM BLOOD Glucose-80 UreaN-11 Creat-0.8 Na-141 K-3.9 Cl-105 HCO3-26 AnGap-14 ___ 08:20PM BLOOD ALT-41* AST-28 AlkPhos-33* TotBili-0.3 ___ 08:20PM BLOOD Lipase-32 ___ 08:20PM BLOOD cTropnT-<0.01 proBNP-29 ___ 08:20PM BLOOD Albumin-4.0 ___ 08:20PM BLOOD D-Dimer-560* ___ 08:20PM BLOOD tTG-IgA-4 Imaging: CTA-Chest IMPRESSION: Segmental left lower lobe pulmonary emboli. Brief Hospital Course: ___ with PCOS on OCP admitted with LLL segmental PE likely the result of cig smoking, obesity, OCPs. Also now found to have c-diff positive diarrhea with episode of diarrhea overnight. . #PE - hemodynamically stable, satting well on room air; risk factors for provoked VTE are OCPs and obesity; no R heart strain by EKG or CT. Patient was started on IV heparin bridge to coumadin. OCPs were held. . #Diarrhea - found to be C-diff positive and treated with flagyl to be continued as outpatient. . #Depression/anxiety. -cont celexa (counseled about theoretical increased bleeding risk) -cont xanax prn . #Transaminitis - ___ RUQ U/S and abd CT showed fatty infiltration -outpatient f/u . #Sore throat: No LAD, no fever, no pharyngeal exudate, symptoms were monitored and subsided. . #Depression/anxiety -cont celexa (counseled about theoretical increased bleeding risk) -cont xanax prn . #Transaminitis - ___ RUQ U/S and ABD CT showed fatty infiltration, Hepatitis panel showed HepB SAB + from vaccination; Hep A IgG+, -outpatient f/u Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times a day as needed as needed for anxiety. 4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0* 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: It is very important that ___ take this medication as it will prevent your clots from worsening. Disp:*45 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: PE Clostridium Difficile Diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to the ___ for anticogulation for a pulmonary embolism seen on imaging studies in the emergency department. During ___ stay ___ also received medication to treat your intermittent back, chest and abdominal crampy pain. ___ also received medications to help with nausea. At night ___ received trazodone to help with sleep. There was no evidence that your pulmomary embolism was interfering with your lung or heart function. ___ were deemed stable for discharge home on a blood thinner to be taken for several months. ___ will have follow-up appointments to monitor your anticoagulation status and your blood thinner (coumadin) will be adjusted accordingly. Some of your medications were stopped on admission. ___ should STOP taking the following medications when ___ are discharged from the hospital: -Oral contraceptive pills (birth control) ___ should START taking the following medications as prescribed: -Coumadin (also known as Warfarin) until told to stop by your PCP -___ (also known as Metronidazole) for 10 days -Ondansetron (zofran) as needed for nausea Please also take all your other medications as prescribed by your physicians. Please also note that smoking is a major risk factor for developing clots such as pulmonary embolisms and that it is very important that ___ stop smoking entirely. Please discuss this issue with your primary care physician if ___ find yourself needing help with quitting smoking. Followup Instructions: ___

{'left flank pain': ['Other pulmonary embolism and infarction'], 'loose watery stools': ['Intestinal infection due to Clostridium difficile'], 'cold symptoms': [], 'sore throat': [], 'transaminitis': [], 'depression': ['Dysthymic disorder'], 'anxiety': [], 'fatty liver': ['Obesity']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Vicodin Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: ___ Interventional Pulmonology: Tumor debulking and bilateral stent placement in the main stem bronchi ___ CT Chest Angiogram: Used to assess for any PE or post-surgical complications. Preliminary read showed no pulmonary emboli were identified at the lobar level though more distal emboli were not excluded. History of Present Illness: Ms. ___ is a ___ year old prior nurse ___/ depression, anxiety, fibromyalgia, and sciatica who presented with dyspnea, diagnosed with NSCLC compressing her mainstem bronchi at ___, transferred to ___ for bronchoscopy with placement of bronchial stents. Patient was treated for a pneumonia this past ___, but otherwise reports feeling well until 4 weeks prior to admission. She first noted a cough. Then food began feeling lodged in her throat and she became unable to keep food down, leading to weight loss of about 30 lbs over the past month. Two weeks prior to admission, the patient felt she as though she were gasping for air when she coughed, and she presented to ___ where imaging and biopsy showed NSCLC compressing her main bronchi bilaterally. She also experienced low grade fevers. At ___, she was started on nebulizers and predisone 40mg PO QD (starting ___ for hypoxia, was treated with a course of ceftriaxone x 10d for post obstructive PNA, and was treated for pain with oxycodone 30mg PO q6H (per palliative care team) in the setting of her fibromyalgia, sciatica, and psychiatric history. Pt endorses chest pain that radiates to the left side of her chest, continued difficulty breathing, and vaginal itching. She denies fevers, chills, N/V, abd pain, changes in bowel or bladder movement, dysuria, myalgias and arthralgias. Past Medical History: Depression Anxiety Fibromyalgia Sciatica s/p tubal ligation s/p venous stripping Social History: ___ Family History: Mother: DM, dementia, schizophrenia NOS, bipolar Father: deceased from subdural hematoma Brother: schizophrenia NOS, bipolar Physical Exam: Admission Physical Exam Vitals: 98.0 78 106/66 20 95% on FM General: alert, oriented, labored rhoncorous breathing on FM HEENT: sclera anicteric, oropharynx clear with opaque mucous Neck: supple, JVP not elevated, no LAD Lungs: inspiratory and expiratory wheezing, rhonchi and rales bilaterally anteriorly and posteriorly CV: RRR, no r/g/m Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no edema Neuro: CNs2-12 intact, pupils equal round and reactive to light, motor function grossly normal Discharge Physical Exam Vitals: 98.3 98.3 77 125/63 16 95RA General: alert, oriented, laying in bed, breathing comfortably on room air HEENT: sclera anicteric, MMM, oropharynx clear Lungs: lungs rhoncorous bilaterally with mild wheezing CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 04:58AM GLUCOSE-91 UREA N-18 CREAT-0.6 SODIUM-136 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-31 ANION GAP-14 ___ 04:58AM WBC-14.8* RBC-4.26 HGB-12.6 HCT-39.6 MCV-93 MCH-29.6 MCHC-31.8* RDW-13.2 RDWSD-44.2 ___ 04:58AM PLT COUNT-434* ___ 04:58AM ___ PTT-30.5 ___ ___ 04:58AM ALBUMIN-3.0* CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1 ___ 04:58AM ALT(SGPT)-38 AST(SGOT)-19 ALK PHOS-98 TOT BILI-0.3 CTA Chest: IMPRESSION: 1. Suboptimal opacification of the pulmonary arteries. Within this limitation, no obvious pulmonary embolism. 2. Large mediastinal mass, slightly larger than on the prior study. Patent left mainstem and right bronchus intermedius stents. 3. Fluid-filled esophagus at the level of carina, which may predispose to aspiration. DISCHARGE LABS: ___ 08:46AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-135 K-4.1 Cl-97 HCO3-31 AnGap-11 ___ 08:46AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.___ w/ depression, anxiety, fibromyalgia, and sciatica who presented with dyspnea, diagnosed with NSCLC compressing her main stem bronchi at ___, transferred for placement of bronchial stenting. # NSCLC: The patient was diagnosed with NSCLC, consistent with adenocarcinoma, with extrinsic compression of both main stem bronchi, transferred for endobronchial stenting by Interventional Pulmonology. The oncology team at ___ ___ has had work-up with negative head CT and CTA A/P for metastatic disease with plans for potential chemo/XRT after stenting. On admission, the patient required 6L NC via Venturi mask. On ___, the patient underwent tumor debulking and placement of bronchial stents bilaterally. The patient was saturating well on room air following the procedure and started a 14 day course of Unasyn inpatient transitioned to Augmentin outpatient 875mg PO BID (first day ___. # Depression/anxiety: Patient continued on her home ALPRAZolam 1 mg PO/NG QAM, ALPRAZolam 2 mg PO/NG QHS, BusPIRone 15 mg PO BID, Escitalopram Oxalate 20 mg PO/NG DAILY. # Fibromyalgia: The patient's pain management was optimized with her outpatient and palliative care teams. For pain control, the patient continued on Morphine SR (MS ___ 30 mg PO Q8H, Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q3H:PRN pain, anxiety, dyspnea, and Gabapentin 200 mg PO/NG TID at OSH. # Vaginal pruritis: Patient likely had vaginal candidiasis and was treated with Miconazole Nitrate Vag Cream 2% 1 Appl VG QD: PRN. # Tobacco abuse: Patient continued on a Nicotine Patch 21 mg daily. TRANSITIONAL ISSUES: - Needs to be connected to oncology at ___ - Needs follow up with interventional pulmonology in 6 weeks with a CT chest scan - Needs continued pain management by primary care and oncology teams Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 20 mg PO DAILY 2. ALPRAZolam 1 mg PO QAM 3. ALPRAZolam 2 mg PO QHS 4. BusPIRone 15 mg PO BID 5. Diazepam 5 mg PO DAILY:PRN anxiety 6. OxycoDONE (Immediate Release) 30 mg PO Q6H:PRN pain Discharge Medications: 1. ALPRAZolam 1 mg PO QAM 2. ALPRAZolam 2 mg PO QHS 3. BusPIRone 15 mg PO BID 4. Escitalopram Oxalate 20 mg PO DAILY 5. Diazepam 5 mg PO DAILY:PRN anxiety 6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN dyspnea RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled q4 hr Disp #*60 Vial Refills:*0 7. Gabapentin 200 mg PO TID RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #*180 Capsule Refills:*0 8. Guaifenesin ER 1200 mg PO Q12H RX *guaiFENesin 1200 mg by mouth twice a day Disp #*60 Tablet Refills:*0 9. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine [Lidoderm] 5 % Lidoderm 5% patch q ___ q ___ Disp #*30 Patch Refills:*0 10. Miconazole Nitrate Vag Cream 2% 1 Appl VG QD: PRN vaginal ___: 7 Days RX *miconazole nitrate [Miconazole 7] 2 % 2% vaginal cream 1 application once a day Disp #*1 Tube Refills:*0 11. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q3H:PRN pain, anxiety, dyspnea RX *morphine 10 mg/5 mL 10 mg by mouth q3hr Refills:*0 12. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 21 mg TD q 24 Disp #*28 Patch Refills:*0 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer inhaled q 6 hr Disp #*100 Ampule Refills:*0 14. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days last day of antibiotics on ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth q12hr Disp #*23 Tablet Refills:*0 15. Morphine SR (MS ___ 30 mg PO Q8H RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth q8hr Disp #*90 Tablet Refills:*0 16. Equipment: Nebulizer Machine. ICD 10: C34.90 Non small cell carcinoma of the lung. Duration of use: 13 months To be used with nebulizers as prescribed. Discharge Disposition: Home Discharge Diagnosis: Primary: Non-small cell lung cancer post-obstructive pneumonia Secondary: Vaginal candidiasis Fibromyalgia Depression Anxiety Sciatica 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 transferred with a tumor compressing your bronchi (smaller airways) leading to difficulty breathing. The interventional pulmonology team took you to the operating room on ___ to remove some of your tumor and place stents in your airways. After the surgery, your breathing improved. You also have experienced episodes of chest pain, that was reproducible with pressing on your chest. Some of the chest pain can occur following your surgery. An electrocardiogram looking at your heart and lab tests sent were normal. We are reassured that there are no acute issues with your heart that need immediate interventions. Finally, you were experiencing episodes of tachycardia, with fast heart beats. The EKGs we captured of your heart were normal, and the episodes of tachycardia seems to have decreased following management of your post-surgical pain. We recommend following up with your primary care physician about further work up. Please continue using the Acapella flutter valve twice a day to help loosen the secretions in your air ways, which will help prevent pneumonia. Please seek immediate care if you experience fevers, chills, chest pain, difficulty breathing, coughing up blood, or any other concerning symptoms. We wish you the best in your health! Your ___ care team Followup Instructions: ___

{'Dyspnea': ['Malignant neoplasm of left main bronchus', 'Malignant neoplasm of right main bronchus'], 'Cough': ['Malignant neoplasm of left main bronchus', 'Malignant neoplasm of right main bronchus'], 'Weight loss': ['Malignant neoplasm of left main bronchus', 'Malignant neoplasm of right main bronchus'], 'Chest pain': ['Malignant neoplasm of left main bronchus', 'Malignant neoplasm of right main bronchus'], 'Vaginal itching': ['Candidiasis', 'unspecified'], 'Depression': ['Major depressive disorder', 'single episode', 'unspecified'], 'Anxiety': ['Anxiety disorder', 'unspecified'], 'Nicotine use': ['Nicotine dependence', 'cigarettes', 'uncomplicated'], 'Fibromyalgia': ['Fibromyalgia'], 'Sciatica': ['Sciatica', 'unspecified side']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancomycin Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: ___ guided vertebral and disc biopsy at L5-S1. History of Present Illness: ___ yo man w/ R. hip MSSA septic arthritis w/ iliopsoas absces in ___ treated w/ I&D & 12 weeks nafcillin w/ -TTE. Persistent osteoarthritis w/ total R. hip replacement on ___ w/ continued pain. Developed worsening low back, groin, and anterior/lateral right leg pain and was seen by Ortho on ___, at which time labs were notable for ESR 6 and CRP 1.8. He had a bone scan on ___, which showed mild increased activity at the right hip arthroplasty. Treated with Prednisone taper on ___ for presumed hip flexor tendinitis with no relief. Referred to Pain clinic, where he was started on Tizanidine and an MRI was ordered. Non-contrast MRI on ___ showed progression of disc disease at L5-S1 and high T2 signal within the disc and new edema in the endplates. The MRI was repeated with contrast ___, which showed abnormal enhancement of L5-S1 and the anterior paraspinal soft tissues consistent with spondylodiscitis without radiographic evidence of abscess or bone destruction. Patient was referred to ___ clinic for further evaluation. Given history of infectious in setting of patient w/ intermittent fevers to 101.0 and worsening night sweats, ID was concerned for osteomyelitis. Mr. ___ was scheduled for bone biopsy outpatient, but was unable to wait when his procedure was delayed. Given concern for infection and initial delay in biopsy, he was admitted to accelerate the biopsy. ROS (+) per HPI. Intermittent fevers to 101.0, self resolve (-) denies chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -Chronic low back pain ___ L5-S1 disc bulge -OSA- no longer on CPAP -Anxiety -Depression - Open appendectomy. - Psoas abscess debridement on ___ Social History: ___ Family History: Father died due to alcoholism and CHF. Mother, brother, and sister are alive and well. Physical Exam: Admission Physical Exam VS: 98.5, 119/72, 84, 18, 98RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple no LAD PULM 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, negative straight leg raise, 2+ reflexes throughout, gait normal, strength ___ throughout, sensation grossly intact throughout SKIN no lesions Discharge Physical Exam: VS: 98.3, 124/75, 65, 18, 98%RA GEN Alert, oriented, no acute distress HEENT NCAT MMM OP clear NECK supple no LAD PULM CTAB no adventitious breath sounds CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g Back: Pain to palpation over lumbar/sacral spine, soreness at biopsy site, no erythema or edema noted at site. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO No focal neurological deficits, AOx3 SKIN no lesions Pertinent Results: Admission labs ___ 07:00AM BLOOD WBC-9.9 RBC-5.00 Hgb-15.4 Hct-45.1 MCV-90 MCH-30.9 MCHC-34.2 RDW-13.4 Plt ___ ___ 07:00AM BLOOD ___ PTT-32.4 ___ ___ 07:00AM BLOOD Glucose-84 UreaN-13 Creat-0.9 Na-143 K-4.4 Cl-108 HCO3-23 AnGap-16 Post-Operative labs: ___ 08:00AM BLOOD WBC-11.9* RBC-5.23 Hgb-15.9 Hct-47.3 MCV-90 MCH-30.4 MCHC-33.6 RDW-13.0 Plt ___ ___ 2:13 pm TISSUE Source: vertebrae and disc. EXTRA SWABS RECEIVED, NOT USED PER ___ 1833 ___. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. Brief Hospital Course: # Bone/disc Biopsy/Vertebral Osteomyelitis: Worsening back pain in setting of previous history of R. hip infections now w/ MRI suggestive of spondylodiscitis unable to r/o infection. 1 month w/ intermittent fevers to Tmax 101.0 and reported night sweats, no luekocytosis, blood cx -, UA -, biopsy gram stain -. If infectious etiology, most likely hematogenous spread given lack of tissue involvement connecting hip to L5-S1 space, cant r/o possibility of R. hip involvement. Vertebral and disc Biopsy at level of L5-S1 was performed under ___ guidance w/o complication and sent for culture, gram stain, and PCR. Post-operatively, Mr. ___ had mild back tenderness which responded well to lose dose oxycodone. No new neurological deficits, back pain stable, wound site clean w/o concern for infection. Patient discharged with appropriate infectious disease follow up for pending cultures. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 400 mg PO Q8H:PRN pain 2. Tizanidine 4 mg PO TID pain 3. Gabapentin 300 mg PO TID pain Discharge Medications: 1. Gabapentin 300 mg PO TID pain 2. Ibuprofen 400 mg PO Q8H:PRN pain 3. Tizanidine 4 mg PO TID pain 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Low Back Pain 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 while you were at ___ ___. You came into the hospital for an image guided biopsy of your vertebrae and disc after CT imaging revealed worsening disc disease which was felt could represent an infection. Infection was a concern because of your previous history of infection as well as your symptoms of worsening back pain, intermittent fevers, and night sweats. A CT guided biopsy was performed and cultures were sent to test for infection. These studies will take a couple days to come back and some of the results will take longer. It will be important that you follow up with your infectious disease doctor. Also, please follow up with your pain management doctor to help get better control of your back pain. Thank you Followup Instructions: ___

{'Back Pain': ['Other chronic pain', 'Displacement of lumbar intervertebral disc without myelopathy'], 'Fever': ['Unspecified osteomyelitis', 'other specified sites'], 'Night Sweats': ['Unspecified osteomyelitis', 'other specified sites'], 'Anxiety': ['Anxiety state', 'unspecified'], 'Depression': ['Depressive disorder', 'not elsewhere classified'], 'Sleep Apnea': ['Obstructive sleep apnea (adult)(pediatric)'], 'Pain': ['Other chronic pain'], 'Disc Disease': ['Other and unspecified disc disorder', 'lumbar region']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amitriptyline / Cholestyramine / Dicloxacillin / diltiazem / niacin / amlodipine Attending: ___. Chief Complaint: Hypertensive emergency Major Surgical or Invasive Procedure: none History of Present Illness: ___ F with history of severe AS s/p TAVR (___), resistant hypertension, PMR on chronic prednisone, and cryptogenic stroke (___), presented with dizziness and weakness in the setting of BP of 200/110. She was at home on ___ when she felt suddenly dizzy. She called an ambulance and had to lie on her couch. Her hands shook. She reports blurry vision, but denies headache. She denies fall, head strike, or loss of consciousness. She denies heart palpitations or chest pain. She reports no change in recent PO's. She additionally denies any dyspnea or headache. She does report a history of having "something bad happen" every time "a blood pressure pill gets changed." Recent hospitalizations that presented with dizziness were worked up as per below: ___: Found to have had a cryptogenic stroke with subacute L temporal and R occipital infarcts ___: Stroke workup negative, presumptive diagnosis was L-sided peripheral vestibular disorder Of note, ___ Cardiology increased her lisinopril dose from 5mg to 10mg recently. She reports frequent changes to her anti-hypertensives, often with dizziness as the result. Medication compliance is unclear as patient lives alone with no nursing services. In the ED: - Initial vitals: T 98.6 HR 80 BP 190/110 RR 16 O2 sat 90% - Administered labetolol 5mg IV, clonidine 0.2mg, lisinopril 10mg. - Subsequently however, orthostatics were positive, with SBP in the ___, so she received IV NS. She was admitted to medicine for BP medication titration. Past Medical History: Subacute L temporal and R occipital infarcts (cryptogenic stroke ___ H pylori infection HTN Dyslipidemia Severe aortic stenosis s/p TAVR PMR Temporal arteritis SIADH Hyponatremia Spinal stenosis Osteopenia Macular degeneration Cataracts Leukopenia Iron def anemia Deviated septum Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ============== ADMISSION EXAM ============== Vitals: T 97.8 HR 59 BP 125/74 O2sat 98 Ra General: alert, no acute distress HEENT: MMM, oropharynx clear Neck: supple, no LAD Lungs: clear to auscultation bilaterally; no wheezes, rales, or rhonchi CV: regular rate and rhythm, normal S1 + S2, soft systolic murmur GI: abdomen soft, non-tender, non-distended Ext: warm, well perfused, 2+ pulses, no edema ============== DISCHARGE EXAM ============== Vitals: 24 HR Data (last updated ___ @ 733) Temp: 98.4 (Tm 98.7), BP: 166/88 (116-224/63-110), HR: 55 (42-64), RR: 16 (___), O2 sat: 98% (94-100), O2 delivery: Ra, Wt: 104 lb/47.17 kg General: No acute distress, sitting up in bed eating breakfast, nontoxic appearing HEENT: NC, AT Lungs: normal WOB on RA, equal chest rise ___ CV: no peripheral edema Neuro: alert, answers questions appropriately, hard of hearing Pertinent Results: ============= ADMISSION LABS ============= ___ 09:35PM BLOOD WBC-2.0* RBC-3.90 Hgb-12.4 Hct-35.1 MCV-90 MCH-31.8 MCHC-35.3 RDW-13.2 RDWSD-43.6 Plt ___ ___ 09:35PM BLOOD Neuts-44.9 ___ Monos-18.2* Eos-5.1 Baso-0.5 Im ___ AbsNeut-0.89* AbsLymp-0.61* AbsMono-0.36 AbsEos-0.10 AbsBaso-0.01 ___ 09:35PM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-135 K-4.3 Cl-94* HCO3-26 AnGap-15 ============= DISCHARGE LABS ============= ___ 06:10AM BLOOD WBC-1.6* RBC-3.23* Hgb-10.3* Hct-29.9* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.3 RDWSD-45.4 Plt ___ ___ 06:10AM BLOOD Glucose-92 UreaN-23* Creat-0.7 Na-135 K-4.4 Cl-97 HCO3-29 AnGap-9* Brief Hospital Course: ___ F with history of severe AS s/p TAVR (___), hypertension, and cryptogenic stroke (___), presented with dizziness and weakness in the setting of BP of 200/110, admitted for labile blood pressures and possible need for med titration. # Hypertensive emergency with subsequent hypotension When she arrived to the ED, her anxiety may have caused an acute hypertensive emergency. She had recently been uptitated by her cardiologist from 5mg to 10mg lisinopril QHS. Med compliance was likely contributing in a large part. In the ER, after receiving both Lisinopril and Clonidine at the same time, her BP got low to SBP 80's. Her lisinopril dose was initially reduced down to 5mg, but with this her BP rose again. Thus, she was ultimately placed back on home Lisinopril 10mg, but told to take in the morning rather than at night, to prevent overnight hypotension. Continued nightly clonidine 0.2mg QHS. # Dizziness Likely related to BP variations, but some of this is also age-related deconditioning. Hypovolemia secondary to poor PO intake possible, but this is likely in the setting of periodic hypertension. Recent TTE makes failure of the mechanical AV unlikely. As above, Lisinopril continued at 10mg, but timing changed to the morning. We gave her instructions on how to stand up safely and slowly, and to stay well hydrated. # Chronic neutropenia - Received heme work-up in past, thought to be benign # Severe AS s/p TAVR - continue ASA and Plavix # PMR - continue prednisone # HLD - continue simvastatin TRANSITIONAL ISSUES ==================== [ ] Lisinopril continued at 10mg daily, but should take it in the morning rather than at night. F/u BP further as outpatient. [ ] Continue to monitor dizziness. [ ] Continue to monitor blood pressure Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO QPM 2. CloNIDine 0.2 mg PO QPM 3. PredniSONE 1 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Ascorbic Acid ___ mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 5. CloNIDine 0.2 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. PredniSONE 1 mg PO BID 10. Simvastatin 20 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypertensive Emergency 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: Dear Ms. ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were feeling dizzy and having trouble with your blood pressure. WHAT HAPPENED TO ME IN THE HOSPITAL? - We changed the timing of your lisinopril from night to morning. We kept the dose the same. - We kept a close eye on your blood pressure. - You had labwork and an EKG, which looked good. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments as scheduled. - Stay well hydrated, drink multiple glasses of water per day - Take your time when going from a sitting to standing position We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

{'dizziness': ['Hypertensive emergency', 'Hypotension due to drugs'], 'weakness': ['Hypertensive emergency', 'Hypotension due to drugs'], 'blurry vision': ['Hypertensive emergency'], 'shaking of hands': ['Hypertensive emergency'], 'history of severe AS s/p TAVR': ['Presence of xenogenic heart valve'], 'resistant hypertension': ['Hypertensive emergency'], 'PMR on chronic prednisone': ['Polymyalgia rheumatica'], 'cryptogenic stroke': ['Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits'], 'hypovolemia': ['Hypovolemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Necrotic liver with abscess Major Surgical or Invasive Procedure: ___: 1. Exploratory laparotomy and lysis of adhesions. 2. Debridement of liver. 3. Ileocolectomy with ileocolonic anastomosis. History of Present Illness: Per Dr. ___ note as follows: ___ gentleman who suffered a motor vehicle accident earlier this year. He had multiple injuries including injury to the liver. He subsequently developed liver necrosis and an abscess ___ that area. Some of his studies showed evidence of an enteric fistula. He has had persistent purulent drainage for the past several months, and is now brought ___ for surgical drainage and exploration with the possibility of bowel resection. Past Medical History: MVC with liver lacs leading to necrotic liver lesion PSH: Exploratory laparotomy, washout of hemoperitoneum, debridement of laceration of the liver, ileocecectomy, ileocolostomy. s/p Left ankle ORIF s/p removal of adenoids ___: 1. Exploratory laparotomy and lysis of adhesions. 2. Debridement of liver. 3. Ileocolectomy with ileocolonic anastomosis Social History: ___ Family History: Noncontributory Physical Exam: VS: 98.8, 116, 125/65, 15, 99% 3L General: NAD CV: sinus tachycardia, reg rhythm Pulm: CTA bilaterally Abd: Soft, non-distended, large midline incision, dressing C/D/I Extr:2+ pulses bilaterally Pertinent Results: ___ Hct-34.2* ___ WBC-4.1 RBC-3.39* Hgb-9.4* Hct-29.8* MCV-88 MCH-27.6 MCHC-31.4 RDW-15.5 Plt ___ ___ ___ PTT-36.8* ___ ___ Glucose-118* UreaN-5* Creat-0.7 Na-135 K-4.5 Cl-99 HCO3-28 AnGap-13 ___ Glucose-100 UreaN-2* Creat-0.4* Na-137 K-4.2 Cl-102 HCO3-30 AnGap-9 ___ ALT-9 AST-14 AlkPhos-90 TotBili-0.2 ___ Calcium-7.8* Phos-3.2 Mg-2.2 ___ Albumin-2.3* . ___ 10:27 am TISSUE NECROTIC LIVER. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. TISSUE (Preliminary): This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. GRAM POSITIVE RODS. SPARSE GROWTH. CORYNEFORM BACILLI, UNABLE TO IDENTIFY FURTHER. VIRIDANS STREPTOCOCCI. RARE GROWTH. Susceptibility testing requested by ___. ___ ___ ___. LACTOBACILLUS SPECIES. RARE GROWTH OF TWO COLONIAL MORPHOLOGIES. Susceptibility testing requested by ___. ___ ___ ___. ANAEROBIC CULTURE (Final ___: PREVOTELLA SPECIES. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. BETA LACTAMASE POSITIVE. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. PREVOTELLA SPECIES. SPARSE GROWTH. THIRD MORPHOLOGY. BETA LACTAMASE POSITIVE. Brief Hospital Course: On ___, he underwent exploratory laparotomy, lysis of adhesions, debridement of liver and ileocolectomy with ileocolonic anastomosis for necrotic liver and abscess. A JP drain was placed. Surgeon was Dr. ___. Postop, he did well. Pain was controlled with a dilaudid PCA. Vital signs remained stable. Vancomycin, Flagyl and Ciprofloxacin were started postop. JP drain output was brown-red initially averaged 200cc which decreased to 40cc. He was started on sips on postop day 2. Diet was advanced to clears on postop day 6 which he tolerated. KUB demonstrated prominent gas distended loops of colon along the descending and sigmoid colon. There was no evidence of perforation or obstruction of anastomosis. He passed flatus and diet was advanced to regular food on postop day 7. On postop day 7, meds were switched to the oral route. Pt was seen by Infectious disease team which recommened patient switch antibiotics to Levofloxacin and Flagyl for four weeks. After four weeks patient will follow up with Dr. ___ attending, ___ clinic on ___. Prior to this visit, patient should obtain CT abdomen and pelvis with contrast. On postop day 9, pt's PICC was taken out. Patient was discharged. Patient was asked if he felt comfortable taking care of the drain himself, which he did. Therefore ___ services were not needed. Pt was instructed to call Dr. ___ office to follow up ___ 2 weeks time. Patient's JP drain will remain ___ place until that time. Patient should record drain output until this follow-up visit with Dr. ___. TRANSITIONAL ISSUES: ==================== - F/u with Dr. ___ surgeon, ___ 2 weeks - F/u with Dr. ___ attending, ___ 4 weeks after CT of abdomen and pelvis with contrast - Continue antibiotics for four weeks - Monitor JP drain output until f/u appt with Dr. ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 2. Calcium Carbonate 500 mg PO TID 3. Vitamin D 400 UNIT PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Milk of Magnesia 30 mL PO PRN constipation 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Acetaminophen 1000 mg PO TID 3. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 (One) tablet by mouth twice daily Disp #*60 Tablet Refills:*0 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 (One) tablet(s) by mouth every eight hours Disp #*90 Tablet Refills:*0 5. Levofloxacin 500 mg PO Q24H RX *levofloxacin [Levaquin] 500 mg 1 (One) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Ibuprofen 600 mg PO Q6H 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every three hours Disp #*100 Tablet Refills:*0 8. Milk of Magnesia 30 mL PO PRN constipation 9. Calcium Carbonate 500 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Necrotic liver with abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please empty and record JP drain output daily. Please call Dr. ___ office ___ if you have any questions regarding the drain or if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, increased abdominal pain, abdominal distension, incision redness/bleeding/drainage, constipation or diarrhea -you may shower with soap and water, rinse, pat dry. Do not apply powder/lotion/ointment to incisions -no driving if taking pain medication Followup Instructions: ___

{'Purulent drainage': ['Abscess of liver', 'Peritoneal adhesions (postoperative) (postinfection)'], 'Necrotic liver': ['Abscess of liver', 'Acute and subacute necrosis of liver'], 'Enteric fistula': ['Other specified disorders of intestine'], 'Persistent purulent drainage': ['Abscess of liver', 'Peritoneal adhesions (postoperative) (postinfection)'], 'Liver necrosis': ['Abscess of liver', 'Acute and subacute necrosis of liver'], 'Ileocolectomy': ['Other specified surgical operations and procedures causing abnormal patient reaction, or later complication'], 'Tachycardia': ['Paralytic ileus'], 'Sinus tachycardia': ['Paralytic ileus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ 8 ___ pigtail catheter placed ___ right abdominal wall abscess History of Present Illness: ___ had an MVC ___ ___, and underwent ex lap, debridement of a liver lac, ileocectomy, and ileocolostomy. He was taken back to the OR for bleeding <24 hours later. Postoperatively, he became septic and was found to have a large R posterior necrotic liver lesion; a drain was placed. Subsequently, he had multiple admissions for antibiotics and drain exchanges/placements. On ___, he underwent ex lap, LOA, liver debridement, and ileocolectomy w/ ileocolonic anastomosis. A JP was placed intraoperatively. He was discharged on ___ on Augmentin. The JP was d/c'd on ___. On ___, he presented with a R flank mass which ultimately proved to be an abscess ___ his previous JP tract; it was drained percutaneously. He was discharged home on ___ on Augmentin and cipro. The drain was removed on ___. He presents today with a painful R flank mass ___ the same location. He reports it developed 2 days ago. He has not had f/c/n/v/d. CT again demonstrated an abscess. ___ drained 40cc of pus and placed a pigtail drain. Past Medical History: MVC with liver lacs leading to necrotic liver lesion PSH: Exploratory laparotomy, washout of hemoperitoneum, debridement of laceration of the liver, ileocecectomy, ileocolostomy. s/p Left ankle ORIF s/p removal of adenoids ___: 1. Exploratory laparotomy and lysis of adhesions. 2. Debridement of liver. 3. Ileocolectomy with ileocolonic anastomosis Social History: ___ Family History: Noncontributory Physical Exam: 99.4 87 136/88 20 99%RA Gen: NAD, A&O x 3 ___: RRR Pulm: CTA b/l Abd: soft, ND, tender around drain site, otherwise NT, +BS, drain w/ purulent brown material Ext: no c/c/e Labs: 13.0>42.4<169 N 82.4 L 10.2 BUN 13 Cr 0.7 ___ 10.8 PTT 30.5 INR 1.0 Pertinent Results: ___ 06:25AM BLOOD WBC-6.4 RBC-4.48* Hgb-12.6* Hct-38.6* MCV-86 MCH-28.2 MCHC-32.7 RDW-14.5 Plt ___ ___ 12:50PM BLOOD ___ PTT-30.5 ___ ___ 06:25AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-137 K-4.3 Cl-99 HCO3-33* AnGap-9 ___ 05:55AM BLOOD ALT-49* AST-35 AlkPhos-115 TotBili-1.0 ___ 06:25AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4 ___ 4:30 pm ABSCESS Site: ABDOMEN RIGHT ABDOMINAL WALL ABCESS. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Preliminary): THIS IS A CORRECTED REPORT ___. Reported to and read back by ___. ___ (___) ___ @ 10:45 AM. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. WORK-UP REQUESTED BY ___. ___ (___) AND ___. ___. CITROBACTER FREUNDII COMPLEX. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may after initiation of therapy. For serious infections, repeat culture and sensitivity testing may. STAPHYLOCOCCUS, COAGULASE NEGATIVE. QUANTITATION NOT AVAILABLE. PREVIOUSLY REPORTED AS PROBABLE ENTEROCOCCUS ___. VIRIDANS STREPTOCOCCI. MODERATE GROWTH OF THREE COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING WORK-UP OF ANAEROBES REQUESTED BY ___. ___. Brief Hospital Course: ___ male admitted to Dr. ___ service with abdominal pain. An abdominal CT was done demonstrating recurrent RLQ abscess near colonic anastomosis concening for fistula. Recurrent air and fluid collection was seen where a pigtail catheter was previously, just deep to the peritoneum, with a tract extending through the right-sided abdominal wall musculature into the subcutaneous fat. This collection was adjacent to the ileocecal anastomosis. No enteric contrast within the collection to indicate leak at the anastomosis. He underwent placement of an 8 ___ drain into the right abdominal abscess with removal of 40cc purulence. Drainage was sent to micro. Vanco and Zosyn were started after drainage of the abscess. ID was consulted. Micro isolated Citrobacter sensitive to cipro, 3 colonies of Strep veridans and coag negative staph. ID recommended Levaquin 500 mg daily and Flagyl m500 mg TID until f/u drain study ___ 3 weeks. WBC decreased to 6.4 from 13. He remained afebrile and drain output initially was 40cc. This further decreased to 25cc. Patient will flush at home and continue antibiotics. Medications on Admission: Tylenol, oxycodone, ibuprofen Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q 8 hours Disp #*30 Tablet Refills:*0 2. Levofloxacin 500 mg PO Q24H RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 4. Acetaminophen 650 mg PO Q6H:PRN pain Maximum 3 grams daily (8 of the 325 mg tablets maximum) 5. Ibuprofen 400 mg PO Q8H:PRN pain Maximum 1200 mg daily Discharge Disposition: Home Discharge Diagnosis: Abdominal wall abscess h/o liver lac s/p MVC, liver abscess h/o ileocecectomy, ileocolostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office ___ if you have any fevers (temperatures of 101 or greater), chills, nausea, vomiting, worsening abdominal pain, drain site appears red or has drainage, drain output changes character (color/consistency/odor) or drainage stops. Empty drain and record all outputs. Change gauze dressing to abdominal drain daily and as needed. Flush drain twice daily with 5 cc sterile saline Continue antibiotics Followup Instructions: ___

{'abdominal pain': ['Other postoperative infection', 'Peritoneal abscess', 'Cellulitis and abscess of trunk'], 'fever': ['Other postoperative infection', 'Peritoneal abscess', 'Cellulitis and abscess of trunk'], 'abscess': ['Other postoperative infection', 'Peritoneal abscess', 'Cellulitis and abscess of trunk'], 'ileocecectomy': ['Surgical operation with anastomosis', 'bypass', 'or graft'], 'ileocolostomy': ['Surgical operation with anastomosis', 'bypass', 'or graft'], 'liver lac': ['Acquired absence of intestine (large) (small)'], 'MVC': ['Personal history of traumatic fracture'], 'purulent brown material': ['Other specified bacterial infections in conditions classified elsewhere and of unspecified site', 'other gram-negative organisms'], 'Citrobacter freundii complex': ['Other specified bacterial infections in conditions classified elsewhere and of unspecified site', 'other gram-negative organisms'], 'Streptococcus veridans': ['Streptococcus infection in conditions classified elsewhere and of unspecified site', 'other streptococcus'], 'Coagulase negative staphylococcus': ['Staphylococcus infection in conditions classified elsewhere and of unspecified site', 'other staphylococcus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Continued purulent drainage, increased drainage around drain insertion site, 10 kg weight loss Major Surgical or Invasive Procedure: ___: ERCP, drain exchange with upsize, feeding tube placement ___: Central line placement ___: PPFT replaced ___: CT guided drain upsizing, 10 -> 14 ___ History of Present Illness: ___ s/p MVC on ___ and was transferred in from an OSH with multiple injuries including an acute abdomen with avulsion of small bowel and multiple liver lacerations. Following an ICU course was found to have a R posterior large necrotic liver lesion in which a drain was placed. He has been treated with antibiotics and was readmitted x 1 for 9 days to restart antibiotics and have new drain placed. He continued antibiotics for one week following that admission and since that time has the drain in place which drains approximately 70-80 cc of milky pale thick drainage daily. The patient reports that the drainage from around the catheter haa increased significantly over the last few days, and it has developed a very bad odor that has caused him to be unable to eat. Since the last admission he has dropped another 10 kg, and has lost nearly 45 kg since the MVC. Patient denies recent fevers or chills, no chest pain or shortness of breath, he reports abdominal pain associated with the drain site area, and has poor appetite and occasional constipation. He still is taking PO dilaudid intermittently for musculoskeletal pain of the lower back and also neck from the ___. The collar has been removed. He reports no edema or abdominal swelling. Reports very low energy and barely able to move about house. Past Medical History: MVC with liver lacs leading to necrotic liver lesion PSH: Exploratory laparotomy, washout of hemoperitoneum, debridement of laceration of the liver, ileocecectomy, ileocolostomy. s/p Left ankle ORIF s/p removal of adenoids Social History: ___ Family History: Noncontributory Physical Exam: VS: 98.8, 118, 121/79, 20, 100%, 98.8 kg Gen: Sl pale, more interactive CV: Sl Tachy, reg rhythm Lungs: CTA B/L Abd: soft, mild tenderness most at drain site on rt lateral abdomen and RUQ, Well healed abdominal incision, drain with milky light tan drainage, drain site slightly red with same tan drainage around site and on dressing Extr: no edema, 2+ DPs Neuro: A+Ox3, Collar has been removed Pertinent Results: On Admission: ___ WBC-8.2 RBC-3.53* Hgb-8.7* Hct-28.9* MCV-82 MCH-24.5* MCHC-30.0* RDW-16.2* Plt ___ PTT-30.0 ___ Glucose-112* UreaN-6 Creat-0.4* Na-131* K-3.9 Cl-96 HCO3-28 AnGap-11 ALT-8 AST-19 AlkPhos-97 TotBili-0.6 Iron-15* calTIBC-113* Ferritn-828* TRF-87* Albumin-2.9* Calcium-8.8 Phos-3.7 Mg-1.___ y/o male admitted for continued medical issues following MVC. On admission the patient had an abdominal CT performed showing: 1. No interval change in size of the larger hepatic abscess, status post interval removal or dislodgement of a previously placed pigtail drain catheter. 2. Pigtail catheter remains in appropriate position in a subhepatic collection, which is contiguous with, but possibly minimally communicating with, the larger collection. 3. Slight decrease in size of the loculated right pleural effusion with pleural thickening and enhancement. There was drainage occuring around the pigtail catheter requiring multiple dressing changes daily. On HD ___ the patient underwent ERCP. Per report, cannulation of the biliary duct initially was not possible using a free-hand technique. Cannulation of the pancreatic duct was successful and deep using a free-hand technique. A ___ 4 cm pancreatic duct stent was placed to facilitate cannulation of the bile duct. An additional cannulation attempt of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Fluoroscopy on the biliary tree showed the common bile duct, common hepatic duct, right and left hepatic ducts, biliary radicles, cystic duct, and gallbladder were filled with contrast and well visualized, and there was no evidence of bile leak. A 10cm by ___ Cotton ___ biliary stent was placed successfully in the main duct due to the stenotic papilla following the sphincterotomy. Also, a nasojejunal feeding tube was placed using standard endoscopic nasojejunal feeding tube placement rechnique. The ___ tube was secured at 120 cm at the nose. Immediately following the ERCP, the patient also underwent exchange and upsizing to ___ Fr of the existing pigtail in the subhepatic fluid collection. The intra-hepatic collection has not had any intervention with this hospitalization. Initially, the patient was kept NPO overnight per protocol following the sphincterotomy, and on the following day, as the day progressed, the patient was having increased abdominal and back pain, and urine output decreased significantly. A foley was placed for monitoring, and he received fluid boluses. A mild elevation in the lipase was noted, and temp to 100.5 was noted and blood cultures were obtained. 2 days following the ERCP the patient had fever to 101.2, and was becoming tachycardic to the 140's. He was also reporting that the epigastric and back pain were worsening. On ___, due to continued decreased urine output, abdominal pain and tachycardia, and fever, the patient was transferred to the SICU. He was kept NPO, and was started on TPN folloewing central line placement. Lipase peaked at 363 and then started to trend down, however his abdominal exam still revealed pain and still with significant back pain. The abscess pigtail drain was draining 150 - 300 cc daily of purulent appearing, thick light tan fluid. Blood cultures have remained negative throughout. With resuscitaion and NPO status, the patient's symptoms started to improve. Urine output improved, he was afebrile, and so was transferred back to the surgical floor. He was continued on TPN. He received 2 units of RBCs for symptomatic Hct 22.9 with appropriate response. As symptoms subsided, he was very slowly advanced on his diet, and the tube feeds were started via the post pyloric feeding tube, which had to be replaced while in the SICU due to clogging. On ___ he underwent an abdominal CT, assessing the severity of the pancreatitis. There was mild ___ stranding and thickening of gerotas fascia. The pigtail catheter was still in appropriate position in the subhepatic fluid collection. The patient was continued on TPN, and he remained NPO. The pigtail drain dressing was noted to have drainage that seems to increase when patient upright or ambulating. On ___ he was sent to CT for another drain upsize to a ___ Fr drain. At the time of the surveillance CT, it was noted that there is oral contrast from the previous CT scan layering in the abscess cavity, suggestive of a fistulous tract to the bowel. He underwent a fluoro study with Optiray injected through the new ___ catheter. This sjowed the abscess cavity filling and a small fistulous communication with what appeared to be the small bowel. Upon return to the floor, the drainage has taken on a brown and thick appearance. At this time he was made NPO and will continue on TPN. TPN was continued on the surgical floor until ___. Prior to discontinuation of the TPN, Mr. ___ received a CT scan with injection of contrast through his pigtail catheter to further elucidate the anatomy. The plan at that time was operative intervention assuming the fistula was still patent. However, the CT did not identify fistula. Per report, the following was identified: "Opacification of the right perihepatic and paracolic gutter abscess cavity without evidence of small bowel fistulous communication on CT." Operative intervention was therefore withheld. Mr. ___ completed a few more days of TPN, and then was transitioned to an oral diet. After several days of increasing PO intake, he was consuming approximately 1800 kcal per day. He was safely discharged on ___ with PTBD in place and planned follow-up in clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Dronabinol 2.5 mg PO BID 2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 3. Calcium Carbonate 500 mg PO TID 4. Vitamin D 400 UNIT PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Milk of Magnesia 30 mL PO DAILY:PRN constipation 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*2 2. Calcium Carbonate 500 mg PO TID 3. Vitamin D 400 UNIT PO DAILY 4. Milk of Magnesia 30 mL PO DAILY:PRN constipation 5. Multivitamins 1 TAB PO DAILY 6. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*40 Capsule Refills:*2 7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain RX *hydromorphone 2 mg 1 tablet(s) by mouth three times a day Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hepatic abscess post endoscopic retrograde cholangiopancreatography pancreatitis Malnutrition 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 ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, yellowing of skin or eyes, drainage stops completetely or increases to greater then 400 cc daily, drainage turns bloody in apprearance, or develops a worsening odor, swelling of legs, increased abdominal size, drainage around the drain is increasing, or the drain site becomes red or painful. You may shower, avoid having the drain hanging freely at any time. Place a new drain sponge around the drain site daily and as needed. Please drain and record the drain bag three times daily and as needed. Bring a copy of the drain output with you to clinic. Please call if the output increases significantly, stops completely, becomes bloody in appearance or develops a worsening odor. No heavy lifting greater than 10 pounds. No driving if taking narcotic pain medication. Please ensure you are hydrating well, and be sure to maintain adequate nutrition. Followup Instructions: ___

{'Continued purulent drainage': ['Abscess of liver', 'Acute pancreatitis', 'Peritoneal abscess'], 'Increased drainage around drain site': ['Abscess of liver', 'Acute pancreatitis', 'Peritoneal abscess'], 'Weight loss': ['Unspecified protein-calorie malnutrition', 'Adult failure to thrive'], 'Abdominal pain': ['Abscess of liver', 'Acute pancreatitis', 'Peritoneal abscess'], 'Poor appetite': ['Unspecified protein-calorie malnutrition', 'Adult failure to thrive'], 'Constipation': ['Unspecified protein-calorie malnutrition', 'Adult failure to thrive'], 'Low energy': ['Unspecified protein-calorie malnutrition', 'Adult failure to thrive']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: BRBPR, hyperkalemia Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: ___ is a ___ M with h/o ESRD on Mo/Th HD and HTN who presents with BRBPR after abdominal cramping night before admission, found to have HTN and hyperkalemia and admitted to ICU for urgent HD. . Patient was discharged from ___ on ___ for uremia after missing HD. Patient was in usual state of health and due for HD today, however he developed some mild abd cramping last night. This AM he had 1 bloody BM with BRBPR and brown/dark brown stool. Patient had no abd pain, malaise, fatigue, dizziness, light-headedness. . In the ED, initial vitals: 98.4 89 ___ ra, found to have K of 6.8, given insulin, dextrose, calcium empirically. GI was consulted and he was given pantoprazole 40mg IV x 1 for possible LGIB. Patient was hypertensive and transitioned to the ICU. . On transfer, vitals were: 98.0 67 178/86 17 100% RA . On arrival to the MICU, patient was without symptoms. He was hypertensive to 200s and his home medications were started. . Past Medical History: - ESRD ___ HTN, on Mo/Th HD for ___ year, has L AF fistula - HTN - Hyperlipidemia - H/O EtOH abuse (sober ___ year) Social History: ___ Family History: non-contributory Physical Exam: ADMISSION VITALS Vitals- T97.8 BP 181/92 P 94 RR16 O2 91RA General- middle aged male, appeared stated age, lying comfortably, thirsty HEENT- NCAT, orpharynx clear, no LAD Neck- no JVD CV- RRR, holosystolic murmur at RUSB Lungs- CTA ___ Abdomen- soft, nt, nd, no organomegaly Ext- no CCE, no mottling of skin, mild diaphoresis Neuro-no focal deficits, moves all 4 extremities purposefully and without incident, no facial droop Rectal: brown stool, no hemmorhoids appreciated, small flecks of gross blood. DISCHARGE General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: left wrist with fistula with notable palpable thrill, Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact Lines: R arm PIV c/d/i Pertinent Results: Admission Labs: ___ 09:40AM BLOOD WBC-9.1# RBC-3.84* Hgb-10.1* Hct-33.0* MCV-86 MCH-26.4* MCHC-30.6* RDW-16.3* Plt ___ ___ 09:40AM BLOOD Glucose-96 UreaN-102* Creat-12.3*# Na-139 K-6.8* Cl-96 HCO3-19* AnGap-31* ___ 09:40AM BLOOD Calcium-8.5 Phos-7.0* Mg-3.2* . Repeat labs: ___ 08:08PM BLOOD WBC-10.1 RBC-3.73* Hgb-10.2* Hct-32.2* MCV-86 MCH-27.3 MCHC-31.6 RDW-16.3* Plt ___ ___ 08:08PM BLOOD Glucose-120* UreaN-32* Creat-5.8*# Na-141 K-4.5 Cl-93* HCO3-30 AnGap-23* ___ 08:08PM BLOOD Calcium-8.9 Phos-3.8# Mg-2.1 ___ 05:18AM BLOOD WBC-6.2 RBC-3.45* Hgb-9.3* Hct-30.1* MCV-87 MCH-26.9* MCHC-30.8* RDW-16.5* Plt ___ ___ 12:34PM BLOOD Hct-30.1* ___ 08:00AM BLOOD WBC-6.7 RBC-3.36* Hgb-8.8* Hct-29.0* MCV-86 MCH-26.3* MCHC-30.5* RDW-16.7* Plt ___ Brief Hospital Course: ___ is a ___ M with h/o ESRD on Mo/Th HD and HTN who presents with lower GI bleeding with hyperkalemia on labs and admitted to ICU for urgent HD. . # Hyperkalemia: Potassium 6.8 with hyperacute T waves on admission. Similar presentation on admission ___ after missing hemodialysis session. Received insulin, dextrose, calcium gluconate in the ED. Improved after urgent HD while in the ICU. . # BRBPR: Patient presented with BRBPR with bowel movement after episode of abdominal cramping. No evidence of ongoing bleed: hemodynamically stable, hematocrit stable. GI evaluated, imaging deferred at this time. Ddx includes gastroenteritis, stool studies were sent and were pending. Patient did not have any subsequent bloody bowel movements, and GI recommended that the patient receive an outpatient colonoscopy. . # ESRD on HD: Patient was followed by Nephrology/Dialysis during admission. He should follow up with his nephrologist as an outpatient. Specifically, given his frequency of admission for hyperkalemia, he should consider increasing the frequency of his HD sessions to 3x/week to prevent such occurrences. . # Hypertension: systolic BPs to the 200s on admission to the ICU in the setting of missing home BP meds. Restarted on home metoprolol, nifedipine, torsemide with good improvement in BP. . # POOR MEDICAL COMPLIANCE: Pt has poor insight into his medical problems and per his home nurse practitioner, has missed multiple dialysis sessions over the past year. He currently resides at an assisted living facility but probably needs higher level of care (e.g. SNF). Social work and case management were involved and counseled patient about this in the past, but he is competent to make his own decisions and has refused SNF in the past. . TRANSITIONAL ISSUES: **Please schedule a colonoscopy for patient within the next month. **Please consider retitration of antihypertensives in coordination with nephrology. **F/u with nephrology regarding frequent hospitalizations for uremia, consider increasing frequency of HD sessions . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain or Fever 2. Bisacodyl ___AILY:PRN constipation 3. Calcium Acetate 1334 mg PO TID W/MEALS 4. Calcium Carbonate 1000 mg PO QID:PRN Dyspepsia 5. Cinacalcet 30 mg PO DAILY 6. Famotidine 20 mg PO DAILY 7. Metoprolol Succinate XL 150 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. NIFEdipine CR 30 mg PO DAILY 10. Ondansetron 4 mg PO Q8H:PRN Nausea 11. Torsemide 100 mg PO DAILY 12. Epoetin Alfa 10,000 units SC PER HD Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain or Fever 2. Calcium Acetate 1334 mg PO TID W/MEALS 3. Calcium Carbonate 1000 mg PO QID:PRN Dyspepsia 4. Cinacalcet 30 mg PO DAILY 5. Metoprolol Succinate XL 150 mg PO DAILY 6. Nephrocaps 1 CAP PO DAILY 7. NIFEdipine CR 30 mg PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN Nausea 9. Torsemide 100 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Epoetin Alfa 10,000 units SC PER HD Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperkalemia, lower GI bleed Secondary: ESRD 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 during your hospitalization at ___. You were admitted to the hospital with rectal bleeding, and were found to have a very high potassium level due to missing your dialysis session. You were given urgent hemodialysis. Your blood counts were stable, and you were seen by the GI doctors who recommended ___ get a colonoscopy as an outpatient. Please ask your primary care doctor to set up a colonoscopy visit for you. This is very important. You should go to your hemodialysis center tomorrow for HD. Best of luck with your recovery. Your blood pressures were very high when you came in to the hospital. Please take all of your high blood pressure medications. It is very important that you get regular dialysis and avoid missing sessions. Followup Instructions: ___

{'BRBPR': ['End stage renal disease', 'Hyperpotassemia'], 'hyperkalemia': ['Hyperpotassemia', 'End stage renal disease'], 'hypertension': ['Hypertensive chronic kidney disease', 'End stage renal disease'], 'lower GI bleeding': ['Blood in stool', 'End stage renal disease'], 'ESRD on HD': ['End stage renal disease', 'Renal dialysis status'], 'POOR MEDICAL COMPLIANCE': ['Noncompliance with renal dialysis', 'End stage renal disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: self-inflicted wound Major Surgical or Invasive Procedure: ___: Bedside neck laceration repair with sutures and ___ drain placement. History of Present Illness: Mr. ___ is a ___ yo gentleman with two prior suicide attempts ___ and ___ and one prior psychiatric hospitalization (___) with previous diagnosis of depression (s/p 6 Ketamine treatments in ___ for "refractory depression") who called an ambulance after stabbing self in the neck in hopes of ending his life. Past Medical History: unspecified depressive disorder Social History: ___ Family History: - ___ Dx: father has "socialization" issues, mother has depression - ___ Hospitalizations: denies - ___ Treatment Hx/Med Trials: mother on antidepressant - ___ Hx Suicide: uncle with suicide Physical Exam: Admission Physical Exam: GA: Comfortable Neuro: GCS of 15, moves all 4 extremities HEENT: No scleral icterus, no hemotympanum, no maxillary mandibular instability, zone two 5 to 7 cm irregular laceration with violation of the areolar tissue noted to be oozing blood but not pulsatile Cardiovascular: Normal S1, S2, regular rate and rhythm, no murmurs/rubs/gallops, 2+ peripheral pulses bilaterally Pulmonary: Clear to auscultation bilaterally Abdominal: Soft, nontender, nondistended, no masses Extremities: No lower leg edema Integumentary: Old laceration to times on left forearm anterior aspect Discharge Physical Exam: VS: T98.4, BP 142 / 81, HR 93, RR 18, O2 99 Ra GEN: NAD, flat affect, slow response to questions HEENT: right neck wound about 6 inches wide, sutures with non-absorbable material. well approximated without erythema, drainage, or fluctuance. Non-tender CV: RRR, no m/r/g PULM: CTAB, no w/r/g ABD: soft, NT, ND EXT: WWP, no edema, 2+ periperhal pulses Pertinent Results: IMAGING: ___: CTA Neck: 1. Large skin laceration along the right anterior triangle (zone 2) with subcutaneous air extending beyond the plane distance muscle into the right parapharyngeal space abutting the right common facial vein. 2. No evidence of pseudoaneurysm or caliber narrowing involving the right common carotid, internal carotid and major branches of the right external carotid artery to suggest injury at this time. No active contrast extravasation or large hematoma. 3. No findings to suggest arteriovenous fistula at this time. 4. Visualized aerodigestive track is grossly unremarkable. No evidence of emphysema in the retropharyngeal or pre vertebral soft tissues to suggest esophageal perforation. 5. Additional findings described above. ___: CXR: No acute cardiopulmonary abnormality. No displaced fracture. ___: BARIUM SWALLOW/ESOPHAGU: No evidence of leak. ___ 11:00AM BLOOD WBC-6.8 RBC-5.47 Hgb-15.3 Hct-44.9 MCV-82 MCH-28.0 MCHC-34.1 RDW-12.0 RDWSD-35.8 Plt ___ ___ 06:41PM BLOOD ___ PTT-25.2 ___ ___ 11:00AM BLOOD Glucose-109* UreaN-11 Creat-1.0 Na-141 K-4.3 Cl-101 HCO3-26 AnGap-14 ___ 11:00AM BLOOD Calcium-10.3 Phos-3.1 Mg-2.0 ___ 06:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 06:41PM BLOOD Lipase-___ y/o M who presented to ___ s/p self-inflicted stab wound to zone 2 of the neck. He had a CTA which was negative for deeper blood vessel injury. He had a barium swallow which was negative for leak. His neck wound was repaired with sutures and a ___ drain was placed. The patient was admitted to the Acute Care Surgery/Trauma service for further care. After remaining hemodynamically stable, the patient was transferred to the surgical floor. He was started on a regular diet which he tolerated well. Psychiatry was consulted. He was placed in 1:1 seclusion for safety. The patient was calm and oriented throughout hospitalization. On ___, the ___ drain was removed and the patient was screened for inpatient psychiatry. His incision remained well approximated with sutures with minimal serous output At the time of transfer, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a 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: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Self-inflicted stab wound to zone 2 ___ischarge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with a stab wound to your neck. The wound was repaired with sutures and a ___ drain was left in place to allow for drainage and to prevent infection. The drain was later removed and your wound is healing well. You had imaging done which did not show damage to the major blood vessels of the neck or injury to the throat. You are now ready to be discharged to inpatient psychiatry. Please note the following discharge instructions: YOUR INCISION: -Your incisions may be slightly red. This is normal. -You may gently wash away dried material around your incision. -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. You can put a piece of gauze over this to cover the area -You may shower. You should not take baths or swim If you have any questions or concerns, please call the ___ clinic at ___. Followup Instructions: ___

{'self-inflicted wound': ['Intentional self-harm by knife', 'Laceration without foreign body of unspecified part of neck'], 'depression': ['Major depressive disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bilateral hip and thigh pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ M presents to ER w/acute onset of moderate to severe bilateral hip and thigh pain x3 weeks prior, symptoms persisted, w/exacerbation with ambulation, essentially pain free at rest, now with increasingly severe symptoms over the last 48 hours Past Medical History: HTN, DM, CAD PSH: none Social History: Retired ___ from ___ where he resides. In ___, visiting family in the area. Physical Exam: Alert and oriented x 3 VS:BP 140/80 HR 64 Carotids: 2+, no bruits or JVD Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: palpable throughout Feet warm, well perfused. Pertinent Results: ___ 05:20AM BLOOD WBC-11.3* RBC-3.36* Hgb-11.3* Hct-32.9* MCV-98 MCH-33.8* MCHC-34.5 RDW-13.3 Plt ___ ___ 05:20AM BLOOD Glucose-140* UreaN-28* Creat-0.9 Na-140 K-4.2 Cl-107 HCO3-23 AnGap-14 ___ 05:20AM BLOOD Calcium-8.5 Phos-3.1# Mg-2.1 ___ ABD/PELVIS 1. 3.6 cm focal infrarenal aortic dissection with fenestrations and contrast entering the false lumen. There is no evidence of rupture. The age is indeterminate. 2. Severe atherosclerotic disease. 3. Multiple right renal cysts. 4. Small probable splenic hemangiomas. 5. Multiple pulmonary nodules, the largest of which measures 6 mm. Brief Hospital Course: ___ M presenting w/acute onset of moderate to severe bilateral hip and thigh pain 3 weeks ago, symptoms persisted, w/exacerbation with ambulation, essentially pain free at rest, now with increasingly severe symptoms over the last 48 hours. Workup for this pain included a abd CT which showed probable focal infrarenal aortic dissection, measuring 3.4 cm in diameter, which is incompletely evaluated on this non-contrast CT. There is no surrounding stranding to suggest evidence of rupture. A CTA of the area showed 3.6 cm focal infrarenal aortic dissection with fenestrations and contrast entering the false lumen. There is no evidence of rupture. The age is indeterminate. He was hypertensive to the 180s so an arterial line was placed and a nicardipine infusion was started with goal BP less than 140. We were able to quickly discontinue the nicardipine and transistion him to an oral antihypertensive regiment. He remained hemodynamically stable with less pain with ambulation, tolerating a regular diet. He was discharged to home in stable condition. He will followup with his PCP when he returns to ___. Medications on Admission: Plavix 75', lopressor 75', amlodipine 5', ramipril 10', atorvastatin 40', Januvia 100', Metformin 500'', Insuling 5U am/pm Discharge Medications: 1. Amlodipine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 2. Atorvastatin 40 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. HydrALAzine 75 mg PO Q6H RX *hydralazine 50 mg 1.5 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Metoprolol Succinate XL 100 mg PO BID RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice daily Disp #*10 Tablet Refills:*0 7. Ramipril 10 mg PO BID RX *ramipril [Altace] 10 mg 1 capsule(s) by mouth twice daily Disp #*10 Capsule Refills:*0 8. Regular 5 Units Breakfast Regular 5 Units Dinner 9. Acetaminophen 650 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Infrarenal Aortic Dissection Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented to the ER secondary to moderate to severe bilateral hip and thigh pain that worsened with walking. Further investigation with a CT scan showed an aortic dissection as the cause of your pain. Your blood pressure was very high. We needed to increase the doses of your current medications and add a new medication called hydralazine (see attached medication list) to control your blood pressure. This is the major treatment for your dissection. Please follow up with your PCP as soon as possible. We have given you a 5 day supply of the new medication. Your blood pressure must be closely monitored with goal BP < 140 systolic. Followup Instructions: ___

{'bilateral hip and thigh pain': ['Dissection of aorta', 'abdominal', 'Osteoarthrosis', 'localized', 'not specified whether primary or secondary', 'pelvic region and thigh'], 'hypertension': ['Unspecified essential hypertension'], 'diabetes': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'hypercholesterolemia': ['Pure hypercholesterolemia'], 'coronary atherosclerosis': ['Coronary atherosclerosis of native coronary artery'], 'tobacco use': ['Personal history of tobacco use'], 'insulin use': ['Long-term (current) use of insulin']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with PMH of HTN, osteoporosis, hip fracture living at assisted living (___) ___ yrs. Family noticed while visiting today that she was disoriented, speech was slurred, could not remember whether pt had breakfast. Pt had been dosing off and becoming more somnolent intermittently last few days. By the time ambulance arrived, patient was really unable to communicate with other people but still recognized her son. No reported fevers at ___. . In ED VS were T98 HR 64 132/72 18 100% RA. Labs were drawn, UA showed trace leuk esterase, pos nitrate, ___ WBCs and many bacteria. WBC of 10.5. Given IV ciprofloxacin for presumed UTI. . On the floor, the patient is somnolent, is oriented to person, knows that she's in the hospital but not which one. Not oriented to time. Patient is difficult to understand and falls asleep multiple times during the interview. Denies dysuria, urinary frequency, abdominal pain or fevers at home. Past Medical History: (per OMR, unable to obtain from the patient) Memory loss Osteoporosis with multiple fractures (hip, vertebral, ulna/radius) HTN Diverticulitis partial SBO Basal Cell Ca s/p resection s/p cataracts s/p TAH/BSO/appy Social History: ___ Family History: unable to obtain from the patient Physical Exam: ADMISSION EXAM: VS: 93.4 ax, 95.5 rectal; 156/96, 87 18 98%RA General: somnolent, eyes closed, opens eyes to voice and mumbles. difficult to understand. Cachetic. HEENT: small irregular pupils on both sides, minimally reactive. MM dry. Cardiovascular: RRR. Normal S1/S2, S4. No murmurs/gallops/rubs. Pulmonary: CTAB, no wheezes/rales. Abd: Soft, NT/ND, +BS. No HSM. Extremities: cool to palpation, no edema. Skin: No rash, ecchymosis, or lesions. Neuro/Psych: Unable to test as patient does not follow commands. pt with general contractures Pertinent Results: ___ 11:30AM BLOOD WBC-10.5# RBC-3.61* Hgb-12.1 Hct-35.2* MCV-97 MCH-33.5* MCHC-34.4 RDW-12.9 Plt ___ ___ 11:30AM BLOOD Neuts-90.1* Lymphs-4.1* Monos-5.0 Eos-0.5 Baso-0.2 ___ 11:30AM BLOOD Glucose-116* UreaN-28* Creat-0.9 Na-139 K-4.5 Cl-102 HCO3-27 AnGap-15 ___ 11:42AM BLOOD Lactate-1.5 ___ 12:50PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-TR ___ 12:50PM URINE RBC->50 ___ Bacteri-MANY Yeast-NONE Epi-0 ================================ IMAGING: ___ CXR: No acute intrathoracic process. Moderate-to-large hiatal hernia as before. ================================ MICROBIOLOGY: ___ URINE CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML. ___ BCx: negative Brief Hospital Course: ___ yo F with HTN and osteoporosis, living at ___ with increasing somnolence, lethargy and confusion in last few days, found to have UTI in the ED. . # UTI: UA with many RBCs, some WBC and bacteria. Patient was started on IV cipro in the ED. Cipro was continued in the hospital given patient's clinical improvement. . # Hypothermia: initially concerning for sepsis, however, her other vital signs remained within normal limits. Patient was monitored with antibiotic treatment and her temperature improved. She remained afebrile throughout the hospital stay. . # AMS: though she does have underlying dementia, patient was reported to be more somnolent in days prior to admission, likely related to UTI. Her mental status improved with treatment of her UTI. At baseline, she is AOx1, only to self. She does know that she lives at ___, but could not say which hospital she was in or what year it is. . # Osteoporosis: history of multiple fractures in the past. Patient was continued on her calcium and vitamin D in house. . # HTN: Her antihypertensives were held initially given concern for sepsis and possible hypotension. Her blood pressure remained within normal limits and became elevated during the second hospital day, so she was restarted on home metoprolol. She will be discharged on home antihypertensive regimen. Medications on Admission: Calcium + Vitamin D BID Tylenol arthritis Fosamax 70 mg metoprolol 25 BID amlodipine 5 daily multivitamin aspirin 81 colace daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for for pain/fevers. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: As you know, you were admitted to ___ for confusion. We performed a urine analysis which showed that you had a urinary tract infection. We treated you with antibiotics and your confusion resolved. When you go home, you will need to continue antibiotics. These changes were made to your medications: START ciprofloxacin 250 mg by mouth every day for 3 more days Followup Instructions: ___

{'Altered mental status': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Somnolence': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Slurred speech': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Disorientation': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Difficulty communicating': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Recognition of son': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Leukocyte esterase': ['Urinary tract infection'], 'Positive nitrate': ['Urinary tract infection'], 'White blood cell count': ['Urinary tract infection'], 'Bacteria in urine': ['Urinary tract infection'], 'Cachetic appearance': ['Osteoporosis'], 'Small irregular pupils': ['Metabolic encephalopathy'], 'Dry mucous membranes': ['Dehydration'], 'Cool extremities': ['Hypothermia not associated with low environmental temperature'], 'No edema': ['Unspecified essential hypertension'], 'Normal heart sounds': ['Unspecified essential hypertension'], 'No murmurs/gallops/rubs': ['Unspecified essential hypertension'], 'Soft abdomen': ['Diaphragmatic hernia without mention of obstruction or gangrene'], 'No hepatosplenomegaly': ['Diaphragmatic hernia without mention of obstruction or gangrene'], 'No rash/ecchymosis/lesions': ['Other persistent mental disorders due to conditions classified elsewhere']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: L facial weakness and numbness Major Surgical or Invasive Procedure: ___ line placement ___ History of Present Illness: ___ year-old right-handed male with no significant past medical history, presents for evaluation of left facial numbness. The patient notes that he was in his usual state of good health until last ___ afternoon, when he noted some pain in his left ear. He also noted that his left tongue did not seem to perceive taste as well. His neck was somewhat stiff, though this improved over the weekend. On ___, he noted some left cheek numbness and he presented to the ED for evaluation of these symptoms. He was tested for Lyme disease, though results have not yet returned. He was discharged and told to follow-up in Neurology urgent care clinic this week. However, over the weekend, he noted that his left face was becoming subtly weak. Today, he noted that his left eye was a bit red. This evening, his facial numbness gradually spread to involve his left forehead and left lips. He was told to call if his symptoms worsened, and was directed to come in for further evaluation. Of note, the patient reports a recent camping trip in the third week of ___, when he was noted to have a tick on him. There was no rash, nor rash since. Review of Systems: No F/C, N/V/D, CP, SOB, vision change or loss, hearing loss or tinnitus, dysphagia, weakness, N/T in the extremities, or incoordination. Past Medical History: None Social History: ___ Family History: none noted Physical Exam: Vitals: T 97.3 F BP 129/60 P 82 RR 18 SaO2 99 RA General: NAD, well-nourished HEENT: NC/AT, left sclera injected, MMM, no exudates in oropharynx, no vesicles in ear canals noted Neck: supple, no nuchal rigidity Lungs: clear to auscultation CV: regular rate and rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no edema, pedal pulses appreciated Skin: no rashes Neurologic Examination: Mental Status: Awake and alert, able to relay history, cooperative with exam, normal affect Oriented to person, place, time Attention: can say days of week backward Language: fluent, non-dysarthric speech, no paraphasic errors, naming, comprehension intact; reading intact Fund of knowledge: normal Memory: registration: ___ items, recall ___ items at 3 minutes No evidence of apraxia or neglect Cranial Nerves: Optic disc margins sharp; Visual fields are full to confrontation. ___ acuity bilaterally. Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Extraocular movements intact, no nystagmus. Facial sensation reduced to light touch on left, V1-V3, but notices no significant difference on PP. Left facial weakness involving eye and mouth, blink is slower on left. Hearing intact to finger rub bilaterally. Palate elevates midline. Tongue protrudes midline, no fasciculations. Trapezii full strength bilaterally. Motor: Normal bulk and tone throughout. No pronator drift. No tremor. D T B WE FiF ___ IP Q H TA ___ Right ___ 5 5 ___ ___ 5 5 Left ___ 5 5 ___ ___ 5 5 Sensation: No deficits to light touch, pin prick, temperature (cold), vibration, and proprioception throughout. Reflexes: B T Br Pa Pl Right ___ 2 2 Left ___ 2 2 Toes were withdrawal bilaterally. Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Normal FFM. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk on toes, heels, and in tandem without difficulty. Romberg absent. Pertinent Results: ___ 10:49AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:49AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 06:10AM GLUCOSE-98 UREA N-11 CREAT-1.0 SODIUM-140 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 ___ 06:10AM CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-2.1 ___ 06:10AM CRP-1.1 ___ 06:10AM WBC-8.1 RBC-4.41* HGB-13.8* HCT-39.6* MCV-90 MCH-31.2 MCHC-34.8 RDW-12.7 ___ 06:10AM PLT COUNT-219 ___ 06:10AM ___ PTT-32.2 ___ ___ 06:10AM SED RATE-1 ___ 02:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-42 GLUCOSE-62 ___ 02:00AM CEREBROSPINAL FLUID (CSF) WBC-56 RBC-1* POLYS-4 ___ MACROPHAG-7 ___ 10:00PM GLUCOSE-106* UREA N-10 CREAT-1.1 SODIUM-140 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 ___ 10:00PM estGFR-Using this ___ 10:00PM ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-162 ALK PHOS-83 TOT BILI-0.5 ___ 10:00PM ALBUMIN-5.0* ___ 10:00PM WBC-6.5 RBC-4.51* HGB-14.1 HCT-40.5 MCV-90 MCH-31.3 MCHC-34.8 RDW-12.7 ___ 10:00PM NEUTS-69.3 ___ MONOS-6.3 EOS-1.8 BASOS-1.0 ___ 10:00PM PLT COUNT-236 Brief Hospital Course: MRI with contrast showed enhancement of cranial nerves 5 and 7. CSF with 56 WBC, 1 RBC, glc 62, prot 42. Initially started on ceftriaxone 2g IV Q24hrs and acyclovir. Acyclovir d/c'd due to low clinical suspicion, HSV PCR pending. Lyme serum western blot pending, CSF lyme pending. Given high suspicion for lyme, planned for 21d course of ceftriaxone. ___ line placed ___ and arranged for home IV infusion therapy. Medications on Admission: none Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) Drop Ophthalmic Q 8H (Every 8 Hours) as needed for for eye irritation. Disp:*1 bottle* Refills:*0* 2. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 19 days: starting ___. Disp:*40 grams* Refills:*0* 3. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once a day for 19 days: after medication infusion. Disp:*50 mL* Refills:*0* 4. Saline Flush 0.9 % Syringe Sig: Twenty (20) mL Injection once a day for 19 days: 10 mL flush before and 10mL flush after each medication infusion and Q8hrs prn. Disp:*QS * Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L facial weakness and numbness, CSF pleocytosis and enhancement of cranial nerves, likely lyme disease Discharge Condition: stable Discharge Instructions: You likely have lyme disease causing your facial weakness and sensory changes. You will need a total 21 day course of IV antibiotics (ceftriaxone). We have arranged for infusions at your dormatory. Please call the the ___ (___) on ___ and as to have Dr. ___ paged to get results of pending blood and spinal fluid studies including lyme disease results. Please follow-up in neurology clinic as below. Followup Instructions: ___

{'pain in left ear': ['Lyme Disease'], 'left tongue does not perceive taste': ['Lyme Disease'], 'stiff neck': ['Lyme Disease'], 'left cheek numbness': ['Lyme Disease'], 'subtly weak left face': ['Lyme Disease'], 'left eye red': ['Lyme Disease'], 'facial numbness spread to involve left forehead and left lips': ['Lyme Disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with hypertension, overactive bladder, ? dementia, transferred from ___ for acute pancreatitis. On ___, noted left sided chest pain, went to hospital, with cardiac work-up negative. On ___, pain came back and had sweats, no chills around midday, called EMS, hypotensive to ___, given IVF and aspirin 324 with improvement in BP to 130s/50s. OSH labs/imaging concerning for biliary ductal dilation with obstructing stone in common bile duct, transferred to ___. In the ED, initial vitals were 97.7 69 118/51 15 95% RA. She reported nausea, no vomiting. Labs from ___: Leukocytosis to 12.9 (neutrophil predominant) Cr at baseline 0.71 AST 207 ALT 114, Alk phos 93, t bili 0.6 Lipase 6927 Trop neg Labs at ___ showed WBC 10.4K, plts 143K, ALT 464, AST 617, lipase 950, Tbili 0.3, lactate 0.9. CTAP: - cholecystectomy, intrahepatic and extrahepatic biliary ductal dilatation (1.2 cm), no obstructing intraductal stone or pancreatic head mass detected, no pancreatic ductal dilatation, no pancreatitis detected. - Normal bowel caliber, colon diverticulosis without diverticulitis. - L5 35% compression fracture. - S/p right total hip, overlying circumscribed fluid collection in lateral right flank subcutaneous fat bay be postoperative fluid vs abscess. Total hip appears intact. CTA negative for PE. Patient received 1 liter NS and 500 mg IV metronidazole. Currently, patient reports ___ left-sided chest pain. There is no abdominal pain. She has no current nausea. There is no fevers or chills. She reports no dyspnea. Review of systems: 10 pt ROS negative other than noted Past Medical History: Hypertension Anxiety Mild cognitive impairment Overactive bladder Social History: ___ Family History: Father with CAD Physical Exam: ADMISSION EXAM: Vitals: ___ 1002 Temp: 97.6 PO BP: 148/71 HR: 77 RR: 18 O2 sat: 93% O2 delivery: Ra ___ 1056 Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Alert, oriented to name, place, date. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. No pain to palpation of chest wall. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: 1+ lower leg edema, left knee well healed scar, LLE slightly larger than right and tender to palpation. DERM: No active rash. Neuro: moving all four extremities purposefully, non-focal. PSYCH: Appropriate and calm. DISCHARGE EXAM: VS: ___ Temp: 98.4 PO BP: 142/74 HR: 61 RR: 18 O2 sat: 93% O2 delivery: RA ___ 0801 Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Alert, oriented to name, place, date. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. No pain to palpation of chest wall. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: 1+ lower leg edema, left knee well healed scar, LLE slightly larger than right and tender to palpation. DERM: No active rash. Neuro: moving all four extremities purposefully, non-focal. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS -------------- ___ 04:00AM BLOOD WBC-10.4* RBC-4.30 Hgb-12.3 Hct-38.7 MCV-90 MCH-28.6 MCHC-31.8* RDW-14.3 RDWSD-47.2* Plt ___ ___ 04:00AM BLOOD Neuts-86.5* Lymphs-5.4* Monos-7.3 Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.03* AbsLymp-0.56* AbsMono-0.76 AbsEos-0.01* AbsBaso-0.02 ___ 04:00AM BLOOD ___ PTT-23.6* ___ ___ 04:00AM BLOOD Glucose-116* UreaN-24* Creat-0.7 Na-139 K-4.8 Cl-107 HCO3-24 AnGap-8* ___ 04:00AM BLOOD ALT-464* AST-617* CK(CPK)-45 AlkPhos-97 TotBili-0.3 ___ 04:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 12:50PM BLOOD Calcium-8.9 Phos-2.7 Mg-2.2 ___ 04:00AM BLOOD Albumin-3.8 ___ 04:06AM BLOOD Lactate-0.9 IMAGING ------- MRCP ___: Prominence of the intra and extrahepatic biliary ducts without an obstructing lesion or calculus. Findings may be a consequence of the post cholecystectomy state. CT A/P (OSH): - cholecystectomy, intrahepatic and extrahepatic biliary ductal dilatation (1.2 cm), no obstructing intraductal stone or pancreatic head mass detected, no pancreatic ductal dilatation, no pancreatitis detected. - Normal bowel caliber, colon diverticulosis without diverticulitis. - L5 35% compression fracture. - S/p right total hip, overlying circumscribed fluid collection in lateral right flank subcutaneous fat bay be postoperative fluid vs abscess. Total hip appears intact. CTA chest (OSH): Negative for pulmonary embolism. Bilateral mild atelectasis, possible consolidative atelectasis/pneumonia in the superior segment of the right lower lobe. CXR (OSH): Clear lungs Left lower extremity ultrasound ___: No evidence of deep venous thrombosis in the left lower extremity veins. ECG reviewed and interpreted by me as SR @ 60 bpm with PACs, NANI, no ST or T wave abnormalities, no previous for comparison MICROBIOLOGY ------------ ___ 7:15 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. DISCHARGE LABS -------------- ___ 06:32AM BLOOD WBC-6.2 RBC-4.37 Hgb-12.6 Hct-39.2 MCV-90 MCH-28.8 MCHC-32.1 RDW-13.6 RDWSD-45.1 Plt ___ ___ 06:35AM BLOOD ___ PTT-28.2 ___ ___ 06:32AM BLOOD Glucose-85 UreaN-12 Creat-0.6 Na-143 K-3.9 Cl-106 HCO3-26 AnGap-11 ___ 06:32AM BLOOD ALT-222* AST-120* LD(LDH)-185 AlkPhos-94 TotBili-0.4 ___ 06:32AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.___ year old female with HTN, overactive bladder, ? dementia, transferred from ___ for acute pancreatitis. # Acute pancreatitis # Abnormal liver function tests # Sepsis: patient presents with pancreatitis. Not obstructive on MRCP. No history of alcohol abuse. Interestingly, does not have abdominal pain, but left-sided chest pain. There has been no nausea. She was hypotensive on presentation to OSH ED, now improved, possibly from inflammation, no evidence of infection. Started on antibiotics at OSH, then stopped when no evidence of infection. Patient tolerated advancement of her diet. She should observe a regular low-fat diet. LFTs were downtrending throughout her hospital course. ERCP team felt there was no need for procedure. She will follow up with her PCP, who can decide if she will need to follow up with Gastroenterology. # Hypernatremia: likely from NPO status, fluid loss from pancreatitis. Improved with PO intake. # Chest pain: reports continued chest pain. ECG without evidence of ischemia. Cardiac biomarkers negative x 2. Acetaminophen was given for pain. # Leukocytosis: mild, likely from inflammation, possible infection. CTA chest with atelectasis vs. pneumonia, no cough or dyspnea. Improved over course of hospitalization. # Hypertension: held home lisinopril initially, but eventually restarted # Anxiety: continued home citalopram TRANSITIONS OF CARE ------------------- # Follow-up: She will follow up with her PCP, who can decide if she will need to follow up with Gastroenterology. Chest pain may deserve further work-up by her PCP. # Contact: Name of health care ___ (SON) Relationship:son Phone ___ Proxy form in chart:No Verified on ___ # Code status: DNR/DNI, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Memantine 10 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Magnesium Oxide 400 mg PO DAILY 4. Acyclovir Ointment 5% 5 % topical BID 5. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 6. Vitamin D 1000 UNIT PO DAILY 7. Citalopram 20 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Donepezil 10 mg PO QHS 11. Alendronate Sodium 70 mg PO QSUN Discharge Medications: 1. Acyclovir Ointment 5% 5 % topical BID 2. Alendronate Sodium 70 mg PO QSUN 3. Citalopram 20 mg PO DAILY 4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID 5. Donepezil 10 mg PO QHS 6. FoLIC Acid 1 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Magnesium Oxide 400 mg PO DAILY 9. Memantine 10 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute pancreatitis Transaminitis Chest pain 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 during your recent hospitalization. You came to the hospital with chest pain, and were ultimately found to have pancreatitis. Further testing showed there was no blockage in your bile duct. You are now being discharged. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: ___

{'Chest pain': ['Acute pancreatitis without necrosis or infection', 'Chest pain', 'unspecified'], 'Leukocytosis': ['Elevated white blood cell count', 'unspecified'], 'Hypernatremia': ['Hyperosmolality and hypernatremia', 'unspecified'], 'Abnormal liver function tests': ['Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]', 'unspecified'], 'Hypertension': ['Essential (primary) hypertension', 'unspecified'], 'Anxiety': ['Anxiety disorder', 'unspecified'], 'Mild cognitive impairment': ['Mild cognitive impairment of uncertain or unknown etiology', 'unspecified'], 'Do not resuscitate': ['Do not resuscitate', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine / Bactrim / Feldene / Celebrex / Naprosyn Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Uncomplicated ERCP ___ History of Present Illness: ___ h/o sleeve gastrectomy with 5d of mailaise, LLQ abdominal pain, evolving generalized abdominal pain and fevers and chills now diagnosed with acute pancreatitis and diverticulitis. She describes progressively worse now severe abdominal pain specifically RUQ and epigastric radiating to back and shoulders and LLQ pain. She was seen in urgent care this weekend w urine sent and cipro prescribed. She came to ___ today where she had hypotension and imaging (CT abdomen) and labs showed acute pancreatitis and diverticulitis and cholestasis. She received IVF and ertapenem She came to ___ and ERCP was performed w sphincterotomy and balloon extraction of stones. ROS: fever/chills, mailaise, vomit x1 last week, reduced oral intake, some dysuria and frequency, no other change in health in 13pt ROS unless described above Past Medical History: OSA on bipap NASH s/p sleeve gastrectomy at ___ arthritis s/p hysterectomy for endometrial hyperplasia panniculectomy Her gallbladder remains after above surgeries Social History: ___ Family History: mother w colon ca Physical Exam: 98.1 95-105/60 62 99% RA aox3 attentive and not confused some scleral icterus tongue dry neck supple face symmetric clear BS regular s1 and s2 obese abdomen, bowel sounds present RUQ++ and epigastric ++ tenderness to palpation less intense tenderness in LLQ unable to appreciate if hepatomegaly present no peripheral edema or rash did not test gait speech fluent mood calm able to sit up on her own Pertinent Results: ERCP Evidence of a sleeve gastrectomy was noted. •The major papilla was on the rim of a large diverticulum. •Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. •There was a filling defect that appeared like sludge in the lower third of the common bile duct. •There was mild upstream dilation with the CBD measuring 8mm in maximal diameter. •A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Minor oozing was noted. •Balloon sweeps were performed of the common bile duct which yielded sludge but no obvious stone. •Further sweeps were performed until no debris was noted. •Completion occlusion cholangiogram revealed no further filling defects. •10cc epinephrine were injected for hemostasis successfully at the major papilla ___ 10:50AM BLOOD WBC-8.0# RBC-4.43 Hgb-12.5# Hct-37.6# MCV-85 MCH-28.2 MCHC-33.2 RDW-13.4 RDWSD-41.4 Plt ___ ___ 10:50AM BLOOD Neuts-83* Bands-8* Lymphs-5* Monos-4* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-7.28* AbsLymp-0.40* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00* ___ 10:50AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-138 K-4.6 Cl-107 HCO3-23 AnGap-13 ___ 10:50AM BLOOD ALT-191* AST-207* AlkPhos-152* TotBili-5.8* ___ 10:50AM BLOOD Lipase-3785* ___ 10:50AM BLOOD Albumin-3.1* Calcium-8.9 Phos-2.9 Mg-1.5* ___ 10:52AM BLOOD Lactate-0.8 ___ CT Impression Fat stranding around pancreas, and second and third portions duodenum. Possibly pancreatitis, possibly duodenitis. Clinical correlation advised. 2. Acute mild uncomplicated sigmoid diverticulitis. 3. Gallstones, distended gallbladder, possibly reflecting fasting state. Clinical correlation necessary. HIDA scan may be considered for further evaluation if there is right upper quadrant pain. 4. Hysterectomy. Other incidental findings as outlined. Brief Hospital Course: ___ w NASH and s/p sleeve gastrectomy now hospitalized w gallstone pancreatitis and acute diverticulitis. She is now s/p ERCP and sphincterotomy for associated choledocolithiasis with obstruction. She has features of early sepsis including hypotension as low as ___ responsive to fluids at ___ and subjective fevers/chills. Lactate was 0.8. #Acute bile duct obstruction, with possible early cholangitis due to choledocholithiasis: She was managed with fluid resuscitation and ERCP with stone extraction. Biliary jaundice improved and she tolerated a full diet. She was instructed to f/u with outpatient surgeon for CCY and will do so through PCP. She will complete 10day antibiotic course with Cipro/flagyl # Acute Diverticulitis - clinically resolved, she will complete 10 days cipro/flagyl #NASH cirrhosis: followed by liver clinic in past at ___ and now by local area hepatologist. This was clinically stable here. #OSA: continued CPAP #Anxiety: diazepam prn #Possible UTI: I called her PCP's office (___) ___ to inquire about UA and if urine culture results are known sent this past ___. I spoke with RN ___ to review results ___ (was given Cipro for UTI) -- UCx multiple organisms present, contaminated specimen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 2. Diazepam 2 mg PO DAILY:PRN anxiety 3. Ranitidine 150 mg PO DAILY Discharge Medications: 1. Diazepam 2 mg PO DAILY:PRN anxiety 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 hr Disp #*18 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*27 Tablet Refills:*0 4. Ranitidine 150 mg PO DAILY 5. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with biliary duct obstruction due to retained gallstones. You underwent successful ERCP with stone removal with significant clinical improvement. You had You tolerated a regular diet without pain. You jaundice should continue to improve. You understand the recommendation to follow up with a surgeon (via PCP ___ for gallbladder removal. Your outside hospital also had suggestion of acute diverticulitis. Therefore you should complete a 10day course of antibiotics for this as prescribed. Followup Instructions: ___

{'abdominal pain': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'fever/chills': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'malaise': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'vomit': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'reduced oral intake': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'dysuria': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'frequency': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'RUQ++ and epigastric ++ tenderness': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'less intense tenderness in LLQ': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ortho-Cyclen (21) / Compazine / Honey Attending: ___. Chief Complaint: L thigh infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ F presents to the BID ___ after being seen at ___ twice in 3 days for left thigh pain and erythema. She first noticed erythema on ___. On ___, she noted an expanding "ball" of fluctance. She took her kids to the ___, but while there started to feel ill; she took her temp which was 101 and presented to the ___ at ___. At ___, drainage was attempted by needle aspiration, but no fluid was obtained. She got a dose of CTX in the ___ on ___. She returned to the ___ ___ ___ became the area of erythema had expanded. She got another dose of CTX and was sent home with po Keflex. Given worsening redness and expanding "ball" of fluctuance, the pt's brother-in-law is (former surgeon at ___ encouraged her to come in for further evaluation. . In the ___, initial vitals: 99.4 109 ___ 99% RA. Exam was notable for an area of eryhtema which has progressed but 1.5" circumfirentially from the area that was demarkated at ___. There was large area of fluctuance, and US of the areashowed a fluid collection. This area was incised and drained (50-75 cc of pus) and then packed. A fluid sample was sent for gram stain and Cx. She recieved morphine for pain, 1g vanc, and 1L NS. Given that the patient has been having fevers and the area of cellulitis was expanding on CTX, she is being admitted for IV abx and close observation. Vitals prior to transfer: T 99.3, 114/81, 83, 18, 100% RA. Past Medical History: Obestiy hypothyroidism GERD Gave birth to her daughter ___-section Social History: ___ Family History: NC Physical Exam: VS: T 98.8, BP 103/64, HR 91, RR 22, 98% RA GENERAL: Well-appearing obese F in NAD, comfortable, appropriate. HEENT: NC/AT, sclerae anicteric, MMM, OP clear. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND EXTREMITIES: WWP, no c/c/e SKIN: Areas off cellulitis demarkated on the right inner thigh near the groin from ___ yesterday as well as a line for our ___ today. Line from today is 1.5-2" away from ___ line. Area of erythema has somewhat regressed from the line demarkated today. Area of I&D gressed with gauze. NEURO: Awake, alert, talkative, CNs II-XII grossly intact. Pertinent Results: ___ 06:55PM BLOOD WBC-11.7* RBC-4.19* Hgb-12.9 Hct-37.6 MCV-90 MCH-30.8 MCHC-34.4 RDW-12.4 Plt ___ ___ 06:55PM BLOOD Neuts-71.1* ___ Monos-4.1 Eos-0.6 Baso-0.5 ___ 03:10PM BLOOD WBC-7.6 RBC-3.79* Hgb-11.6* Hct-33.8* MCV-89 MCH-30.7 MCHC-34.5 RDW-11.8 Plt ___ ___ 06:55PM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 ___ 07:04PM BLOOD Lactate-1.2 micro: blood cx pending wound cx GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. Brief Hospital Course: ___ F who presents with expanding area of cellulitis of the left thigh and underlying abscess, s/p I&D in the ___. . # cellulitis/abscess: Patient presented to ___ with worsening pain and swelling of her left thigh. Also noted expanding "ball" of fluctuance. Patient had previously gone to ___ twice and was treated with ceftriaxone. She was discharged from the ___ on Keflex after her second visit. Attempt at drainage was unsuccessful and no wound cultures were obtained. On presentation to BI ___ she was afebrile (Tmax 99.4) and found to have area of erythema which progressed 1.5 inches from area marked at ___ the day prior. There was fluctuance and US showed fluid collection. The area was incised and drained (50-75 cc of pus) and then packed. Gram stain showed 2+ PMNs and no organisms. Wound cultures were sent and eventually grew out rare coagulase negative staph (however had already received ceftriaxone and Keflex at OSH). She was started on vancomycin. Pain was treated with morphine. On the floor patient looked well. She was continued on vancomycin and started on amoxicillin. She remained afebrile and repeat WBC count in the afternoon improved. Her pain was controlled without narcotics. Patient was discharged with plans to complete course of Bactrim and Keflex with frequent ___ visits for wound care. . # Hypothyroidism: Con't home levothyroxine . # GERD: Nexium not on formulary, so given omeprazole while admitted. . transitional issues - patient will need frequent wound care for dressing changes - wound cultures were pending at time of discharge - patient was full code on this admission Medications on Admission: Nexium levothyroxine 112mcg Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 9 days. Disp:*18 Tablet(s)* Refills:*0* 3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Keflex ___ mg Capsule Sig: One (1) Capsule PO four times a day for 9 days. Disp:*36 Capsule(s)* Refills:*0* 5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every eight (8) hours as needed for pain for 3 days: Do not drive or drink alcohol while taking this medication. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary diagnosis: cellulitis, abscess 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 while you were in the hospital. You were admitted because you were found to have an abscess and a skin infection of your left inner thigh. You had the abscess drained in the emergency department and were started on intravenous antibiotics. You felt well overnight without fevers and the redness of your skin started to improve. Your white blood cell count normalized. We do not have the culture results back from the wound, but these should be follwed up by your primary doctor. . Please continue to take all medications as prescribed and follow up with your doctors as ___. . Please START taking: --Keflex (please take until ___ --Bactrim (please take until ___ --Percocet (do not drive or drink alcohol while taking this medication). Followup Instructions: ___

{'erythema': ['Cellulitis and abscess of leg, except foot'], 'pain': ['Cellulitis and abscess of leg, except foot'], 'fever': ['Cellulitis and abscess of leg, except foot'], 'fluctuance': ['Cellulitis and abscess of leg, except foot'], 'swelling': ['Cellulitis and abscess of leg, except foot'], 'obesity': ['Obesity'], 'hypothyroidism': ['Unspecified acquired hypothyroidism'], 'GERD': ['Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Aneurysm Major Surgical or Invasive Procedure: Pipeline embolization of Left ICA aneurysm History of Present Illness: She is a ___ nurse that works in the ___ in the dialysis unit. She started noticing some tingling sensation on the right side of the face that did not disappear, and work up obtained an MRI/MRA; the report came back positive for aneurysm. +FH for aneurysm. She presents today for Pipeline embolization of Left ICA aneurysm. Past Medical History: Anxiety depression Social History: ___ Family History: her father is diagnosed with a 3 to 4 mm aneurysm that he has actually been followed by Dr. ___ here at ___, she had also two second-degree relatives with brain aneurysms. Physical Exam: on discharge: ___ x 3. NAD. PERRLA, 3-2mm. CN II-XII intact. LS clear RRR abdomen soft, NTND. ___ BUE and BLE. No drift. Groin site, clean, dry, intact without hematoma. Pertinent Results: Please see OMR for relevant imaging reports Brief Hospital Course: Pipeline embolization of her Left ICA aneurysm On ___ she was admitted to the neurosurgical service and under general anesthesia had a successful Pipeline embolization of her Left ICA aneurysm. Her operative course was uncomplicated. For further procedure details, please see separately dictated operative report by Dr. ___. She was extubated, groin angiosealed and transferred to be recovered in the PACU and then transferred to the ___ when stable. On POD #1 she remained stable. She ambulated well independently and was discharged home. Medications on Admission: NuvaRing lorazepam 0.5 ___ daily as needed sertraline 25 mg daily brilinta 90 bid aspirin 81 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain no greater than 4 grams of Tylenol in 24 hours 2. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Docusate Sodium 100 mg PO BID hold for loose stool. Stop once done taking oxycodone 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain decrease use as pain improves. ___ request less than prescribed. RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 5. Senna 17.2 mg PO QHS hold for loose stools. Stop once done taking oxycodone 6. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 (One) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Sertraline 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •Do not go swimming or submerge yourself in water for five (5) days after your procedure. •You make take a shower. Medications •Resume your normal medications and begin new medications as directed. •You may be instructed by your doctor to take one ___ a day and/or Plavix. If so, do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You ___ Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •Mild to moderate headaches that last several days to a few weeks. •Fatigue is very normal •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 puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •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 Followup Instructions: ___

{'tingling sensation on the right side of the face': ['Cerebral aneurysm'], 'Anxiety': ['Anxiety disorder'], 'depression': ['Major depressive disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: latex Attending: ___. Chief Complaint: left tibial shaft fracture Major Surgical or Invasive Procedure: Placement of left tibial intramedullary nail on ___ History of Present Illness: ___ w Left distal ___ tib/fib shaft fx on ___ while ice skating presents for left heel pain x 2 days. She was seen at ___ originally but followed with Dr. ___ in clinic on ___ and had long leg cast applied and wedged. For the past 2 days she has had increasing pain at the heel and tightness of the toes, enough now that the pain is waking her from sleep despite pain meds and elevation. She called the answering service and I advised her to come in due to the possibility of a heel sore. The patient is scheduled to see Dr. ___ on ___ to likely plan IM nailing of the tibia which she is more amenable to now given the difficulty getting around with the long leg cast. She denies any numbness or tingling. She has not taken oxycodone for several days but continues to take Tylenol around-the-clock. Otherwise feels well and denies any fevers, chills, chest pain, or shortness of breath. Of note, patient reports that she had a CT scan of the ankle at ___ and it was on the disc that she brought to clinic. The patient was evaluated in clinic on ___ and decided that she would no longer like to pursue closed treatment and elected for surgical intervention. The risks, benefits, indications for surgery were thoroughly discussed with the patient, and she elected to undergo surgery, which was scheduled for ___. Past Medical History: Migraines, PVCs Social History: ___ Family History: NC Physical Exam: Upon Admission: ___ General: Well-appearing female in no acute distress. Left lower extremity: -Long-leg cast clean dry and intact without skin breakdown at the edges. -I bivalved the entire long-leg cast and reinforced the cast with tape. I also removed the entire heel portion of the cast, exposing the skin to reveal a 2 x 2 cm stage I pressure ulcer without a break in the skin or surrounding erythema or drainage. - wiggles exposed toes - SILT exposed toes - Toes wwp with BCR Upon Discharge: General: Well-appearing, breathing comfortably on RA Detailed examination of LLE: -ace dsg CDI -Fires FHL, ___, TA, GCS -SILT ___ n distributions -WWP distally Pertinent Results: please see OMR for pertinent labs and studies ___ 05:45AM BLOOD WBC-10.1* RBC-3.58* Hgb-9.3* Hct-30.1* MCV-84 MCH-26.0 MCHC-30.9* RDW-12.9 RDWSD-39.5 Plt ___ ___ 05:45AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-144 K-4.2 Cl-108 HCO3-22 AnGap-14 ___ 05:45AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for placement of left intramedullary nail, 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. 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 weight bearing as tolerated in the left lower extremity, and will be discharged on aspirin 325mg daily x4weeks 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: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily Disp #*60 Tablet Refills:*0 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*50 Tablet Refills:*0 4. Calcium Carbonate 1250 mg PO TID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*50 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 8. Senna 8.6 mg PO DAILY RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*50 Tablet Refills:*0 9. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Left tibial shaft 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: 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 to the left lower 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 325mg 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. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - 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 <30 DAYS OF REHAB Physical Therapy: Weightbearing as tolerated to left lower extremity Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided. Call your surgeon's office with any questions. Followup Instructions: ___

{'left heel pain': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'increasing pain at the heel': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'tightness of the toes': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'numbness or tingling': [], 'fevers, chills, chest pain, or shortness of breath': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Lipitor / Lidocaine / Penicillins / Sulfa (Sulfonamides) / IV Dye, Iodine Containing Attending: ___ ___ Complaint: Progressive right knee pain Major Surgical or Invasive Procedure: Right total knee replacement History of Present Illness: Ms. ___ is a ___ year old female with a history of osteoarthritis and right knee pain presents for definitive treatment. Past Medical History: Angina Hypertension Mitral valve prolapse Dyspnea Hiatal hernia GERD Thyroid disease Psoriatic arthritis s/p tonsillectomy s/p appendectomy s/p knee arthroscopy Social History: ___ Family History: NC Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: right lower Weight bearing: partial weight bearing Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: ___ 05:30AM BLOOD WBC-14.0* RBC-3.38* Hgb-10.5* Hct-30.7* MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt ___ ___ 05:30AM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-135 K-4.6 Cl-102 HCO3-26 AnGap-12 Brief Hospital Course: Ms. ___ was admitted to ___ on ___ for an elective right 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,post operative day one drain was removed. She remained hemodynamically stable. Her pain was controlled. She progressed with physical therapy to improve her strength and mobility. She was discharged today in stable condition. Medications on Admission: Atenolol Norvasc Diovan Zetia Trazadone Protonix Vicoden Allegra Colace Calcium MVI Pantanol Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 weeks. Disp:*21 * Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Diphenhydramine HCl 25 mg Capsule Sig: ___ Capsules PO Q6H (every 6 hours) as needed. 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. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. traZODONE 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4-6H () as needed. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Osteoarthritis Discharge Condition: Stable Discharge Instructions: If you experience any 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 your right leg. Please use your crutches for ambulation. You may 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 do not drive or operate any machinery while taking this medication. 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: Partial weight bearing Knee immobilizer: when not in CPM and at bedtime 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. After 5 days you may shower, but make sure that you keep your incision dry. Your skin staples may be removed 2 weeks after your surgery or at the time of your follow up visit. Followup Instructions: ___

{'right knee pain': ['Osteoarthrosis'], 'angina': ['Other and unspecified angina pectoris'], 'hypertension': ['Unspecified essential hypertension'], 'mitral valve prolapse': ['Mitral valve disorders'], 'dyspnea': [], 'hiatal hernia': [], 'GERD': [], 'thyroid disease': [], 'psoriatic arthritis': ['Psoriatic arthropathy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: facial swelling Major Surgical or Invasive Procedure: ___: Incision and Drainage of Left Submandibular Space via transcervical approach. Incision and Drainage of Left Sublingual Space via Transoral approach and Extraction of teeth #18 and #20 History of Present Illness: ___ longstanding smoker is transferred from ___ for 5 days of left-sided facial swelling. He saw a dentist yesterday who started him on erythromycin and vicodin which did not help. He had a root canal ___ yrs ago and never had a crown and has been followed by ___ Dental and has had episodes similar to this though not as severe in the past and the pain usually subsides. He reports chills no fevers. He has no chest pain difficulty swallowing difficulty breathing. The symptoms have been incredibly gradual. CT scan was performed It showed periapical lucency with tongue asymmetry, possible deep space abscess with mild tracking. ___ vitals 98.2 80 16 0139/72 695%RA CT ___: COMMENTS: Periapical lucency with cortical breakthrough (3:41) involving the last left mandibular molar (with dental work) has tracking fluid with faint rim enhancement extending into the base of the tongue/floor of mouth measuring up to 1.3 x 0.6 cm (3:54). Adjacent cervical adenopathy is likely reactive greater on the left than the right. 1.6 cm nodule arising from the inferior pole of the right thyroid can be evaluated by nonurgent/outpatient ultrasound. ___ ___ initial vitals were: 98.3 77 116/64 16 97% ra Oro-maxillary-facial surgery was consulted and they recommended admission to medicine, to continue IV clinda and make NPO for surgery tomorrow as add on. Pt was given morphine, NS, nicotine patch . Past Medical History: PMH: sleep apnea (seen in sleep clinic, no CPAP) depression submandibular/sublingual infection, requiring OMFS I&D and tooth extraction Past psych history: Depression, social anxiety, ADHD Hospitalizations:Parital program ___ at ___ Outpatient Treaters: Dr. ___, ___ Medication Trials:Wellbutrin, Paxil, Zoloft and Cymbalta with no results SI/SA/HI/assaultive behavior: SI during depression ___, denies SA/HI/assultive behavior Social History: ___ Family History: Father with alcoholism, sister that he lives with bipolar Physical Exam: Admission exam: Vitals - 98.1 123/81 78 98%RA GENERAL: NAD HEENT: pt with pain opening his mouth, please see OMFS note for full dental exam NECK: LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose Discharge exam: Vitals - 97.8 ___ 79(70-90) 18 96%RA GENERAL: NAD HEENT: pt with decreased pain on opening his mouth, poor dentition, bandage in place, s/p removal of ___ drain, please see ___ note for full dental exam NECK: LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose Pertinent Results: ___ 15 CT from ___: COMMENTS: Periapical lucency with cortical breakthrough (3:41) involving the last left mandibular molar (with dental work) has tracking fluid with faint rim enhancement extending into the base of the tongue/floor of mouth measuring up to 1.3 x 0.6 cm (3:54). Adjacent cervical adenopathy is likely reactive greater on the left than the right. 1.6 cm nodule arising from the inferior pole of the right thyroid can be evaluated by nonurgent/outpatient ultrasound. Admission labs: ___ 01:30AM BLOOD WBC-11.2* RBC-4.18* Hgb-12.8* Hct-37.3* MCV-89 MCH-30.7 MCHC-34.4 RDW-13.1 Plt ___ ___ 01:30AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-140 K-4.0 Cl-107 HCO3-24 AnGap-13 ___ 05:10AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9 Discharge labs: ___ 06:27AM BLOOD WBC-9.3 RBC-4.65 Hgb-14.5 Hct-41.2 MCV-89 MCH-31.2 MCHC-35.2* RDW-13.0 Plt ___ ___ 06:27AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-139 K-4.1 Cl-102 HCO3-28 AnGap-___rief Hospital Course: Mr ___ is a ___ with depression, OSA, and longstanding tobacco history who was transferred from ___ for dental abscess and facial swelling. #Left submandibular space infection: CT showed periapical lucency with cortical breakthrough involving the last left mandibular molar (with dental work), tracking fluid with faint rim enhancement extending into the base of the tongue/floor of mouth measuring up to 1.3 x 0.6 cm. ___ consulted and patient underwent incision and drainage and tooth extraction x2 with ___ drain placed. Remained afebrile on admission and leukocytosis resolved. Post-op pain well-controlled with oral medications. Drain removed ___ and patient discharged home with ___ follow up. Initially treated with IV clindamycin and transitioned to PO clindamycin 300mg qid for 7 additional days as an outpatient. ___ also recommended chlorhexadine mouthwash bid. Post op pain controlled with tylenol, ibuprofen and PO dilaudid for breakthrough pain. #Thyroid nodule: CT incidentally showed 1.6 cm nodule arising from the inferior pole of the right thyroid can be evaluated by nonurgent/outpatient ultrasound. TRANSITIONAL ISSUES: [] Continue clindamycin 300mg po qid on discharge for additional 7 days (last date is ___. [] CT incidentally showed 1.6 cm nodule arising from the inferior pole of the right thyroid can be evaluated by nonurgent/outpatient ultrasound. [] Patient discharged with 2mg PO dilaudid q6h PRN for breakthrough pain for 4 additional days after discharge (16 pills). # Emergency Contact: ___ ___. Declined HCP. # Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO DAILY 2. Gabapentin 100 mg PO QHS Discharge Medications: 1. Citalopram 10 mg PO DAILY 2. Gabapentin 100 mg PO QHS 3. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills:*0 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % rinse mouth twice a day Refills:*0 5. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 6. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six (6) hours Disp #*16 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: submandibular abscess secondary diagnosis: obstructive sleep apnea depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted to ___ because of an infection in your jaw. You had surgery by the oral surgeons to drain this. A drain was placed to allow pus to drain after the surgery. We treated you with pain medication and antibiotics. You were able to be discharged home after you improved. -Your ___ care team Followup Instructions: ___

{'facial swelling': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'chills': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'pain opening his mouth': ['Acute apical periodontitis of pulpal origin'], 'no chest pain': ['Chronic airway obstruction'], 'difficulty swallowing': ['Chronic airway obstruction'], 'difficulty breathing': ['Chronic airway obstruction'], 'periapical lucency with cortical breakthrough': ['Acute apical periodontitis of pulpal origin'], 'tracking fluid with faint rim enhancement extending into the base of the tongue/floor of mouth': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'adjacent cervical adenopathy': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], '1.6 cm nodule arising from the inferior pole of the right thyroid': ['Nontoxic uninodular goiter'], 'sleep apnea': ['Obstructive sleep apnea (adult)(pediatric)'], 'depression': ['Depressive disorder'], 'longstanding smoker': ['Tobacco use disorder'], 'ADHD': ['Attention deficit disorder with hyperactivity'], 'social anxiety': ['Other anxiety states']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: quinidine gluconate Attending: ___. Chief Complaint: Intraventricular bleed Major Surgical or Invasive Procedure: NONE History of Present Illness: HPI: Mr. ___ is a ___ year-old male with a past medical history of atrial fibrillation on coumadin, HTN, HLD. Per report from the outside hospital and his wife, the patient called his PCP today indicating that he has a bleed hemorrhoid. He was instructed to go to the nearest Emergency Department for evaluation. According to his wife, the patient presented to ___ ED. Upon arrival at ___, Mr. ___ stated he was there for a bleed hemorrhoid and something related to a fall. He was confused and not making much sense at the time. The patient underwent a CT of head and cervical spine. The head CT showed bilateral intraventricular blood. The CT of the cervical spine was negative, per report. Mrs. ___ INR at the outside hospital was 3. He was given Vitamin K and one unit of FFP. At some point thereafter, the patient had a seizure and was intubated for airway protection. He was transferred to ___ for further evaluation. Upon my evaluation, the patient was intubated and on propofol. Sedation was turned off. His repeat INR was 2.5 at that time. CT imaging of the head was reviewed. Kcentra was given to reverse vitamin K dependent factors. The patient was loaded with 1 gram of dilantin. A stat repeat head CT and CTA was obtained. Imaging was reviewed in real-time with Dr. ___. Due to the large amount of blood products in the lateral ventricles, the patient was taken emergently to the Operating Suite from CT scanning where he underwent bilateral occipital EVD placement. Incidentally, the patient suffered a right posterior ocular bleed that required an injection by his ophthalmologist. This occurred approximately two weeks ago. He had no further complications related to this event. The patient's wife, ___, and son, ___, were updated on their loved one's condition and plan for operative procedure. Informed consent was obtained. Past Medical History: HTN, HLD, Coumadin (treated with maze procedure, taking coumadin. Social History: ___ Family History: Unknown Physical Exam: PHYSICAL EXAM: O: HR 75 BP: 144/78 RR 16 O2 Sat 100% on 40% fiO2 Gen: Intubated, sedated. GCS 4T (E1, V1, M2) HEENT: PERRL 2mm, brisk reaction. Neuro: Mental status: Unresponsive. Extensor posturing to noxious stimuli. + Corneal, gag and cough reflexes. Motor: Extensor posturing especially noted in ___ UEs upon noxious stimulation. Little to no movement to LEs noted. Toes mute to plantar stroke bilaterally. Pertinent Results: CT/CTA ___: CT Head: Interval increase in large amount of intraventricular hemorrhage compared to the prior exam. The total width of the frontal horns of the lateral ventricles measure about 5.9 cm, previously 4.7 cm. Hemorrhage extends into the ___ ventricle as seen previously. There is effacement of the sulci but the basilar cisterns are patent. Opacification of the left maxillary sinus with fluid and a calcification. CTA: There is no evidence of aneurysm, conclusion or stenosis. There is consolidation within the upper lobes bilaterally, left greater than right concerning for infection. Labs: WBC 12, Hgb 13.1, Hbg 37.6, plt 167 Pt 24, INR 2.3, PTT 36.3 Na 138, K 4.4, Cl 103, HCO3 25, BUN 34, Cr 1.2, Gluc 143 Ca 9.2, Phos 2.1, Mg 1.9 Brief Hospital Course: Mr. ___ was brought emergently to OR on ___ for bilateral posterior EVD placement for large bilateral intra-ventricular hemorrhage. He was brought to ICU for close monitoring. At 0400 on ___ on exam the patient had no corneals and developed pupil asymmetry with a nonreactive left pupil. He received an additional dose of 50grams of Mannitol. The family was at the bedside, a short meeting was held with the family and the neurosurgery team regarding the patient's condition and prognosis with surgery and without surgery. The family did not want any further surgical interventions, they felt that, that is what the patient would say if he could. The patient was made DNR/DNI. Another family meeting was held with the ICU team regarding changing status to CMO. The family requested more time in order to give the rest of the family members a chance to say goodbye. In the afternoon the patient was made comfort measures only, shortly after he was pronounced dead. Medications on Admission: Medications prior to admission: Lisinopril 40mg daily Warfarin 1mg MWF, 2mg all other days ASA 81mg daily Atorvastatin 20mg daily Fluticasone 50mcg 1 spray each nare before HS Omeprazole 20mg daily Sotalol 80mg BID Spironolacton-HCTZ ___ daily Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: ___

{'Intraventricular bleed': ['Intracerebral hemorrhage'], 'Bleed hemorrhoid': ['Unspecified hemorrhoids with other complication'], 'Atrial fibrillation': ['Atrial fibrillation'], 'HTN': ['Unspecified essential hypertension'], 'HLD': ['Other and unspecified hyperlipidemia'], 'Seizure': [], 'Right posterior ocular bleed': [], 'Extensor posturing': [], 'Corneal, gag and cough reflexes': [], 'Motor': [], 'Toes mute to plantar stroke bilaterally': [], 'Opacification of the left maxillary sinus with fluid and a calcification': [], 'Consolidation within the upper lobes bilaterally, left greater than right concerning for infection': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, heart palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___, ___ but conversant in ___, with h/o HTN, SVT and DM admitted for SVT and generalized weakness after recent gastrointestinal illness a/w BRBPR. History obtained from the patient and her daughter - she was in her USOH until ___ night when she had tenesmus and became lightheaded while straining on the toilet. She later developed associated fevers/chills, threw up once, and then developed profuse diarrhea. Her daughter took her to the ___ ED on ___ ___. Per the patient's daughter, her blood tests were mostly normal and as she began having more diarrhea, she started to feel better in the ED. She was discharged home after 4 hrs. Yesterday, she continued to have diarrhea, loss of appetite (no further vomiting), and developed small amts of BRBPR - mostly on the toilet paper but also in the bowl. She felt very weak yesterday. Her daughter called her PCP who ___ over the phone. The patient was feeling OK this morning - still with loss of appetite, but diarrhea and vomiting had resolved, still had persistence of BRBPR - however, this afternoon the patient had the sudden onset of palpitations (has had this before). EMS was called and found pt to be in SVT - vagal maneuvers and fluid bolus failed; she was brought to ED. . In the ED, initial VS 98.0 162 105/71 18 99%. The patient endorsed chest pressure but never pain. She never became lightheaded. She was thought to be in SVT. Adenosine 6 mg IV was given x 1 and she reverted to NSR. She was given 2L NS. Labs notable for nl LFTs and elevated WBC to 15.9 with left-shift. Bleeding hemorrhoids were seen on rectal exam. . Currently, VS 98.8 110/62 102 18 97% on RA. The patient appears fatigued. She states she did have hemorrhoids in the past several years ago. Her last episode of SVT was > ___ year ago - she has intermittently been taking her diltiazem the past few days ___ weakness. In the past, she took both digoxin and verapamil for SVT. She does endorse abd tenderness in the LLQ. . ROS: per HPI, denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, constipation, melena, dysuria, hematuria. + for early satiety - ? gastroparesis Past Medical History: Adult Onset DM x ___ years Renal cell carcinoma s/p R nephrectomy ___ yrs ago at ___ ___ HTN HL H.pylori - ___ Diverticulosis - seen on Cscope in ___ SVT Social History: ___ Family History: No female cancers. Mother died age ___ unknown cause Father died age ___ from liver failure Brother and sister with HTN and diabetes Physical Exam: On admission: VS - 98.8 110/62 102 18 97% on RA GENERAL - NAD, pleasant HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, TTP to light touch in LLQ, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, full strength throughout, nl gait . On discharge, abd pain is resolved. external hemorrhoids visualized. Heart is RRR. Pertinent Results: On admission: . ___ 05:30PM BLOOD WBC-15.9* RBC-4.09* Hgb-12.3 Hct-36.4 MCV-89 MCH-30.1 MCHC-33.8 RDW-12.8 Plt ___ ___ 05:30PM BLOOD Neuts-85.4* Lymphs-11.1* Monos-3.0 Eos-0.4 Baso-0.2 ___ 05:30PM BLOOD Glucose-181* UreaN-9 Creat-0.7 Na-134 K-3.7 Cl-102 HCO3-22 AnGap-14 ___ 05:30PM BLOOD ALT-12 AST-18 AlkPhos-49 TotBili-0.4 ___ 05:30PM BLOOD Lipase-27 ___ 05:30PM BLOOD cTropnT-0.02* ___ 06:10AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.4* . Blood cultures x 2: NGTD Brief Hospital Course: Hospitalization Summary: ___, primarily ___ but conversant in ___, with h/o HTN, SVT, and DM admitted for SVT and generalized weakness after recent gastrointestinal illness a/w BRBPR. . # SVT: Presented to ED with HRs in the 160s. Vagal maneuvers were unsuccessful and she converted to NSR with adenosine 6 mg. Telemetry showed no further events. The patient has a history of SVT and had been intermittently taking diltiazem 30 mg TID over the preceding few days because of her gastrointestinal illness. She was restarted on this regimen on discharge. . # N/V/D, abd pain: Nausea, vomiting, and diarrhea had all resolved prior to admission but the patient had a recent episode of gastroenteritis. She had persistence of LLQ abdominal pain and leukocytosis so empiric ___ (started by PCP) was continued to complete a 7-day course out of concern for possible contribution from diverticulitis. Abd pain had resolved prior to discharge and the patient was eating a regular diet. . # BRBPR: Rectal exam revealed bleeding external hemorrhoids. She had no pain or itching. Hct was stable and the patient was encouraged to increase the amount of fiber in her diet. She was scheduled for GI follow-up. . # DM: Patient was restarted on home metformin on discharge. . # HTN: continued lisinopril 20 mg ___ 81 mg ___ . # HL: continued statin . # GERD: continued omeprazole 20 mg ___ . # Depression: continued effexor . # Transitional Issues: - The patient was full code during this admission - contact was with daughter ___ ___ - completion of antibiotic course (___) - suppression of SVT with diltiazem - further management of bleeding hemorrhoids Medications on Admission: Lisinopril 20 mg ___ Metformin 1000 mg BID Simvastatin 20 mg ___ 81 mg ___ Omeprazole 20 mg ___ Effexor ER 75 mg ___ Diltiazem 30 mg TID Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Last day is ___. 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days: Last day is ___. Discharge Disposition: Home Discharge Diagnosis: Primary: SVT Hemorrhoidal bleeding Abdominal pain . Secondary: DM HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the ___ ___. You were admitted for a very fast heart rate (supraventricular tachycardia) and for rectal bleeding after your recent gastrointestinal illness. Your fast heart rate resolved with a medication called adenosine and you had no further episodes. We think your rectal bleeding was the result of hemorrhoids and you should increase the amount of fiber in your diet to help treat this problem. You will complete a 1-week course of antibiotics for possible diverticulitis in addition to gastroenteritis. . We made the following changes to your medications: We STARTED ciprofloxacin 500 mg twice per day and metronidazole 500 mg three times per day for a total of 7 days (you should complete the prescription that Dr. ___ . Your follow-up appointments are listed below. Followup Instructions: ___

{'weakness': ['Other specified cardiac dysrhythmias', 'Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'heart palpitations': ['Other specified cardiac dysrhythmias', 'Atrial fibrillation'], 'fevers/chills': [], 'vomiting': [], 'diarrhea': [], 'loss of appetite': [], 'BRBPR': ['External hemorrhoids with other complication'], 'abd tenderness': [], 'early satiety': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: tetracycline Attending: ___. Chief Complaint: Pancreatic cancer Major Surgical or Invasive Procedure: ___: 1. Exploratory laparoscopy. 2. Radical pancreaticoduodenectomy with distal gastrectomy. 3. En bloc resection of main portal vein and replace right hepatic artery. 4. Cholecystectomy. 5. End-to-end primary repair of portal vein. 6. Placement of gold fiducials. 7. End-to-side duct to mucosa pancreaticojejunostomy. 8. End-to-side hepaticojejunostomy. 9. Antecolic ___ gastrojejunostomy. 10.Transgastric feeding jejunostomy. History of Present Illness: Mrs. ___ is a ___ woman who has completed preoperative chemotherapy and radiation for borderline resectable pancreatic ductal carcinoma characterized by main portal vein involvement and encasement of the very large replaced right hepatic artery. She has completed chemoradiation as well as preoperative plugged occlusion of the replaced right hepatic artery with development of adequate arterial collaterals to the right liver. She is now taken to the operating room for definitive surgical resection and vascular reconstruction. The risks and benefits of surgery have been discussed with the patient in great detail and are documented in a separate note. Past Medical History: Hypothyroidism - ___'s Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: ___ Family History: She notes that her mother had an episode of "jaundice" at ___ or ___ years, was diagnosed with colon cancer at age ___, and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is ___ of five children, all in good health. Sister with ___ disease. Physical Exam: Prior to Discharge: VS: 98.5, 80, 161/87, 18, 96% RA GEN: NAD CV: RRR, no m/r/g PULM: CTAB ABD: Trapdoor incision open to air with steri strips and c/d/I. RLQ 2 old JP sites with dsd and c/d/i EXTR: Warm, no c/c/e Pertinent Results: ___ 07:00AM BLOOD WBC-6.2# RBC-2.36* Hgb-8.0* Hct-24.3* MCV-103*# MCH-33.9* MCHC-32.9 RDW-13.7 RDWSD-51.2* Plt ___ ___ 07:00AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-134 K-3.4 Cl-100 HCO3-23 AnGap-14 ___ 04:11AM BLOOD ALT-56* AST-76* AlkPhos-55 TotBili-0.3 ___ 07:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6 ___ 06:44PM ASCITES Amylase-11 ___ 06:45PM ASCITES Amylase-8 PATHOLOGY: Pancreatic adenocarcinoma Brief Hospital Course: The patient with pancreatic ca s/p neoadjuvant therapy was admitted to the HPB Surgical Service for elective Whipple. On ___, the patient underwent pancreaticoduodenectomy (Whipple), open cholecystectomy and portal vein reconstruction, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with an NG tube, on IV fluids, with a foley catheter and a JP drain in place, and epidural catheter for pain control. The patient was hemodynamically stable. The ___ hospital course was uneventful and followed the ___ Clinical Pathway without deviation. Post-operative pain was initially well controlled with epidural and PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#3, and the foley catheter discontinued at midnight of POD#4. The patient subsequently voided without problem. The patient was started on sips of clears on POD#4, which was progressively advanced as tolerated to a regular diet by POD#7. JP amylase was sent in the evening of POD#6; the JP was discontinued on POD#7 as the output and amylase level were low. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on ___, 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. Staples were removed, and steri-strips placed. The patient was discharged home without services. 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. Venlafaxine 75 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Creon ___ CAP PO TID W/MEALS 4. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Docusate Sodium 100 mg PO BID 7. Loratadine 10 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Fish Oil (Omega 3) 90 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 4. Venlafaxine XR 150 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H do not exceed more then 3000 mg/day 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 8. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 Tablet Refills:*0 9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*5 11. Senna 8.6 mg PO BID 12. Fish Oil (Omega 3) 90 mg PO DAILY 13. Loratadine 10 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. Prochlorperazine 10 mg PO Q6H:PRN nausea 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 18. Creon ___ CAP PO TID W/MEALS 19. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pancreatic adenocarcinoma 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 surgical resection of your pancreatic mass. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. ___ office at ___ or ___ ___, RN 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. . 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. . G/J-tube: Capped. Followup Instructions: ___

{'Pancreatic adenocarcinoma': ['Malignant neoplasm of pancreatic duct'], 'Hypothyroidism': ['Hypothyroidism'], 'Depression': ['Major depressive disorder', 'single episode', 'unspecified'], 'Hyperlipidemia': ['Hyperlipidemia', 'unspecified'], 'Nephrolithiasis': ['Personal history of urinary calculi']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tetracycline Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of Stage IA (ypT1N0M0) PDAC s/p neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant FOLFOX, now with metastatic disease to the lung on Rexahn trial (DF/___ trial ___ who presents with fever. The patient was admitted 5 months ago with high grade fevers due to pan-sensitive klebsiella bacteremia of unclear source. Since discharge, the patient had been doing well, but had continued to have low grade fevers 99-100 which was attributed to her chemotherapy which improved with taking dexamethasone. over the last week or so, the patient had noticed increased fatigue and dizziness, with persistently low grade fevers ~100. She contacted her outpatient oncologist who recommended she keep a close eye on her temperature. The day prior to admission it spiked to 103. In addition, over the last few days, she has had increased rhinorrhea and sinus congestion, but states she has had milder versions of these symptoms throughout the winter. In addition she has had a mild headache without vision changes. Furthermore, over the last ___ days, she has had positional, substernal chest pain which she described as throbbing. It is constant, without radiation and exacerbated with deep breaths and lying flat. It is relieved with leaning forward. It is not associated with dyspnea and is without radiation. Lastly, over the last 3 weeks, she has had intermittent loose, non-bloody stool up to 3 times per day. 2 days ago she took Imodium which stopped her BMs. She has not have a BM since. Given her fever, she presented to ___ ED for further evaluation. She initially presented to ___ where vitals were Temp 103.1, BP 103/74, HR 110, RR 18, and O2 sat 94% RA. Labs were notable for WBC 6.5, H/H 9.0/27.6, Plt 414, Na 131, K 4.4, BUN/Cr ___, phos 2.2, Mg 1.7, LFTs/lipase wnl, lactate 2.1, and UA negative. Blood cultures were sent. CXR was negative. CTA chest was negative for pneumonia but remonstrated metastatic disease. She was given zosyn, Tylenol, ibuprofen, and NS. She was transferred to the ___ ED. On arrival to the ED, initial vitals were 98.6 79 100/62 18 94% RA. Exam was notable for stenal tenderness to palpation. Labs were notable for WBC 4.0, H/H 8.5/26.3, Plt 326, Na 139, K 4.1, and BUN/Cr ___. Influenza A/B PCR was negative. ECG showed NSR with inferior Q waves. Of note, the patient was admitted with sepsis in ___ due to pan-sensitive klebseilla bacteremia without obvious source. On arrival to the floor, patient reports the above history and feels slightly more energized. She has no fevers or chills. Chest pain as noted above. No dyspnea or abd pain. No dysuria. Past Medical History: - Pancreatic CA - Hyperlipidemia - Hypothyroidism - GERD - Depression - Nephrolithiasis - Right Breast ALH in ___ s/p excision - s/p remote eye surgery to correct strabismus she had when she was a child Social History: ___ Family History: She notes that her mother had an episode of "jaundice" at ___ or ___ years, was diagnosed with colon cancer at age ___, and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is ___ of five children, all in good health. Sister with ___ disease. Physical Exam: GEN: Well appearing pleasant Caucasian woman sitting up in bed HEENT: Oropharynx clear, MMM, sclerae anicteric ___: RRR no murmurs RESP: CTAB ABD: Soft, nontender, nondistended EXT: warm, no peripheral edema SKIN: Dry, no rashes NEURO: alert, fluent speech, answers questions appropriately, PERRL, palate elevates symmetrically ACCESS: POC c/d/i Pertinent Results: PERTINENT LABS: Blood culture x 2 (___) ___ NGTD Blood culture x 3 (___) ___ NGTD Rapid Flu PCR (___): Negative Respiratory Viral Screen (___): inadequate sample PERTINENT IMAGING CXR ___ at ___ 1. Linear opacity in the left lower lobe likely due to linear atelectasis noted. 2. Slightly enlarged heart. Right venous catheter in place. CTA Chest ___ at ___ 1. Large irregular right lower lobe lesion with numerous nodules bilaterally. 2. no acute thoracic abnormality seen otherwise. Brief Hospital Course: ___ with metastatic pancreatic cancer and history of klebsiella bacteremia, who presented from home with fevers to 103, rhinorrhea, congestion, and substernal chest pain. #Fevers Presented with fever to ___ with URI symptoms and suspected pericarditis (substernal chest pain that was worse with lying flat and better with sitting forward). Given her previous history of klebsiella bacteremia and immunosuppression in the setting of chemotherapy, she was started on broad spectrum antibiotics. Blood cultures were unrevealing and she had no further episodes of fever while hospitalized. Her antibiotics were peeled off and ultimately stopped on the morning of discharge. EKG was unchanged from prior. A TTE was considered, but her pericarditis symptoms self-resolved with supportive care and was deferred. # Metastatic Pancreatic Adenocarcinoma: # Secondary Neoplasm of Lung: Currently on Phase ___ trial ___ of RX-3117 (oral cytidine analogue) + abraxane. She will follow up tomorrow in clinic for continuation of therapy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) ___ unit oral TID W/MEALS 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Omeprazole 40 mg PO DAILY 5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 6. Venlafaxine XR 150 mg PO DINNER 7. Vitamin D ___ UNIT PO DAILY 8. coenzyme Q10 200 mg oral DAILY 9. colesevelam 625 mg oral BID 10. turmeric 1 capsule oral DAILY 11. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. coenzyme Q10 200 mg oral DAILY 2. colesevelam 625 mg oral BID 3. Creon (lipase-protease-amylase) ___ unit oral TID W/MEALS 4. Levothyroxine Sodium 125 mcg PO DAILY 5. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 6. Omeprazole 40 mg PO DAILY 7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. Pyridoxine 50 mg PO DAILY 9. Pyridoxine 50 mg PO DAILY 10. turmeric 1 capsule oral DAILY 11. Venlafaxine XR 150 mg PO DINNER 12. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever Pericarditis Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ___ MD ___ Completed by: ___

{'fever': ['Acute upper respiratory infection', 'Disease of pericardium'], 'rhinorrhea': ['Acute upper respiratory infection'], 'sinus congestion': ['Acute upper respiratory infection'], 'mild headache': [], 'positional substernal chest pain': ['Disease of pericardium'], 'loose non-bloody stool': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tetracycline Attending: ___. Chief Complaint: Abnormal LFTs Major Surgical or Invasive Procedure: ERCP with stent History of Present Illness: Ms. ___ is a ___ woman with history of depression, hypothyroidism, nephrolithiasis and several months of morning "fogginess" transferred from ___ after her PCP referred her to the ED for elevated LFTs and MRI reportedly showed "CBD stricture vs malignancy or stone." RUQUS in our ED confirmed CBD intrahepatic biliary ductal dilation and CBD up to 1.7cm. No evidence of cholangitis. Admitted for further workup including MRCP. Ms. ___ presented to her PCP about ___ month or two ago complaining of feeling "foggy" in the morning, the sensation that she could not concentrate. Initially, her TSH was rechecked and her levothyroxine dose was adjusted upwards to her current dose. This did not seem to help so her PCP did routing liver function tests and discovered elevated AST/ALT and alkaline phosphatase. Wokrup including HBV, HCV HAV were all negative and per records, she had an RUQUS done on ___ which showed dilated hepatic bile duct and possible fatty infiltrate. She had noted ETOH use the weekend prior . She was referred to her local hospital, ___, and reportedly an MRI was done which showed, "CBD stricture vs malignancy or stone," and referred her to ___ for potential ERCP. Upon arrival to us, she was feeling well, no complaints currently. She denies ab pain but does note that her urine has seemed more dark lately and she did have one bowel movement about a week ago that was tan colored instead of her usual brown. ROS: (+)also notes headaches occasionally, also notes feeling slightly "bloated" in her abdomen (-)comprehensive ROS was otherwise negative. Past Medical History: Hypothyroidism Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: ___ Family History: She notes that her mother had an episode of "jaundice" many years ago and has since passed away from other causes. She cannot recall the etiology (if any) to which this was attributed to. Physical Exam: VS: 06.7 P82 138/91 R18 97% on RA GEN: Alert, lying in bed, no acute distress, alert and talkative with a ___ accent HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, motor function grossly normal Pertinent Results: ___ 09:36PM LACTATE-1.1 ___ 09:19PM GLUCOSE-83 UREA N-15 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18 ___ 09:19PM estGFR-Using this ___ 09:19PM ALT(SGPT)-674* AST(SGOT)-316* ALK PHOS-334* TOT BILI-1.1 DIR BILI-0.6* INDIR BIL-0.5 ___ 09:19PM LIPASE-136* ___ 09:19PM ALBUMIN-4.5 ___ 09:19PM WBC-6.5 RBC-4.40 HGB-12.9 HCT-38.5 MCV-88 MCH-29.3 MCHC-33.5 RDW-14.3 RDWSD-45.9 ___ 09:19PM NEUTS-52.2 ___ MONOS-6.5 EOS-2.2 BASOS-0.5 IM ___ AbsNeut-3.38 AbsLymp-2.48 AbsMono-0.42 AbsEos-0.14 AbsBaso-0.03 ___ 09:19PM PLT COUNT-282 ___ 09:19PM ___ PTT-32.4 ___ Impression: •Normal major papilla. •Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. •A single stricture that was 5 mm long was seen at the middle third of the common bile duct just below the cystic duct takeoff. •There was moder post-obstructive dilation with the upstream bile duct measuring 15mm. •A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. •Spy cholangioscopy was performed. ___ stricture was noted under direct visualization: it appeared as a tapered lumenal narrowing without neovascularization/tumor vessels or papillary mucosal projections noted. ___ the main bile duct appeared normal to the bifurcation. ___ cystic duct also appeared normal. ___ forceps were taken of the stricture for histopathology. •Cytology samples were obtained for histology using a brush in the middle third of the common bile duct. •A 7cm by ___ ___ biliary stent was placed successfully using a Oasis stent introducer kit. Recommendations: •Return to ward under ongoing care. •NPO overnight with aggressive IV hydration with LR at 200 cc/hr •If no abdominal pain in the morning, advance diet to clear liquids and then advance as tolerated •CT pancreas protocol •Ciprofloxacin 500mg PO BID x 5 days. •Follow up path and cytology reports; further management will depend on the results. Please call Dr ___ office at ___ in 7 days for the results. •Repeat ERCP in 6 weeks for stent pull and re-evaluation •Follow-up with Dr. ___ as previously scheduled. •Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ___ Brief Hospital Course: A/P: ___ woman with history of depression, hypothyroidism, nephrolithiasis and several months of morning "fogginess" transferred from ___ after her PCP referred her to the ED for elevated LFTs and ultrasound showing intrahepatic ductal dilatation. RUQUS in our ED confirmed CBD intrahepatic biliary ductal dilation and CBD up to 1.7cm. No evidence of cholangitis. Admitted for further workup including MRCP. #CBD stricture/bile obstruction: asymptomatic infiltrative pattern with elevated AST/ALT into the 100s with moderately elevated alk phos. Would expect a higher bilirubin with biliary obstruction but seems like it may have been higher recently given previous acholic stools and dark urine which were reported. The biliary ductal dilatation is concerning for obstruction, either due to stone or malignancy. There is no evidence of cholangitis either on exam or by labs. MRCP at OSH reviewed, consistent for CBD stricture near cystic duct, dilated pancreatic duct, no clear mass/stone. She underwent ERCP confirming CBD stricture, bx sent. stent placed. She did well post procedure and her diet was advanced. SHe was given Cipro 500mg BID x5 days. - Her plan will be for her to follow up with ERCP and have repeat ERCP to address stent. She will also have CTA pancreas, ordered by ERCP team. They will follow up with her and regarding biopsy results. # Leg swelling: Minimal difference on L side. ___ negative for DVT #Hypothyroidism/depression: continued home meds. #Hypertension: SBP up to 160s since arrival. No prior dx of essential HTN. Will continue to follow for now. PCP follow up ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine 75 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Venlafaxine XR 75 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: CBD stricture Hypothyroidism Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for ERCP and were found to have a stricture in your common bile duct. You will need to return for another procedure to have your stent removed. You will also need to schedule a CT scan of your liver and pancreas. Please call the radiology dept to schedule this test ASAP: ___. You will be called with the results of your biopsy and for follow up with the GI team. Followup Instructions: ___

{'fogginess': ['Major depressive disorder', 'single episode', 'unspecified'], 'elevated LFTs': ['Obstruction of bile duct', 'Other specified abnormal findings of blood chemistry'], 'dark urine': ['Obstruction of bile duct'], 'tan colored stool': ['Obstruction of bile duct'], 'headaches': ['Major depressive disorder', 'single episode', 'unspecified'], 'bloated abdomen': ['Major depressive disorder', 'single episode', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tetracycline Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo woman with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant FOLFOX, on Phase ___ DF/HCC ___ trial, who presents after C4D8 of chemotherapy with fever to ___ F. Mrs. ___ was admitted twice early this month with fevers. During her first admission (___) she was found to have klebsiella bacteremia (pansensitive) possibly from GI source and e coli UTI. She was discharged but returned later that day with recurrent fever and URI symptoms. She completed a 14 day course of ciprofloxacin ___. Yesterday (morning of chemotherapy), she had lower abdominal cramps and loose bowel movement. Her stool was nonbloody and watery with small "pieces". She otherwise felt well and presented for C4D8. When she got home, she called her oncologist with a fever, initially ___. Her fever persisted over several hours with Tmax 102.2F. She also had 2 further loose bowel movements that evening and presented to ___ for evaluation. At ___, she had low grade temps to 99.5. Basic labs included WBC 4.9 and normal BMP/LFTs. She had a RUQ US and CXR which were unrevealing. She received CTX given prior culture data of pansensitive e coli and klebsiella and was transferred to ___. In the ED here, her Tmax was 100.3F. On arrival to floor, Mrs. ___ states she has a resolving tension headache, which usually accompanies her fevers. She does not currently feel feverish or chilled. She denies nausea/vomiting, dysuria. She reports resolving nasal congestion and dry cough since her URI symptoms first developed during her last admission (___). Her husband developed URI symptoms 2 weeks ago after her presumed viral URI. She denies suspicious food intake or other sick contacts. Past Medical History: Hyperlipidemia Hypothyroidism GERD depression nephrolithiasis Remote eye surgery to correct strabismus she had when she was a child hx right breast ALH ___ s/p excision at OSH dry eyes dry mouth since chemotherapy Metastatic recurrence of pancreatic cancer: Presented with transaminitis and malignant CBD stricture ___. CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of neoadjuvant FOLFIRINOX (___), followed by SBRT (___), and then Whipple ___. Her final pathologic staging was T1N0 (1.3 cm PDAC in head of pancreas; ___ nodes, negative margins, + PNI and grade II large vessel angiolymphatic invasion). She received 3 cycles of adjuvant FOLFOX (___). In ___, CT torso showed multiple subcm pulmonary nodules, which were noted to increase on follow up CTs ___ and ___. A lung biopsy confirmed metastatic disease ___ and she was consented and started on Phase ___ open label trial of RX-3117 in combination with abraxane at ___. C1D1 ___. Social History: ___ Family History: She notes that her mother had an episode of "jaundice" at ___ or ___ years, was diagnosed with colon cancer at age ___, and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is ___ of five children, all in good health. Sister with ___ disease. Physical Exam: General: Well appearing ___ woman sitting in chair HEENT: Oropharynx clear, MMM, no lesions CV: RRR no murmur PULM: Clear bilaterally to auscultation ABD: Soft nontender nondistended, normoactive bowel sounds LIMBS: No peripheral edema, WWP SKIN: No rashes NEURO: Alert, oriented, provides clear history ACCESS: R POC is accessed and c/d/i Pertinent Results: ___ 06:00AM BLOOD WBC-2.5* RBC-2.62* Hgb-8.1* Hct-25.2* MCV-96 MCH-30.9 MCHC-32.1 RDW-16.8* RDWSD-58.4* Plt ___ TSH 1.5 - Micro - U/A: bland UCx No growth BCx x 2 pending (one from port, one peripheral): NGTD Flu swab ___ ___ negative BCx x 2 ___ ___: NGTD Norovirus negative C diff PCR positive, but toxin NEGATIVE Stool culture: negative ======= IMAGING ======= RUQ ___ ___: FINDINGS: The liver is diffusely echogenic consistent with severe fatty infiltration. The patient is status post cholecystectomy. The common duct measures 3 mm. The right kidney measures 9.8 cm. The right renal cortex is preserved. There is no hydronephrosis in the right kidney. The pancreas is not seen due to bowel gas. IMPRESSION: Fatty infiltration of the liver. CXR ___ ___: The heart is not enlarged. The lungs are clear bilaterally with normal pulmonary vascular distribution. There is no pleural fluid. A right-sided Port-A-Cath terminates in the distal superior vena cava. IMPRESSION: No acute pulmonary infiltrates. Brief Hospital Course: ___ with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, ___ (___), adjuvant FOLFOX, on Phase ___ DF/___ ___ trial, who presents after C4D8 of chemotherapy with fever to ___ F and 3 episodes of loose stool. # Fever, diarrhea Recently admitted (___) for fever after chemotherapy and was found to have klebsiella bacteremia (pansensitive) possibly from GI source and e coli UTI. She completed treatment with ciprofloxacin on ___. She presented to ___ with fever to ___ shortly after C4D8 of chemotherapy. Initial workup included RUQ US and CXR which were unrevealing. She was started on ceftriaxone to treat empirically for the previous klebsiella bacteremia. Stool studies were sent and her C diff PCR returned positive. Ceftriaxone was discontinued and PO vancomycin was started. However, 12 hours later, her C diff toxin returned negative. All antibiotics were held and she was observed for 24 hours without recurrence of fever. The rest of her infectious workup was negative as noted in the previous section. This is Mrs. ___ ___ fever that has occurred after chemotherapy. Her case was discussed with her outpatient oncologist with the suspicion that her fevers are caused by her chemotherapy treatment. She will see her oncologist in follow up the week after discharge for further recommendations. [ ] outpatient plan for management of post-chemotherapy fevers # Metastatic recurrence of Stage IA pancreatic adenocarcinoma s/p ___ On Phase ___ trial ___ of RX-3117 (oral cytidine analogue) + abraxane; s/p ___. Suspicion that fever is in setting of chemotherapy as above. Her trial drug ___-311___ was held for this cycle due to concern for infection. Please note for future admissions that Mrs. ___ home Creon is 3x the strength of BI formulary Creon. She tolerated a regular diet in the hospital with Creon 6 capsules with meals and 4 capsules with snacks. # Hot flashes She reported hot flashes since initiation of chemotherapy. A TSH was checked, which returned normal after patient's discharge. [ ] inform patient of normal TSH Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) ___ unit oral TID W/MEALS 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Venlafaxine XR 150 mg PO DINNER 7. Vitamin D ___ UNIT PO DAILY 8. coenzyme Q10 200 mg oral DAILY 9. colesevelam 625 mg oral BID 10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. turmeric 1 capsule oral DAILY Discharge Medications: 1. coenzyme Q10 200 mg oral DAILY 2. colesevelam 625 mg oral BID 3. Creon (lipase-protease-amylase) ___ unit oral TID W/MEALS 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 11. Senna 8.6 mg PO BID:PRN Constipation - First Line 12. turmeric 1 capsule oral DAILY 13. Venlafaxine XR 150 mg PO DINNER 14. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever with negative infectious workup Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ___ MD ___ Completed by: ___

{'Fever': ['Fever', 'Secondary malignant neoplasm of unspecified lung', 'Diarrhea'], 'Diarrhea': ['Fever', 'Secondary malignant neoplasm of unspecified lung', 'Diarrhea'], 'Hot flashes': ['Hyperlipidemia', 'Hypothyroidism', 'Gastro-esophageal reflux disease without esophagitis'], 'Lower abdominal cramps': ['Major depressive disorder', 'single episode', 'unspecified'], 'Loose bowel movement': ['Personal history of malignant neoplasm of pancreas', 'Personal history of nicotine dependence'], 'Nasal congestion': ['Menopausal and female climacteric states']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: aspirin / Penicillins / latex Attending: ___. Chief Complaint: right knee pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with right knee pain presenting for elective total knee arthroplasty Past Medical History: MVA in ___ with likely R ankle ATFL tear-> no ___ but dev RLE DVT now on xarelto -Right knee medial meniscectomy ___ ___, ___ -Asthma -Bilateral carpal tunnel syndrome -Osteoarthritis -Polyarthralgia -Chronic pain -Complex regional pain syndrome -GERD -Right-sided sciatica -Right shoulder arthroscopy -Endometrial ablation -Tubal ligation -Cholecystectomy -Appendectomy Social History: ___ Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. On day of surgery, patient was unable to be intubated secondary to airway difficulties; thus surgery was aborted. She will reschedule her surgery in the next few months. During her hospitalization, surgery was aborted secondary to airway difficulty and inability to intubate. Otherwise, pain was controlled with oral pain medications. The patient's weight-bearing status is weight bearing as tolerated on the affected extremity. Ms ___ is discharged to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. butalbital-acetaminophen 50-325 mg oral DAILY:PRN 2. Gabapentin 800 mg PO TID 3. Dronabinol Dose is Unknown PO Frequency is Unknown 4. aclidinium bromide 400 mcg/actuation inhalation BID 5. Zolpidem Tartrate 10 mg PO QHS 6. Rivaroxaban 20 mg PO DAILY 7. TraMADol 50 mg PO TID 8. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 9. Omeprazole 20 mg PO DAILY 10. Loratadine 10 mg PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN shortness of breath or wheezing Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*100 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*100 Tablet Refills:*0 3. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*100 Tablet Refills:*0 4. Dronabinol unknown PO Frequency is Unknown 5. aclidinium bromide 400 mcg/actuation inhalation BID 6. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN 7. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 8. butalbital-acetaminophen 50-325 mg oral DAILY:PRN 9. Gabapentin 800 mg PO TID 10. Loratadine 10 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Rivaroxaban 20 mg PO DAILY 13. TraMADol 50 mg PO TID 14. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: right knee pain/osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please reschedule your surgery to ___. You will need re-evaluation and preoperative assessment. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. Please follow up with your primary physician regarding this admission and any new medications and refills. Resume your home medications unless otherwise instructed. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. Physical Therapy: none Treatments Frequency: none Followup Instructions: ___

{'right knee pain': ['Osteoarthritis of knee'], 'airway difficulties': [], 'inability to intubate': [], 'shortness of breath': ['Chronic obstructive pulmonary disease', 'Obstructive sleep apnea (adult) (pediatric)'], 'wheezing': ['Unspecified asthma'], 'chronic pain': ['Other chronic pain'], 'polyarthralgia': [], 'complex regional pain syndrome': [], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'right-sided sciatica': ['Sciatica', 'right side'], 'obesity': ['Obesity', 'unspecified', 'Body mass index [BMI] 40.0-44.9', 'adult'], 'nicotine dependence': ['Nicotine dependence', 'cigarettes', 'uncomplicated'], 'DVT': ['Personal history of other venous thrombosis and embolism'], 'long term (current) use of antithrombotics/antiplatelets': ['Long term (current) use of antithrombotics/antiplatelets']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ years old woman with past medical history of hypertension comes to the ED complaining of abdominal pain. Patient refers she was in her usual state of health until 9 days ago when she started having intermittent severe crampy abdominal pain. She refers that sometimes the pain was so severe that it was associated with nausea but no emesis. She also refers some chills and subjective fevers but no recorded fevers and loose bowel movements. Yesterday her pain worsened so she called her PCP who ordered ___ CBC and UA, both of which were normal so she was sent home. This morning her pain was again worse so she went back to her PCP and had done a CT scan of abdomen and pelvis that showed acute diverticulitis with small abscess so she was referred to the ED for surgical evaluation. Past Medical History: HTN Diverticulosis Social History: ___ Family History: non-contributory Physical Exam: PHYSICAL EXAM: upon admission: ___ VITAL SIGNS: 98.4, 81, 138/79, 18, 100% RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G PULMONARY: CTA ___, No crackles or rhonchi GASTROINTESTINAL: soft, non-distended, mildly tender diffusely in lower abdomen. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact CNII-XII: WNL Physical examination upon discharge: ___: GENERAL: NAD CV: ns1, s2, no murmurs LUNGS: clear ABDOMEN: hypoactive BS, soft, non-tender EXT: no calf tenderness bil., no pedal edema bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 04:15AM BLOOD WBC-6.2 RBC-3.96 Hgb-12.7 Hct-36.8 MCV-93 MCH-32.1* MCHC-34.5 RDW-11.1 RDWSD-37.8 Plt ___ ___ 04:49AM BLOOD WBC-6.1 RBC-3.74* Hgb-12.1 Hct-34.7 MCV-93 MCH-32.4* MCHC-34.9 RDW-11.1 RDWSD-38.0 Plt ___ ___ 01:44PM BLOOD WBC-8.6 RBC-3.86* Hgb-12.5 Hct-37.0 MCV-96 MCH-32.4* MCHC-33.8 RDW-11.4 RDWSD-40.0 Plt ___ ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD Glucose-83 UreaN-5* Creat-0.6 Na-142 K-4.3 Cl-105 HCO3-24 AnGap-13 ___ 08:30PM BLOOD Glucose-70 UreaN-12 Creat-0.5 Na-136 K-4.2 Cl-95* HCO3-23 AnGap-18 ___ 04:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3 ___ 08:38PM BLOOD Lactate-1.0 ___: CT scan abdomen and pelvis: Sigmoid diverticulitis with 1.2 cm intramural abscess. No evidence of macro-perforation. -3 mm hypodensity within the pancreatic body likely represents a benign intra-ductal papillary mucinous neoplasm. Nonurgent MRCP is recommended for further evaluation. RECOMMENDATION(S): Non-urgent MRCP NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:00 pm, 5 minutes after discovery of the findings. Brief Hospital Course: ___ year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. She was reported to have sigmoid diverticulitis with 1.2 cm intramural abscess. The patient was started on a course of intravenous ciprofloxacin and flagyl and placed on bowel rest. Her white blood cell count was monitored. After the patient's abdominal pain decreased, she was started on clears and advanced to a regular diet. The patient was discharged home on HD #5. Her vital signs were stable and she was afebrile. She was tolerating a regular diet and voiding without difficultly. She was ambulatory and return of bowel function. Discharge instructions were reviewed and questions answered. The patient was given a prescription for completion of a course of ciprofloxacin and flagyl. The patient was instructed to follow up with her primary care provider. +++++++++++++++++++++++++++++++++++++++++++++++ Of note: incidental finding on cat scan imaging showed a 3 mm hypo-density within the pancreatic body likely represents a benign intra-ductal papillary mucinous neoplasm. Non-urgent MRCP is recommended for further evaluation. The patient was informed of this finding and given a copy of her report. Medications on Admission: ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream. 1 gram Use as directed PRN - (Prescribed by Other Provider) LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth Q Day NIACIN - niacin ER 500 mg tablet,extended release 24 hr. 1 tablet(s) by mouth once a day RALOXIFENE - raloxifene 60 mg tablet. 1 tablet(s) by mouth daily RHIZINATE X3 - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth Daily - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 4,000 unit capsule. 1 capsule(s) by mouth Daily - (Prescribed by Other Provider) MULTIVIT-MIN-LYCOP-LUT-HERB___ [PHYTOMULTI] - PhytoMulti 3 mg-3 mg-200 mg tablet. 2 tablet(s) by mouth Daily - (Prescribed by Other Provider) VIT A AND D3 IN COD LIVER OIL [COD LIVER OIL] - cod liver oil 4,000 unit-400 unit/5 mL oral liquid. 1 Tbsp by mouth Daily - (Prescribed by Other Provider) --------------- --------------- --------------- --------------- Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days ___ RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days last dose ___ RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: diverticulitis 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. You underwent imaging which showed sigmoid diverticulitis with a intra-mural abscess. You were placed on bowel rest and given a course of antibiotics. Your abdominal pain has decreased and you have resumed a diet. You are being discharged home with the following recommendations: 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. Followup Instructions: ___

{'abdominal pain': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'chills': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'nausea': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'subjective fevers': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'loose bowel movements': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'tender diffusely in lower abdomen': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'hypoactive BS': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'soft, non-distended, mildly tender diffusely in lower abdomen': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'no guarding, rebound, or peritoneal signs': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], '+BSx4': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'alert and oriented x 3, speech clear': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'no calf tenderness bil., no pedal edema bil': ['Diverticulitis of large intestine with perforation and abscess without bleeding'], 'neuro: alert and oriented x 3, speech clear': ['Diverticulitis of large intestine with perforation and abscess without bleeding']}

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: lightheadedness Major Surgical or Invasive Procedure: packed red blood cell transfussion History of Present Illness: ___ F with history of HTN, p/w Left temporal artery aneurysm developing after traumautic fall 3 weeks ago, that started bleeding while washing her face yesterday morning. . The patient reports that she was washing her face yesterday morning when the left temple started bleeding. ___ was evaluating her at the time, she called lifeline and was ___ to the ER via EMS. Per report, she lost apporaixmately 200-300 cc lost in field and additonal ~200cc in ED with uncontrolled bleeding during transport. Estimated blood loss is about 1 liter. . In the ER, the artery was ligated with sutures at bedside by surgery. She was intially admitted to observation in the ER to moniter her Hct. On admission Hct was 37.2 and now has stabilized at around 29. She was not transfused, but SBPs dropped transiently to ___. She was given more fluids (500cc) and on re-evaluation vitals normalized but Pt continued to be symptomatic, stating she feels lightheaded with standing. She also developed abdominal pain and subsequntly had an Abdominal-CT which was negative. She was also orthostatic in the ER. She was given total approx 2000ml of NS in the ER. . On the floor the patient is lying comfortably in bed stating her only complaint is feeling lightheaded with standing. While in the room she was able to get up and go to the bathroom but felt very lightheaded. She also states that her abdominal pain/cramps is longstanding(years) and is unchanged from baseline. She denies any fever/chills, N/V, changes in bowel or bladder habits, recent weight loss or gain, SOB, chest discomfort, or headaches. . Review of sytems: (+) 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: HTN Colonic Volvulus with Colon resection Hysterectomy Incarcerated inguinal hernia with repair and small bowel resection Insomnia Melanoma Social History: ___ Family History: Noncontributory Physical Exam: Vitals: T: 98.7 BP 128/84 P: 106 R: 16 O2: 96%RA Orthostatics: Laying flat: 162/74 HR 80, sitting 160/80 HR 80, Standing 145/80 HR 88. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Left temple with with crusted blood, and sutures in place. 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 Skin: no rashes, but multiple ecchaymoses. pt. states she ___ for the past several years. denies abuse. left knee wound -- dressed. Neuro: Alert and oriented x 3. Motor: grossly intact Sensation: grossly intact DTR: intact ___: unremarkable Gait: unsteady Pertinent Results: CBC/HCT. ON ADMISSION: ___ 12:50PM BLOOD WBC-11.8* RBC-3.80* Hgb-12.2 Hct-37.2 MCV-98 MCH-32.2* MCHC-32.9 RDW-13.1 Plt ___ ___ 08:45PM BLOOD WBC-11.0 RBC-3.32* Hgb-10.3* Hct-31.5* MCV-95 MCH-31.0 MCHC-32.6 RDW-13.0 Plt ___ ___ 05:50AM BLOOD Hct-29.1* ___ 10:50AM BLOOD WBC-8.0 RBC-3.04* Hgb-9.5* Hct-29.2* MCV-96 MCH-31.2 MCHC-32.6 RDW-13.1 Plt ___ ___ 07:25AM BLOOD WBC-7.2 RBC-3.05* Hgb-9.7* Hct-29.8* MCV-98 MCH-31.7 MCHC-32.4 RDW-13.4 Plt ___ ON DISCHARGE: ___ 06:35AM BLOOD WBC-9.6 RBC-3.47* Hgb-10.9* Hct-32.6* MCV-94 MCH-31.3 MCHC-33.4 RDW-15.1 Plt ___ . ELECTROLYTES. ___ 10:50AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-139 K-4.3 Cl-103 HCO3-29 AnGap-11 ___ 07:25AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 ___ 06:35AM BLOOD Glucose-82 UreaN-11 Creat-0.5 Na-140 K-3.9 Cl-103 HCO3-29 AnGap-12 . LFTs ___ 10:50AM BLOOD ALT-13 AST-23 LD(LDH)-148 AlkPhos-53 TotBili-0.2 . URINE ANALYSIS. ___ 01:30PM URINE ___ Bacteri-NONE Yeast-NONE ___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___ . . RADIOLOGY. CHEST (PORTABLE AP) Study Date of ___ 10:02 AM : Mild loss of volume in the right lung reflected in rightward mediastinal shift is unchanged. There is no discrete atelectasis. Lungs are clear and there is no pleural effusion. Heart size normal. Pulmonary vasculature unremarkable. . CT ABDOMEN/PELVIS W/CONTRAST Study Date of ___ 11:58 AM 1. No evidence of diverticulitis or other acute abdominal process. 2. New tiny pulmonary nodule at the right lung base. These could potentially be infectious/inflammatory in etiology. Correlation should be made with past medical history of malignancy. If none is known, a chest CT in one year may be warranted to document stability. Brief Hospital Course: This is a ___ with history of HTN who p/w Left temporal artery aneurysm c/b rupture with approximately 1L of blood loss s/p ligation with here with orthostatic hypotension. # Temporal Artery Bleed: Left temporal aneurysmal bleed(approximately 500 ml-1 liter) at home after washing her face presenting to the ED with stable vitals initially and HCT of 37.2 and complaints of lightheaded. Trauma Surgery was consulted in the ER and ligated her left temporal artery. The temporal artery was stable while admitted to the floor. She will follow up with Dr. ___ surgery) as an outpatient. Her sutures were placed ___ and should be removed in about ___ days. She has an appt scheduled with her primary care doctor, ___ on ___. # Lightheadedness/Orthostasis: The first day on the floor she continued to have symptoms of lightheadedness and was positive for orthostatics (BP 160/74 laying down, 145/74 standing). She was given IVF. The following day she also had feelings of lightheadedness, borderline orthostatics and was transfused 1 unit of packed red blood cells given no improvement in her symptoms and her advanced age. After the transfusion her Hct went from 29.8 to 32.6. with improvement in symptoms of lightheadness but still feelings of unsteadiness while walking. Physical therapy was consulted and felt she would benefit from Rehab. On day of discharge she no longer had symptoms of lightheadedness when standing from sitting and orthostatics were negative. # Abdominal Pain/Cramps: In the ED patient complained of cramps and subsequently had an Abdominal-CT which was negative, however she stated that this pain was due to her long standing cramps for years that are normally controlled with OTC pain medications. She did not have any abdominal pain and an unremarkable abdominal exam as well as normal LFTs throughout the hospitalization . Medications on Admission: Escitalopram 10mg daily Atenolol 25mg daily Amlodipine 2.5mg daily Aspirin 81mg daily Calcium Carbonate 500mg twice a day Cholecalciferol 400unit twice a day lunesta PRN MVI Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for advanced age. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Acute blood loss from Temporal Artery bleed secondary: HTN Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were seen and treated at ___ for bleeding from your temporal artery which was stopped in the ED. After the bleeding was stopped you continued to have lightheadedness in the ED so you were transferred to the medicine floor for further evaluation. While on the medicne floor your red blood cell count was low but stable. This was also most likely due to your blood loss. Since you continued to have symptoms of lightheadness/dizziness and after 3 days and a low red blood cell count you were given one unit of red blood cells. On the day of discharge you were seen by physical therapy, who felt you were stable enough to go to rehab for further physical therapy before going home. You have been scheduled to see your primary care physciain for follow up on ..... ___ MD ___ Completed by: ___

{'lightheadedness': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension'], 'orthostatic hypotension': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension'], 'abdominal pain': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: seasonal Attending: ___. Chief Complaint: left inguinal hernia Major Surgical or Invasive Procedure: ___ Left Incarcerated recurrent Inguinal Hernia Repair History of Present Illness: ___ with history of L inguinal hernia repair presented with sudden onset of painful left groin buldge. Patient awoke with bulge in left groin and constant pain. Denies vomiting, some nausea, fevers/chills. Last BM was 2 days prior. Last flatus was yesterday. Denies sense of abdominal bloating. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: proximal and mid LAD (___) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -cluster headache (no terrible headaches for years) -Left leg tibial/fibula ganglion cyst -BPH PSH 1. History of Left sided inguinal herniorraphy with mesh (___ ___ 2. Coronary stent placement 3. Left leg cyst excision Social History: ___ Family History: No family history of cancer, arrhythmia, cardiomyopathies, or sudden cardiac death. His uncle and cousin died of MIs in their ___. Physical Exam: Vitals: 98 82 136/64 17 98%ra Gen: no acute distress, alert and oriented, well appearing Abd: hernia repair site in left inguinal region with dressing c/d/i, mild tenderness to palpation; abdomen nondistended, nontender, no rebound or guarding Cardio: regular rate and rhythm Pulm: nonlabored breathing, clear to ascultation Ext: nonedematous, noncyanotic Pertinent Results: ___ 10:15AM BLOOD WBC-6.6 RBC-4.30* Hgb-13.8* Hct-42.4 MCV-99* MCH-32.2* MCHC-32.6 RDW-13.9 Plt ___ ___ 10:15AM BLOOD Neuts-72.8* Lymphs-17.5* Monos-6.0 Eos-3.2 Baso-0.5 ___ 10:15AM BLOOD ___ PTT-29.4 ___ ___ 10:15AM BLOOD Glucose-98 UreaN-22* Creat-0.7 Na-136 K-4.4 Cl-103 HCO3-25 AnGap-12 CT ABD & PELVIS WITH CONTRAST Study Date of ___ Abdomen: The lung bases demonstrate minimal dependent atelectasis. No pleural or pericardial effusion is seen. A subcentimeter hypodensity in segment 4A of the liver likely represents a cyst. Calcification is again seen in the spleen. An accessory spleen is noted. The gallbladder, pancreas, adrenal glands, stomach, and small bowel are within normal limits. Bilateral renal hypodensities most likely represent cysts; the largest arises from the lower pole of the right kidney and measures 4.4 x 3.8 cm. Neither kidney demonstrates hydronephrosis. Colonic diverticula do not demonstrate evidence for acute inflammation. There is no free intraperitoneal air or ascites. Major intra-abdominal vasculature appears patent and normal in caliber with dense calcified and non-calcified aortic atherosclerotic plaque. Pelvis: The prostate, seminal vesicles, and rectum demonstrate no acute abnormalities. The bladder is distended with layering contrast. No free fluid is seen in the pelvis. Fat containing right inguinal hernia is seen. No left inguinal hernia is seen. No concerning lytic or sclerotic osseous lesions are detected. IMPRESSION: No CT evidence for acute intra-abdominal or pelvic process or incarcerated hernia. Brief Hospital Course: The patient was admitted on ___ under the acute care surgery service for management of an incarcerated left inguinal hernia. Initial CT scan report said there was no hernia, but the clinical suspicion was high for an incarcerated inguinal hernia so he was taken to the operating room for open left inguinal hernia repair. 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 subsequently advanced and he tolerated it well. On ___ the patient's pain was under control; he was tolerating a regular diet and functioning independently so he was discharged home. At the time of discharge the patient understood the recommendation for follow up and instructions for no heavy lifting for minimum of 6 weeks after the surgery. Medications on Admission: 1. Verapamil 2. Plavix 75 daily 3. Lisinopril 4. Simvastatin 40 Discharge Medications: 1. Acetaminophen 650 mg PO Q8H RX *acetaminophen 650 mg 1 tablet(s) by mouth q8hrs Disp #*60 Tablet Refills:*2 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drive or use alcohol while taking this medicaiton RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs prn Disp #*40 Tablet Refills:*0 3. Verapamil SR 240 mg PO Q24H 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 Discharge Disposition: Home Discharge Diagnosis: left inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen and evaluated by the Acute Care Surgery Service at ___ for your left inguinal hernia. We took you to the operating room and repaired the hernia. You are now in better condition and are safe to return home and continue your recovery there. You will need to avoid heavy lifting for at least 6 weeks. You will have some pain and swelling at the surgical site, but these will improve with time. Please take the pain medication as prescribed; also take the stool softener while taking narcotic pain medications to prevent constipation. You will need to follow up with us in clinic in 2 weeks so we can monitor your recovery. **You can take off your dressing on ___, ___. Until then, do not get the area wet (take a sponge bath if necessary). After taking the bandage off you can shower, allowing warm water to run over the wound but do not scrub the wound; pat dry with a clean towel; leave the steristrips (white bandages) in place; these will fall off on their own (or you can remove them ___ days after your surgery). 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 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: ___

{'painful left groin bulge': ['Inguinal hernia'], 'constant pain': ['Inguinal hernia'], 'nausea': ['Inguinal hernia'], 'fevers/chills': ['Inguinal hernia'], 'cluster headache': ['Pure hypercholesterolemia'], 'left leg tibial/fibula ganglion cyst': ['Pure hypercholesterolemia'], 'BPH': ['Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'], 'CAD RISK FACTORS': ['Coronary atherosclerosis of unspecified type of vessel, native or graft', 'Unspecified essential hypertension'], 'vomiting': ['Inguinal hernia'], 'no rebound or guarding': ['Inguinal hernia'], 'mild tenderness': ['Inguinal hernia'], 'nontender': ['Inguinal hernia'], 'nonedematous': ['Inguinal hernia'], 'nontender, no rebound or guarding': ['Inguinal hernia'], 'nonlabored breathing': ['Inguinal hernia'], 'clear to ascultation': ['Inguinal hernia'], 'noncyanotic': ['Inguinal hernia'], 'no acute distress': ['Inguinal hernia'], 'alert and oriented': ['Inguinal hernia'], 'well appearing': ['Inguinal hernia'], 'no acute abnormalities': ['Inguinal hernia'], 'no concerning lytic or sclerotic osseous lesions': ['Inguinal hernia'], 'no free intraperitoneal air or ascites': ['Inguinal hernia'], 'no CT evidence for acute intra-abdominal or pelvic process or incarcerated hernia': ['Inguinal hernia']}

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: chest tightness and left arm tingling Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with a history of CAD (2 DES placed into LAD on ___, hyperlipidemia, HTN, and smoking history presenting with left chest tightness. On the day prior to admission, the patient felt a pressure in his left arm associated with calminess, diaphoresis, lightheadedness and weakness that lasted for a couple of hours. He does not recall if he took nitroglycerin. On the day of admission, the patient felt pressure in his left chest with associated lightheadednes. These episodes came on with rest. He said that these symptoms felt different from his last MI (during his old MI, he felt indigestion), but had a feeling that these symptoms were related to his heart. . The patient recalls one incident since his last cath when he felt indigestion (his anginal equivalent), but he took nitroglycerin and it went away. He also had a couple of other incidents, but cannot recall them. . On presentation to the ED, his vitals were T: 98.3 HR: 87 BP: 130/64 RR: 18 O2 sat: 100%RA. The patient presented to the ED with ___ chest tightnes which was relieved with one SLNG and his tightness resolved in minutes. His first set of cardiac biomarker were within normal limits. His EKG was unchanged since prior. He took his home aspirin and Plavix before coming to the hospital. His CXR was unremarkable. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On review of systems, the patient has said that since his NSTEMI that it has been difficult to lift his left foot and push off the ball of it when walking. He also feels numbness on the arch of his left foot. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: proximal and mid LAD (___) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -cluster headache (no terrible headaches for years) Social History: ___ Family History: No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. His uncle and cousin died of MIs in their ___. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.4 BP=134/86 HR=68 RR=18 O2 sat=100% RA GENERAL: Pleasant thin male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. ___, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No facial droop NECK: Supple. JVP not elevated CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. No chest wall tenderness LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Full range of motion of his extremities SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Neuro: Patient able to ambulate. Can walk on heels and balls of feet. CN II-XII intact. ___ strength and intact sensation in upper extremity. 2+ patellar/Achilles reflex in ___. ___ dorsiflexion in left foot, otherwise ___ has ___ strength. Decreased sensation in lateral aspect of left lower calf and wrapping onto arch of the foot, otherwise sensation normal. No babinski sign. No Romberg sign. No pronater drift. Pertinent Results: Admission physical exam: ___ 11:45AM BLOOD WBC-5.7 RBC-4.57* Hgb-14.1 Hct-41.7 MCV-91 MCH-30.7 MCHC-33.7 RDW-13.9 Plt ___ ___ 11:45AM BLOOD Neuts-61.9 ___ Monos-6.0 Eos-5.3* Baso-0.4 ___ 05:50AM BLOOD ___ PTT-32.2 ___ ___ 11:45AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-140 K-4.3 Cl-105 HCO3-27 AnGap-12 Cardiac enzymes: ___ 11:45AM BLOOD CK(CPK)-96 CK-MB-NotDone cTropnT-<0.01 ___ 07:11PM BLOOD CK(CPK)-72 CK-MB-NotDone cTropnT-<0.01 ___ 05:50AM BLOOD CK(CPK)-58 CK-MB-NotDone cTropnT-<0.01 Studies: EKG: Sinus rhythm. Prior inferoposterior myocardial infarction. Compared to the previous tracing of ___ the rate has increased. Otherwise, no diagnostic interim change. ___ ___ CXR: No acute intrathoracic process. Stress Echo (___): . INTERPRETATION: A ___ y/o man s/p NSTEMI and stents ___ was referred to the lab for evaluation of chest pain. He exercised 9.25 minutes of ___ protocol ___ METS) and stopped due to fatigue. This represents an excellent physical working capacity for his age. He denied any arm, neck, back or chest discomfort throughout the test. There were no significant ST segment changes throughout the study. The rhythm was sinus with no ectopy throughout the study. There was an appropriate blood pressure and heart rate response to exercise. . IMPRESSION: No ischemic EKG changes or anginal type symptoms. Echo report sent separately. Echo: The patient exercised for 9 minutes 15 seconds according to a ___ treadmill protocol ___ METS) reaching a peak heart rate of 142 bpm and a peak blood pressure of 156/54 mmHg. The test was stopped because of fatigue. This level of exercise represents a very good exercise tolerance for age. In response to stress, the ECG showed no diagnostic ST-T wave changes (see exercise report for details). There were normal blood pressure and heart rate responses to stress. Resting images were acquired at a heart rate of 75 bpm and a blood pressure of 112/60 mmHg. These demonstrated normal regional and global left ventricular systolic function. Right ventricular free wall motion is normal. Doppler demonstrated no aortic stenosis, aortic regurgitation or significant mitral regurgitation or resting LVOT gradient. Echo images were acquired within 56 seconds after peak stress at heart rates of 133 - 115 bpm. These demonstrated appropriate augmentation of all left ventricular segments with slight decrease in cavity size. There was augmentation of right ventricular free wall motion. IMPRESSION: Very good functional exercise capacity. No ECG or 2D echocardiographic evidence of inducible ischemia to achieved workload. Suboptimal study - sub-optimal image quality during post-exercise acquisitions. Brief Hospital Course: Summary: ___ yo male with a history of CAD (2 DES placed into LAD on ___, hyperlipidemia, HTN, and smoking history presenting with left chest tightness. CORONARIES: The patient has known CAD with a cath report from ___ and an intervention with placement of 2 DES into the proximal and distal LAD (lesions were hazy though FFR showed pressure gradient difference). At that time, he only had single vessel disease. The patient presents with a different type of discomfort than his previous anginal pain. Cardiac enzymes x 3 were normal and there were no EKG changes. The patient did not experience any discomfort during the hospitalization. He was continued on Plavix, high dose aspirin, lisinopril and a statin. A beta blocker was held because he had an adverse reaction to it in the past. Since his discomfort was different than his prior and his last cath was only 2 months ago, it was decided to perform a stress echo on the patient. The stress echo was normal revealing excellent physical endurance and a very good functional exercise capacity without ECG of 2D echo evidence of inducible ischemia. On discharge, the patient was given a prescription for sublingual nitroglycerin. He has a PCP appointment on ___ and ___ planned to have his PCP organize cardiology followup. -follow cardiac enzymes . # Dyslipidemia: From ___ his lipid panel showed LDL calc: 75, HDL: 41, ___: 122, Total choleterol: 122. He was advised to increase his simvastatin 10 mg dose for a goal of LDL<70. On discharge, the patient was given a prescription for pravastatin 20 mg daily because it will provide cost savings. # Left foot drop and associated numbness: The patient complains of difficulty pushing on the ball of his left foot. The physical exam revealed ___ dorsiflexion of the foot and sensory loss on the lateral aspect of the calf wrapping on the the arch of the foot. He did not have any back or neck pain. The remainder of his neurological exam was normal. Since his symptoms are only distal, they might be due to compression of a nerve. He was given an appointment at the neurology urgent clinic for further evaluation. Outpatient followup: 1. Check LDL if at goal 2. Neurology for left foot weakness Medications on Admission: 1. Clopidogrel 75 mg Daily 2. Aspirin 325 mg Daily 3. Verapamil 240 mg SR Daily PRN headaches (one tablet BID) 4. Lisinopril 5 mg daily 5. Simvastatin 10 mg qHS 6. Nitroglycerin 0.3 mg Tablet PRN chest pain 7. Flexeril PRN muscle spasm Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for headache. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: ___ repeat up to three times. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Flexeril 5 mg Tablet Sig: unknown dose Tablet PO PRN as needed. Discharge Disposition: Home Discharge Diagnosis: Primary -atypical chest pain -coronary artery disease . Secondary -hypercholesterolemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You came to the hospital because you were having left arm tightness/numbness and also left chest tightness. There was concern that it was your heart. You also had a bout of indigestion since your last cath. Your bloodwork, EKG and stress echo showed no evidence of a heart attack. . You will be continued on the same medications. You should ask your primary care physician at your appointment on ___ about your cholesterol. In the past, your LDL was noted to be 76. . You have an appointment at the neurology clinic for your foot. They can further evaluate the reason why it's difficult to push off the ground. Followup Instructions: ___

{'chest tightness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'left arm tingling': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'pressure in his left arm': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'calminess': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'diaphoresis': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'lightheadedness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'weakness': ['Other chest pain', 'Coronary atherosclerosis of native coronary artery'], 'difficulty pushing off the ground with left foot': ['Other acquired deformities of ankle and foot'], 'numbness in the arch of the foot': ['Other acquired deformities of ankle and foot']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: seasonal Attending: ___ Chief Complaint: Lightheadedness Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: ___ with h/o CAD s/p stents x2 in ___, on ASA + Plavix, who presents with one week of lightheadedness, fatigue, right shoulder pain, and shortness of breath (SOB). He reports that the fatigue/SOB occurs after 1 flight of stairs, which is abnormal for him. He also had symptoms with lifting boxes at work. In regards to the shoulder discomfort, he describes it as a "hollow feeling" in his right shoulder without frank pain, with some extension into the right arm. His symptoms improve with SL nitro. There is no particular pattern with exertion, but sometimes it wakes him up at night. He also reports some intermittent epigastric pain which he reports is how his prior MI presented, but currently not associated with activity. He denies any peripheral edema. He has had sclerotherapy recently for ganglion cyst in his leg and held Plavix about 1 month ago for that. In the ED, initial vitals were T 97.6 HR 78 BP 125/70 RR 16 SaO2 99% on RA. Labs and imaging significant for normal CBC, Chem 10, and troponin. EKG: NSR at 67 bpm with Q waves in III and aVF, similar to baseline. Vitals on transfer were T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on RA. On arrival to the floor, patient reports some epigastric discomfort and right arm discomfort similar to before. REVIEW OF SYSTEMS: On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is as above. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: proximal and mid LAD (___) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -cluster headache (no terrible headaches for years) -Left leg tibial/fibula ganglion cyst -BPH Social History: ___ Family History: No family history of cancer, arrhythmia, cardiomyopathies, or sudden cardiac death. His uncle and cousin died of MIs in their ___. Physical Exam: Admission: GENERAL: WDWN in NAD.Oriented x3. Mood, affect appropriate. VS: T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without elevation of JVP cm. CARDIAC: RRR, no murmurs, rubs or gallops. LUNGS: CTAB ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No clubbing, cyanosis or edema. 2+ ___ pulses NEURO: CN II-XII grossly intact, moving all extremeties, sensation grossly normal. Gait not tested. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge Vitals: T 97.6 BP 140/90 HR 75 RR 18 SaO2 100% on RA NECK: Supple without elevation of JVP cm. CARDIAC: RRR; no murmurs, rubs or gallops. LUNGS: CTAB EXTREMITIES: No clubbing, cyanosis or edema. 2+ ___ pulses Pertinent Results: ___ 12:00PM WBC-4.7 RBC-4.58* HGB-14.6 HCT-44.2 MCV-97 MCH-31.8 MCHC-32.9 RDW-13.8 ___ 12:00PM NEUTS-62.6 ___ MONOS-6.2 EOS-4.3* BASOS-0.5 ___ 12:00PM PLT COUNT-184 ___ 12:00PM ___ PTT-28.6 ___ ___ 05:57AM WBC-4.9 RBC-4.55* Hgb-14.2 Hct-43.5 MCV-96 MCH-31.3 MCHC-32.7 RDW-13.6 Plt ___ ___ 12:00PM GLUCOSE-93 UREA N-21* CREAT-0.9 SODIUM-140 ___ 05:57AM Glucose-95 UreaN-17 Creat-0.9 Na-140 K-4.6 Cl-103 ___ 05:57AM Calcium-9.3 Phos-3.2 Mg-2.2 HCO3-28 AnGap-14 ___ 12:00PM cTropnT-<0.01 ___ 06:50PM CK(CPK)-80 CK-MB-3 cTropnT-<0.01 ___ 05:57AM CK(CPK)-81 CK-MB-2 cTropnT-<0.01 ECG ___ 11:05:56 AM Sinus rhythm. Prior inferior myocardial infarction. Compared to the previous tracing of ___ no diagnostic interim change. CHEST (PA & LAT) ___ 2:10 ___ The cardiomediastinal, pleural and pulmonary structures are unremarkable. There is no pleural effusion or pneumothorax. No focal airspace consolidation is seen to suggest pneumonia. Heart size is normal. There are mild degenerative changes of thoracic spine, with anterior osteophytosis. Cardiac catheterization ___ 1. Selective coronary angiography of this left dominant system demonstrated no angiographically apparent, flow-limiting coronary artery disease. The LMCA was normal in appearence. The LAD stents were widely patent with no significant flowing limiting lesions. The dominant LCx had no significant lesions. The RCA was small, non-dominant with no significant luminal narrowing. 2. Limited resting hemodynamics revealed normal left ventricular filling pressures, with an LVEDP of 5mmHg. The was no transvalvular gradient to suggest aortic stenosis. The was normal systemic blood pressure, with a central aortic pressure of 113/72 mmHg. Brief Hospital Course: ___ yo man with history of CAD s/p drug-eluting stenting of proximal and mid LAD in ___, now presenting with right arm discomfort, epigastric pain, fatigue, and shortness of breath with exertion. # Arm discomfort, fatigue, dyspnea: Symptoms were concerning for unstable angina given new onset over past week, though symptoms were predominantly on exertion and resolve with rest. Of note, he does have some epigastric discomfort which is a similar presentation to his prior MI. However, troponins were negative and EKG unchanged. Coronary angiography revealed no flow-limiting lesions and in particular no in-stent restenosis or thrombosis. Unclear what was causing his shortness of breath with right arm discomfort, but small vessel ischemia or diastolic dysfunction could not be excluded; he was already on dual anti-platelet therapy, ACE-I, and a calcium channel blocker. We continued his Plavix (although not clear he needs this ___ years S/P DES). Atorvastatin was begun to avoid drug-drug interactions with simvastatin. He would also benefit from a beta-blocker for post-infarct secondary prevention given prior NSTEMI in ___, but we deferred substitution of his veramapil for a beta-blocker to his outpatient cardiologist. # Hypertension: continued on ACE-I and verapamil # BPH: Continued on alfuzosin # CODE: full # EMERGENCY CONTACT: wife ___ number: ___ Cell phone: ___ Transitions of care: -follow up with outpatient cardiology. Medications on Admission: alfuzosin 10 mg po daily Plavix 75 mg daily cyclobenzaprine 10 mg TID PRN lisinopril 5 mg daily ranitidine 300 mg po daily simvastatin 80 mg po daily verapamil 240 mg ER daily aspirin 325 mg daily MVI Omega 3/vitamin E Discharge Medications: 1. alfuzosin 10 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO daily (). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for muscle spasm. 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a day. 6. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omega 3 Oral 10. vitamin E Oral 11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Chest pain without biomarker evidence of myonecrosis Coronary artery disease with prior myocardial infarction Hypertension Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure participating in your care at ___. You were admitted to the hospital for chest pain. Cardiac catheterization was re-assuring that there was no blockage in your coronary arteries. REGARDING YOUR MEDICATIONS... Medications STARTED that you should continue: atorvastatin Medications STOPPED this admission: simvastatin Medication DOSES CHANGED that you should follow: NONE Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Please followup with your primary care physician ___ ___ days regarding the course of this hospitalization. Followup Instructions: ___

{'Lightheadedness': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Fatigue': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Right shoulder pain': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Shortness of breath': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Epigastric pain': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction'], 'Hollow feeling in right shoulder': ['Coronary atherosclerosis of native coronary artery', 'Old myocardial infarction']}

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: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with DES to LAD History of Present Illness: ___ yoM with PMH of hypercholesterolemia, cluster H/A, tobacco use admitted with NSTEMI. Patient had episode of chest pressure and dyspnea awakening from sleep at 3am. No associated diaphoresis and nausea, no vomiting or other symptoms. Pressure lasted approximately 1 hr, so patient presented to ED. In ED, VS 167/74 46 20 100% on RA. Given SLN x 1, morphine and GI cocktail with resolution of symptoms. Initial EKG with NSR; q waves in II, III, AVF; nonspecific ST changes in precordial leads. First troponin negative, second elevated to 0.50. Patient given ASA 325mg, loaded with 600mg plavix, started on heparin and integrilin drip. Emergent cardiac catheterization with DES to proximal 50% and distal 70% LAD stenosis. On transfer to floor, VS 84 150/90 100%on RA. Patient comfortable, without further chest pain, palpitations, SOB or other complaints. On review of systoms, patient denies history of exertional angina or dyspnea, dizziness, palpitations, PND, orthopnea, peripheral edema. No history of fevers, chills, cough, dark or tarry stool, exertional buttock or calf pain. Of note, patient denies any cardiac history. Exercise stress test earlier this year just notable for elevated BP. Past Medical History: 1.CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. OTHER PAST MEDICAL HISTORY: cluster H/A Brief Hospital Course: ___ yoM with PMH of hypercholesterolemia, tobacco use admitted with NSTEMI s/p catheterization with serial DES to LAD. 1. NSTEMI: Admitted with chest pain that woke patient from sleep at 3:30am and lasted approximately 3 hours. Multiple risk factors for CAD including HTN, hyperlipidemia, current tobacco use and age. EKG with equivocal ST abnormalities in right precordial leads. Second set of troponin/CKMBs positive. Received aspirin, plavix and started on heparin and integrilin drips. Cardiac catheterization found 2 serial LAD lesions ___ and mid) and 3.0mm Promus stents placed (non-overlapping/spot-stenting). Patient had no immediate complications. ECHO showed normal biventricular cavity sizes with preserved global and regional biventricular systolic function. The patient remained chest pain free throughout hospitalization. Patient started on aspirin 325mg daily indefinately, plavix 75mg daily for at least one year. Recommend reduction of risk factors via lifestyle modification and medication management. Importance of smoking cessation was especially stressed. 2. HTN: Patient was continued on his home medications of verapamil SR 240mg and lisinopril 5mg with target BP < 130/80. Although patient would benefit from a B-blocker, he suffers from cluster headaches and has a compelling reason to be on calcium channel blocks. 3. Hyperlipidemia: Fasting lipid panel on admission showed total cholesterol: 140 HDL: 41 LDL: 75. Given NSTEMI, patient was placed on simvastatin 80mg during hospitalization. Discharged on home dose of stain although this should be uptotrated as outpatient to reach goal LDL < 70. Medications on Admission: verapamil SR 240mg daily zocor 10mg daily lisinopril (?) 5mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual see below as needed for chest pain: take 1 every 5 minutes (up to 3 tablets) until pain resolves. Disp:*30 tablets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: NSTEMI Secondary Diagnosis: HTN dyslipidemia Discharge Condition: good: hemodynamically stable, chest pain free Discharge Instructions: You were admitted after an episode of chest discomfort and shortness of breath. These were symptoms of a heart attack, or a non- ST elevated myocardial infarction. You were treated with a cardiac catheterization, where 2 drug eluting stents were used to open blockages in your LAD, an artery in your heart. After this procedure, you will need to take aspirin 325 mg daily indefinately and plavix 75 mg for at least ___ year to prevent a new clot from forming in your stents. You should refrain from strenuous activity and heavy lifting for ___ days. It is also important for you to be compliant with your other medications to reduce your risk of having another heart attack in the future. You blood pressure and lipid levels will be followed closely by your primary care physician. You need to stop smoking. Please make the following changes to your medications: 1. Please take Aspirin 325 mg daily 2. Please take plavix 75 mg daily Please take all of your other medications as previously prescribed. Note: your dose of simvastatin may have to be adjusted by your primary care physician based on your fasting lipid panel. This test is pending at the time of discharge and will be sent to your doctor. If you develop chest pressure, shortness of breath, bleeding, redness or pain at your right groin, new rash, confusion, fever, or any other concerning symptom please call your physician or return to the emergency department. Followup Instructions: ___

{'chest pain': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'dyspnea': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'hypercholesterolemia': ['Pure hypercholesterolemia'], 'tobacco use': ['Tobacco use disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma; stabbing left flank, facial trauma Major Surgical or Invasive Procedure: ___ ORIF of Right mandibular fracture, MMF left mandible ___ ex-lap and control of left intercostal artery bleed History of Present Illness: ___ year old male who was stabbed in the left flank as well as struck the left side of face. Patient went to an outside hospital where he was found to have facial fracture as well as states left-sided jaw pain. Patient denies any nausea or vomiting. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Constitutional: Comfortable HEENT: Laceration underneath chin 1.9cm Blood from left tympanic membrane Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Left flank stab wound GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mood Exam on discharge: VS: 98.6 97.7 57 121/70 18 98RA Gen: NAD, A+Ox3 Neuro; WNL HEENT: PEERL EOMI Neck: WNL Cardiac: RRR No MRG Abd: Soft, NT/ND w/o R/G Wound: C/d/I w/o erythema or induration Pertinent Results: ___ 04:20AM BLOOD WBC-9.4 RBC-3.93* Hgb-12.4* Hct-37.2* MCV-95 MCH-31.6 MCHC-33.3 RDW-12.9 RDWSD-44.6 Plt ___ ___ 04:35AM BLOOD WBC-9.0 RBC-3.80* Hgb-12.0* Hct-36.3* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___ ___ 02:32AM BLOOD WBC-15.1* RBC-4.14* Hgb-13.3* Hct-40.0 MCV-97 MCH-32.1* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt ___ ___ 06:00AM BLOOD WBC-19.1* RBC-5.28 Hgb-17.3 Hct-50.5 MCV-96 MCH-32.8* MCHC-34.3 RDW-13.4 RDWSD-47.0* Plt ___ ___ 04:20AM BLOOD Plt ___ ___ 09:00AM BLOOD ___ PTT-24.3* ___ ___ 04:20AM BLOOD Glucose-120* UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-24 AnGap-17 ___ 04:20AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9 ___ 09:12AM BLOOD Type-ART pO2-455* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 ___ 07:22AM BLOOD Glucose-125* Lactate-2.6* Na-140 K-4.5 Cl-110* ___ 07:22AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-97 ___ 07:22AM BLOOD freeCa-1.04* ___: cat scan of the orbit: 1. No temporal bone fracture. 2. Partially visualized left mandibular fracture, better seen on the dedicated facial bone CT. ___: CTA head: 1. Normal head and neck CTA. 2. No acute intracranial abnormality. 3. Displaced fracture involving the left mandibular condyle and a non-displaced fracture involving the anterior body of the right mandible between the first and second premolar extending posteriorly and superiorly. 4. Soft tissue swelling and laceration involving the chin. ___: CT of the sinus: Comminuted impacted fracture of the left mandibular condyle with involvement of the temporal-mandibular joint with associated small foci of air. Brief Hospital Course: Mr. ___ is a ___ year old male who was admitted to ___ on ___ with a stab wound to the left flank and facial fractures. On ___ he was taken to the operating room with the acute care surgery team for an exploratory laparotomy. ___ was consulted for the right body mandible fracture and left subcondylar mandible fracture. On ___ he was taken to the operating room with OMFS for ORIF right body fracture and closed reduction maxillomandibular fixation. ICU course: Patient was taken to the operating room for an exploratory laparotomy, please see operative note for further details. He was taken to the ICU intubated post-op not on any pressors. He remained hemodynamically stable with stable Hcts. He was extubated on POD0 without issues. OMFS was consulted for his open mandibular fracture. His ICU course by systems is as follows: Neuro: his pain was well controlled with fent and then intermittent dilaudid CV: HD stable Resp: He was extubated on POD0 without issues. GI: He was initially NPO/IVF until his Hcts remained stable Heme: Hcts remained stable. ID: Unasyn was started for an open mandibular fracture He completed 5 days of Ciprodex ear drops. The patient worked with ___ who determined that discharge to ___ was appropriate. The ___ hospital course was otherwise unremarkable, and only significant for disposition and placement due to the fact the patient is homeless. 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 able to ambulate ad lib. The patient will follow up with Dr. ___ at ___ of Dental Medicine, ___, unit ___, ___ for ___, the Acute Care Surgery Clinic on ___, and ___ for outpatient Audiogram on ___ 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. Medications on Admission: none Discharge Medications: 1. OxycoDONE Liquid ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Disp #*100 Milliliter Refills:*0 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 4. Docusate Sodium (Liquid) 100 mg PO BID 5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation 6. Pseudoephedrine 60 mg PO Q6H:PRN congestion 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion 9. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Trauma: Left RP abdominal wall bleeding left mandibular condyle fracture left mandibular fossa fracture left TMJ dislocation Discharge Condition: Mental Status: Clear and coherent( ___ speaking) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you involved in an altercation which resulted in a stabbing injury to the left flank and injuries to the left side of the face. You sustained a fracture to your jaw and an abdominal wall bleed. You were taken to the operating room for an exploratory laparotomy and repair of your jaw. You incisional pain has been controlled with oral analgesia. Your vital signs have been stable and you are preparing for discharge with the following instructions: Followup Instructions: ___

{'Trauma': ['Fracture of subcondylar process of mandible', 'Dislocation of jaw'], 'Stabbing': ['Laceration of intercostal blood vessels', 'Contusion of other intra-abdominal organs'], 'Jaw pain': ['Fracture of subcondylar process of mandible'], 'Facial trauma': ['Fracture of subcondylar process of mandible', 'Dislocation of jaw'], 'Abdominal wall bleed': ['Laceration of intercostal blood vessels', 'Contusion of other intra-abdominal organs']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Assault/EtOH withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: ___ with past medical history of ETOH withdrawal and seizure who presents after an assault early on AM of admission. In the ED, he reported that someone attempted to get money from him for marijuana at which point he was assualted. In the ED, initial VS were 98.0 105 153/77 20 98% RA. Labs notable for clean UA (no bloodwork sent). CT head showed small posterior subgaleal hematoma but no intracranial bleed. CT sinus/mandible showed communited fracture of nasal bone through nasal septum. CT C-spine showed possible avulsion injury of superior endplate of C5, no compression Fx or retropulsion. C-spine flex-ex was normal; CT abdomen-pelvis showed no acute abdominal process. Neurosurgery evaluated the patient and felt no evaluation was necessary. The patient was initially comfortable but became tremulous, tachycardic, and c/o HA, suspicious for EtOH withdrawal. Patient received 5 mg Diazepam CIWA Q2H; this was insufficient, so he was escalated to 20 mg Q1H for a brief period in the ED. This controlled his withdrawal symptoms and he was noted to be drowsy but arousable thereafter. He was switched to Q2H Diazepam and admitted. He also received thiamine, folate, Ibuprofen, and Zofran. VS on transfer were 85 113/76 19 97%. On arrival to the floor, patient reports that he has a bad headache and feels shaky. His last drink was early this AM (before 6 AM). He drank particularly heavily overnight, reporting ___ beers and "lots" of whisky shots. He normally drinks one 6-pack of beers and several shots every day or every other day. Past Medical History: ETOH ABUSE ETOH WITHDRAWAL COMPLICATED BY SURGERY GERD Social History: ___ Family History: Reports that all his family is deceased, denies significant medical history. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.5 88 18 143/84 96 RA General: Mildly uncomfortable, but non-toxic appearing, well-nourished HEENT: Contusions over glabella, ecchymosis over left eyelid. PERRLA, EOMI. Oropharynx clear. Poor dentition Neck: Soft supple, full ROM. No TTP of cervical vertebrae CV: RRR. S1 and S2. No m/r/g Lungs: No increased WOB. CTAB Abdomen: + BS. Soft, non-distended. Mild TTP of RUQ. Negative ___ sign. No peritoneal signs. GU: Deferred Ext: Warm, well-perfused without cyanosis, clubbing or edema Neuro: Cn2-12 grossly intact, AAOx3, moves all extremities to commands Skin: Contusions as per HEENT DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ___ 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:55AM URINE COLOR-Straw APPEAR-Clear SP ___ PERTINENT LABS: DISCHARGE LABS: IMAGING: ___ NON-CON HEAD CT:IMPRESSION: Small posterior subgaleal hematoma. No fracture. Otherwise normal head CT. No intracranial hemorrhage. ___ CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST IMPRESSION: Deformity of the nasal bone and anterior septum due to fracture of undetermined age. No additional fracture. No soft tissue hematoma. ___ CT C-SPINE W/O CONTRAST IMPRESSION: Bony oaaicle near superior endplate of C5 indicating avulsion injury of undetermined age. No compression fracture. No retropulsion. ___ C-SPINE FLEX AND EXT ONLY 2 VIEWS IMPRESSION: Preliminary Report1. 3 mm ossific fragment inferior to C4 vertebral body, better assessed on CT Preliminary Report2 hr prior. Preliminary Report2. No abnormal vertebral movement on flexion and extension views. Preliminary Report3. For details on C7 and the dens please refer to CT cervical spine. ___ CT ABD & PELVIS W/O CON IMPRESSION: 1. Hepatic steatosis. 2. No acute lower thoracic or lumbar vertebral fracture. 3. Largely distended, normal-appearing bladder. 4. No acute intra-abdominal pathology. No free fluid. Brief Hospital Course: ___ with history of EtOH abuse, ETOH withdrawal with seizures who presents after an assault for management of EtOH withdrawal. ___- transferred to the ICU for persistent symptoms despite q2H diazepam on CIWA. He is almost 48hrs after last drink which is usual window to experience withdrawal, and given chronic use and hx he is at high risk for withdrawal seizure. Slurring words likely from benzo intoxication on floor. RR 12 as of ___. -d/c CIWA, IV phenobarb protocol started -Check phenobarb level #EtOH Abuse: Patient with history of ETOH withdrawal and seizures. Patient spaced to Q2H diazepam in ED. Reports he started drinking after his mother died in ___, and expresses interest in quitting. - Start 100 mg thiamine, 1 mg folic acid daily, multivitamin - Social work consult #trauma S/p assault: Imaging in ED revealed a subgaleal hematoma but no intracranial bleed, communited fracture of nasal bone through nasal septum, and possible avulsion injury of superior endplate of C5. was evaluated by neurosurgery who recommend no further intervention. ENT recommends outpatient follow up for nasal fracture Neurosurgery consulted, do not recommend further intervention. - Pain control with acetaminophen/ibuprofen - Per ENT, can follow up as outpatient in clinic for nasal fracture ___ - Per neurosurgery, no need for followup or repeat imaging #Isolated elevated PTT (59.1). INR 1.0. Unclear etiology - needs confirmation. - Recheck labs - If sustained consider putting on Pneumoboots prophylaxis #RUQ tenderness: Most likely ___ trauma from altercation. CT abd/pelvis without acute pathology. LFTs mildly elevated consistent with acute alcohol use. -CTM, pain control per below #GERD: continue home omeprazole TRANSITIONAL ISSUE: ====================== - F/u ENT as outpatient Medications on Admission: OMEPRAZOLE 20 MG DAILY Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Broken nose (nasal spetum fracture) Alcohol abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted to the ICU for alcohol withdrawal. You were treated with medications to prevent like-threatening complications of alcohol withdrawal. We recommended you stay in the hospital longer for close monitoring and evaluation by social work for help with your alcohol abuse. You understood the risks of leaving the hospital at this time were severe, and included seizure, injury, and DEATH. You expressed an understanding in this, and decided to leave AGAINST MEDICAL ADVICE. Please return to the hospital if you experience seizures or other medical complications (SEE BELOW). Followup Instructions: ___

{'Assault': ['Unarmed fight or brawl'], 'EtOH withdrawal': ['Alcohol withdrawal'], 'Seizures': ['Other convulsions'], 'Heavy drinking': ['Acute alcoholic intoxication in alcoholism', 'continuous'], 'Nasal fracture': ['Closed fracture of nasal bones'], 'Headache': [], 'Tremulous': [], 'Tachycardic': [], 'HA': [], 'Thiamine': [], 'Folate': [], 'Ibuprofen': [], 'Zofran': [], 'Diazepam': [], 'CT head': ['Small posterior subgaleal hematoma', 'No intracranial bleed'], 'CT sinus/mandible': ['Deformity of the nasal bone and anterior septum due to fracture of undetermined age'], 'CT C-spine': ['Bony oaaicle near superior endplate of C5 indicating avulsion injury of undetermined age'], 'CT abdomen-pelvis': ['Hepatic steatosis', 'No acute lower thoracic or lumbar vertebral fracture', 'Largely distended, normal-appearing bladder', 'No acute intra-abdominal pathology', 'No free fluid'], 'Neurosurgery': [], 'ENT': [], 'RUQ tenderness': [], 'Elevated PTT': [], 'INR': [], 'GERD': ['Esophageal reflux'], 'Tobacco use disorder': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ R hemi-colectomy History of Present Illness: HPI: ___ with reported history of redundant colon and conservatively-managed sigmoid volvulus presents with acute onset abdominal pain and nausea. Ms ___ awoke at 0200 this morning with sharp low abdominal pain that came in waves. She developed nausea and chills and had one episode of non-bloody diarrhea. She presented to the ___ ED where she proceeded to have an episode of nonbloody, nonbilious emesis. CT A/P revealed cecal volvulus, for which a surgical consult is requested. Upon interviewing Ms ___, she reports her pain to now be constant and located in the RLQ. She endorses nausea but denies any further emesis. She additionally denies fevers, hematemesis, hematochezia. She has not passed flatus since the onset of her pain. Past Medical History: Past Medical History: 1. Reports hx of sigmoid volvulus treated conservatively with bowel rest/NGT. 2. Hx chronic abdominal discomfort followed by ___ gastroenterologist. Pt reports numerous tests performed without definite etiology. 3. Depression 4. Essential tremor 5. Hx b/l varicose veins Social History: ___ Family History: NC Physical Exam: Physical Exam: upon admission ___: Vitals: T 97.7, Hr 85, BP 166/83, RR 18, O2Sat 100% RA GEN: Thin woman in NAD. Alert and oriented. HEENT: No scleral icterus. Mucus membranes dry. CV: RRR PULM: Clear to auscultation b/l ABD: Soft, minimally distended. Tender RLQ and infraumbilical area. Prominence over LUQ which is nontender. No R/G. Ext: Warm without edema. Pertinent Results: ___ 05:30AM BLOOD WBC-7.0 RBC-3.92* Hgb-11.2* Hct-34.6* MCV-88 MCH-28.5 MCHC-32.3 RDW-13.6 Plt ___ ___ 05:25AM BLOOD WBC-8.3 RBC-4.59 Hgb-12.7 Hct-40.3 MCV-88 MCH-27.6 MCHC-31.5 RDW-13.3 Plt ___ ___ 05:25AM BLOOD Neuts-86.0* Lymphs-10.9* Monos-2.4 Eos-0.3 Baso-0.4 ___ 05:30AM BLOOD Plt ___ ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD Glucose-113* UreaN-6 Creat-0.8 Na-140 K-3.6 Cl-103 HCO3-30 AnGap-11 ___ 06:30AM BLOOD Glucose-121* UreaN-6 Creat-0.7 Na-139 K-3.7 Cl-101 HCO3-32 AnGap-10 ___ 05:25AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 ___ 06:30AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.8 EKG: ___: Sinus rhythm. Left bundle-branch block. Non-specific septal T wave changes. No previous tracing available for comparison. Tracing #1 EKG: ___: Sinus rhythm. Left bundle-branch block. Compared to tracing #1 no change. TRACING #2 ___: cat scan of abdomen and pelvis: IMPRESSION: 1. Cecal volvulus with closed loop obstruction. 2. Multiple hypodensities within the liver, the largest of which are compatible with cysts. Others are too small to characterize but are statistically likely to represent cysts. ___: x-ray of the abdomen: IMPRESSION: Ileus or early obstruction. Followup is recommended. Brief Hospital Course: ___ year old female admitted to the acute care service with abdominal pain and nausea. Upon admission, she was made NPO, given intravenous fluids, and underwent a cat scan of the abdomen which showed a cecal volvulus. She was placed on intravenous antibiotics. On HD #1, she was taken to the operating room where she underwent a right colectomy with primary anastomosis. Her operative course was stable with minimal blood loss. She was extubated after the procedure and monitored in the recovery room. Her post-operative course has been stable. Her surgical pain was controlled with intravenous analgesia. She was started on sips on POD # 1 and her pain regimen was converted to oral analgesia. Her bowel function was slow to return and she underwent an x-ray of the abdomen which showed a ileus vs obstruction. She was given a dose of methynaltrexone. On POD #5, she began passing flatus and her diet was advanced. She resumed her home meds. Her vital signs are stable and she is afebile. She is tolerating a regular diet. Her white blood cell count is 7.0 with a hematocrit of 35. She has been ambulating. She is preparing for discharge home with follow-up in the acute care clinic for staple removal. She has also been advised to follow up with her primary care physician to further evaluate the finding of left bundle ___ block on recent EKG. Medications on Admission: ___: Citalopram 10; Clonazepam 0.5 HS Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: may cause drowsiness, avoid driving while on this medication. Disp:*30 Tablet(s)* Refills:*0* 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: sigmoid volvulus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hosptial with abdominal pain. You had a cat scan of your abdomen done which showed a twising of the colon. This can lead to a bowel obstruction. You were taken to the operating room where you had a segment of your colon removed. You have made a nice recovery and you are ready for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 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. 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. You will need to follow-up in the acute care clinic for removal of your staples. Followup Instructions: ___

{'abdominal pain': ['Volvulus'], 'nausea': ['Volvulus'], 'chills': ['Volvulus'], 'diarrhea': ['Volvulus'], 'constipation': ['Paralytic ileus'], 'tremor': ['Essential and other specified forms of tremor'], 'depression': ['Depressive disorder'], 'left bundle branch block': ['Other left bundle branch block']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old gentleman with ahistory of diverticulosis seen on prior colonoscopies whopresents with 3 weeks of low abdominal pain and profusenon-bloody diarrhea. He saw his PCP who dismissed his symptoms. He and his wife were en route to ___ and had a layover in ___ when his diarrhea and abdominal pain became worse. They ended up staying the night in a hotel in ___ where he spent the entire night in the bathroom having severe abdominal pain, profuse diarrhea, and diaphoresis. The next morning, he caught the first flight back to ___ and came directly to the ___ ED. His most recent colonoscopy was in ___. He was told he had diverticuli and some polyps were biopsied. Past Medical History: diverticulitis, BPH, OA, GERD, colonic adenomas, HPL Social History: ___ Family History: NC Physical Exam: EXAM: upon admission: ___ VS - 97.7 73 143/92 18 99% RA GEN - NAD, awake/alert, cooperative & pleasant HEENT - NCAT, EOMI, dry mucous membranes, no scleral icterus ___ - RRR PULM - CTAB ABD - soft, nondistended, mild suprapubic tenderness to palpation without evidence of rebound or guarding EXTREM - warm, well-perfused; no peripheral edema Physical examination upon discharge: ___: vital signs: t=97.7, hr=59, bp=116/61, rr=18, 98% room air CV: ns1, s2, -s3, -s4 LUNGS: diminished bases bil ABDOMEN: soft, hypoactive BS, mild tenderness left lower quadrant, no rebound EXT: no calf tenderness bil., no pedal edema bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 06:06PM BLOOD WBC-5.8 RBC-4.36* Hgb-14.0 Hct-41.5 MCV-95 MCH-32.1* MCHC-33.7 RDW-15.5 Plt ___ ___ 12:41PM BLOOD WBC-6.5 RBC-4.35* Hgb-13.9* Hct-40.6 MCV-93 MCH-32.1* MCHC-34.3 RDW-15.3 Plt ___ ___ 12:41PM BLOOD Neuts-56.5 ___ Monos-5.7 Eos-5.0* Baso-0.6 ___ 09:00AM BLOOD Plt ___ ___ 09:00AM BLOOD Glucose-85 UreaN-13 Creat-1.4* Na-140 K-4.1 Cl-104 HCO3-26 AnGap-14 ___ 06:06PM BLOOD Glucose-81 UreaN-12 Creat-1.4* Na-139 K-3.9 Cl-101 HCO3-26 AnGap-16 ___ 12:41PM BLOOD Glucose-96 UreaN-16 Creat-1.4* Na-137 K-4.3 Cl-100 HCO3-27 AnGap-14 ___ 12:41PM BLOOD ALT-33 AST-35 AlkPhos-54 TotBili-0.7 ___ 09:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2 ___: cat scan of abdomen and pelvis: Small amount of ascites in the lower pelvis which is abnormal but not specific. Given clinical concern for diverticulitis the possibility could be considered when it is noted that the fluid resides near as diverticula at the rectosigmoid junction. 2. Fatty infiltration of the liver. 3. Findings consistent with mesenteric panniculitis. 4. Moderate atherosclerotic change, including mild aortic ectasia. Follow-up ultrasound is suggested to reassess in one year. /___ 9:12 am 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). Brief Hospital Course: The patient was admitted to the hospital with a 3 week course of abdominal pain. Upon admission, he was made NPO, given intravenous fluids, and underwent imaging. Cat scan imaging showed moderate to severe sigmoid diverticulosis. The patient was placed on bowel rest and placed on intravenous ciprofloxacin and flagyl. He resumed a clear liquid diet on HD #3, but reported increased burning sensation in his abdomen. He was again placed on bowel rest with resolution of his abdominal pain. He resumed clear liquids on HD #4, and advanced to a regular diet. His white blood cell count remained normal, along with a negative c.diff. The patient was ambulating without difficulty. On HD #6, the patient was discharged home in stable condition. He was instructed to complete a 10 day course of ciprofloxacin and flagyl. His vital signs upon discharge were stable and he was afebrile. He was voiding without difficulty and moving his bowels. Follow-up appointments were made with the acute care service and with his primary care provider. Moderate atherosclerotic change, including mild aortic ectasia were reported on the abdominal cat scan. Follow-up ultrasound was suggested to reassess in one year. Both the patient and his wife were informed of these findings and a copy of the cat scan report was provided. Medications on Admission: doxazosin (unknown dose), gemfibrozil 600', omeprazole 20', flonase 50 prn Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H last dose ___ RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 2. Doxazosin 2 mg PO HS 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H last dose ___ RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*18 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: sigmoid diverticulosis 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 diarrhea. You underwent a cat scan of the abdomen which showed diverticulosis. You were placed on bowel rest. Your abdominal pain has resolved and you are preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 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. Followup Instructions: ___

{'abdominal pain': ['Diverticulitis of colon (without mention of hemorrhage)'], 'diarrhea': ['Diverticulitis of colon (without mention of hemorrhage)'], 'suprapubic tenderness': ['Diverticulitis of colon (without mention of hemorrhage)'], 'diminished bases bil': ['Abdominal aortic ectasia'], 'mild tenderness left lower quadrant': ['Diverticulitis of colon (without mention of hemorrhage)'], 'hypoactive BS': ['Diverticulitis of colon (without mention of hemorrhage)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending: ___. Chief Complaint: Hypoxia & GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o M with PMHx of Dementia, CAD s/p PCI, COPD and recent ARDS s/p appendectomy who was at ___ prior to recent admission for GI bleed. Pt was discharged on ___ and was found this morning to have black guaic positive stools and increased work of breathing. . In the ED, initial vs were: T 100.3 P ___ BP 102/48 R 30 O2 sat of 100% on NRB. Pt triggered on arrival with diaphoresis and tachypnea. He was noted to black guaic + stool and concentrated urine. He was weaned from NRB and had a Tmax of 102 in the ED. CXR showed worsening in bilateral infiltrates and he was given Zosyn, Levofloxacin, Protonix and 1L IVF for possible PNA. PIV was placed and blood was typed/crossed for GI bleed. . On arrival to the ICU, pt was oriented to person only and c/o feeling tired and thirsty. Pt has mild shortness of breath but denies cough, congestion or significant increased work of breathing. He denies abd pain, nausea, vomiting, diarrhea, bloody stools, changes in vision or sore throat but does report decreased appetite. Past Medical History: Severe Dementia Depression CAD s/p MI in ___ c/b VF with stenting of the L circ, PCI to R PDA with DES in ___ COPD Recent ARDS s/p appendectomy Type II DM Hypertension Spinal Stenosis Hyperlipidemia CDiff Zoster on rectal area . Surgical History s/p CCY s/p hernia repair s/p appendectomy Social History: ___ Family History: His father died of a myocardial infarction at ___. His mother died of a myocardial infarction at 74. His three brothers, who died one of a motor vehicle accident and one of leukemia. Physical Exam: T 97 HR 95 BP 98/41 RR 29 Sats 95% on 6LNC General: NAD, comfortable, breathing comfortably with NC O2 HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: no pre-cervical lymphadenopathy Lungs: Bilateral inspiratory rales, no rhonchi, no congestive cough CV: Irreg, mildly tachy, intermittent S4. PMI non-displaced Abdomen: soft, NT/ND, NABS, no rebound or guarding Ext: cool hands, warm feet, good distal pulses Pertinent Results: ___ 01:55AM BLOOD WBC-11.2* RBC-3.29* Hgb-10.4* Hct-31.2* MCV-95 MCH-31.8 MCHC-33.4 RDW-17.2* Plt ___ ___ 07:15PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.8* Hct-33.0* MCV-95 MCH-30.9 MCHC-32.7 RDW-17.5* Plt ___ ___ 01:55AM BLOOD ___ PTT-28.8 ___ ___ 07:15PM BLOOD ___ PTT-28.8 ___ ___ 07:15PM BLOOD Glucose-166* UreaN-6 Creat-0.6 Na-133 K-3.7 Cl-93* HCO3-31 AnGap-13 ___ 01:55AM BLOOD Glucose-168* UreaN-6 Creat-0.6 Na-135 K-3.3 Cl-97 HCO3-32 AnGap-9 ___ 01:55AM BLOOD CK(CPK)-31* ___ 01:55AM BLOOD CK-MB-NotDone cTropnT-<0.01 ___ 07:15PM BLOOD Albumin-2.6___ 01:55AM BLOOD Calcium-7.5* Phos-1.3* Mg-1.7 ___ 10:50PM BLOOD Type-ART Temp-37.2 pO2-66* pCO2-45 pH-7.48* calTCO2-34* Base XS-8 ___ 07:16PM BLOOD Lactate-2.4* . CXR ___: FINDINGS: AP upright portable chest radiograph is obtained. As compared with the prior radiograph, there has been no significant change. Motion artifact somewhat limits evaluation. Bilateral extensive parenchymal opacities are again noted, consistent with the provided history of ARDS. There has been no significant interval change. Small bilateral pleural effusions cannot be excluded. Heart size is difficult to assess. No large pneumothorax is present. Bony structures appear intact. Brief Hospital Course: # Hypoxic Resp Distress: Pt with poor substrate given recent ARDS who p/w fever, increased O2 requirement and worsening in bilateral infiltrates concerning for PNA. Appeared clinically euvolemic to dry and large A-a gradient on ABG. There was no evidence of COPD exacerbation or acute CO2 retention. Oxygenation remained poor despite broad spectrum antibiotics, patient was unable to be weaned off O2, he remained on 6 L plus facemask. After discussion with HCP and patient on ___, decision was made to transition patient to CMO. IV antibiotics were continued at the family's request because they wanted to have some more time to spend with him. Patient passed away on ___. . # GI bleed: Pt presented with guaiac positive black stools, but had stable hematocrit at his baseline. He likely has a slow upper GI bleed. After patient was made CMO, morphine was used to treat abdominal pain. Medications on Admission: Sitagliptin 50mg daily Vancomycin 250mg po BID Ipratropium neb q6hrs Senna prn Clotrimazole TP Lasix 20mg IV Insulin SS Lactobacillus BID Levalbuterol neb q6hrs Omeprazole 40mg BID Sertraline 50mg daily Simvastatin 40mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: ___

{'Hypoxia': ['Pneumonia', 'Acute respiratory failure', 'Hypoxemia'], 'GI bleed': ['Blood in stool'], 'feeling tired': [], 'thirsty': [], 'mild shortness of breath': ['Pneumonia', 'Acute respiratory failure'], 'decreased appetite': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: vancomycin / Thorazine / contact metal agent Attending: ___. Chief Complaint: Inguinal hernia Major Surgical or Invasive Procedure: ___: right-sided inguinal hernia repair History of Present Illness: Per resident: ___ active IVDA, ETOH abuse with Hep C, on methadone program who presented to the clinic with Rt inguinal hernia. the patient niticed the hernia ___ m ago and had a few ER visit for symoptomatic hernia , it was never incarcerated and was not operated on. Denies trauma, or heavy lifting. He also denies fevers, chills, nausea, of decreased PO intake. Pt requesting the hernia to be repaired. Past Medical History: HCV, Bipolar disorder Active IVDU heroin sometimes sniffs ETOH active drinker came to the clinic s/p car accident with Lt tibial Fx and shoulder injuries on ___ for which he had surgery and plating in both sites Per patient (probably at ___) Past Surgical History: Incision, drainage, and packing of left forearm abscess. ___ Lt tibial and Rt shoulder Fixation ___ ___ Social History: ___ Family History: NC Physical Exam: VS:T99.3 P45 (pt states baseline ___ BP 166/82 RR 18 02 100%RA General: no acute distress, alert and oriented x 3 Cardiac: regular rhythm, bradycardia, NL S1,S2 Resp: clear to auscultation, bilaterally Abdomen: soft, non-tender, non-distended, no rebound tenderness/guarding Wounds: abdominal lap sites with primary dgs, slight serosanguinous staining x 1; no periwound erythema or ecchymosis Ext: no lower extremity edema or tenderness Pertinent Results: LABS: ___ 05:00AM BLOOD Hct-37.2* ___ 04:39PM BLOOD Hct-36.5* Brief Hospital Course: The patient presented to pre-op on ___ . Pt was evaluated by anaesthesia and was taken to the operating room where he underwent a laparoscopic right inguinal hernia repair. 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. Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with the patient's home methadone dose and prn oxycodone. He was transitioned to oral oxycodone-acetaminophen upon discharge. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. He was noted to have bradycardia during the hospitalization, which was asymptomatic and the baseline heart rate, per patient. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient tolerated a Regular diet post-operatively; intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a 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 may be inaccurate and requires futher investigation. 1. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain - Mild RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q 4 hours Disp #*40 Tablet Refills:*0 3. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO AS DIRECTED BY PRESCRIBING PROVIDER ___: Home Discharge Diagnosis: Right-sided inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You have undergone repair of your right sided inguinal hernia, recovered in the hospital and are now preparing for discharge with the following 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, operating heavy machinery or consuming alcohol 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. Followup Instructions: ___

{'Inguinal hernia': ['Unilateral inguinal hernia'], 'Hep C': ['Unspecified viral hepatitis C without hepatic coma'], 'IVDA': ['Opioid abuse'], 'ETOH abuse': ['Alcohol abuse'], 'Bipolar disorder': [], 'Lt tibial Fx': [], 'Rt shoulder injuries': [], 'Bradycardia': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: vancomycin / Thorazine / contact metal agent Attending: ___. Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ undomiciled man with a history of hepatitis C, opioid use disorder, alcohol abuse who presented to the ED with 1 day history of hematemesis. The patient reports one episode 2 days prior of a couple tablespoons of blood which then occurred again morning of admission. He denies any blood in his stool or melena. He denies any chest or abdominal pain. He denies any shortness of breath. He also reports some bilateral leg swelling without pain, warmth, fevers which has been present for several weeks for which another hospital prescribed him Bactrim. In the ED, initial vitals were: 9 98.9 81 129/100 18 98% RA. Exam was notable for brown stool, guaiac negative, lower extremities with 2+ pitting edema and excoriations. Minimal erythema, no warmth. EKG SR, NA, NI, new TWI V4-V6. Labs without significant anemia and overall stable. While there were no red flags in the ED, with stable VS, labs and no hematemesis in the ED given pulmonary vascular congestion on CXR, EKG changes compared with prior and no documented history of CHF, he was admitted for further workup. On the floor, he was initially ornery and requesting to leave AMA because he needed to use. He arrived in dirty urine and stool covered clothing and he was cleaned up. He reports feeling unwell, "like my body is deteriorating" Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Otherwise ROS is negative. Past Medical History: HCV Bipolar disorder Opioid Use Disorder with active IV heroin use (last used a few hours prior to admission) sometimes sniffs ETOH active Surgical history: Incision, drainage, and packing of left forearm abscess. ___ Lt tibial and Rt shoulder Fixation BWH ___ Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 PO 158 / 84 70 20 98 Ra Pain Scale: ___ General: Patient appears dishelved, unkempt and foul smelling. Alert, oriented and in no acute distress HEENT: Sclera anicteric, poor dentition Neck: supple, JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated Abdomen: soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Bilateral ___ pitting up to knees Neuro: CN2-12 grossly in tact, motor and sensory function grossly intact in bilateral UE and ___, symmetric. Nodding off during exam DISCHARGE PHYSICAL EXAM General: Alert, oriented and in no acute distress HEENT: Sclera anicteric, poor dentition Neck: supple, JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated Abdomen: soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Bilateral ___ pitting up to knees R > L. Minimal / resolving erythema RLE, several scabbed over excoriations Neuro: CN2-12 grossly intact, motor and sensory function grossly intact in bilateral UE and ___, symmetric. Pertinent Results: Admission Labs: ___ 11:55PM BLOOD WBC-6.0 RBC-3.38* Hgb-11.4* Hct-33.8* MCV-100* MCH-33.7* MCHC-33.7 RDW-14.8 RDWSD-54.7* Plt ___ ___ 11:55PM BLOOD Neuts-45.6 ___ Monos-12.7 Eos-1.7 Baso-0.8 Im ___ AbsNeut-2.73# AbsLymp-2.33 AbsMono-0.76 AbsEos-0.10 AbsBaso-0.05 ___ 11:55PM BLOOD ___ PTT-33.9 ___ ___ 11:55PM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-135 K-3.5 Cl-96 HCO3-26 AnGap-17 ___ 11:55PM BLOOD Lipase-28 ___ 11:55PM BLOOD Albumin-3.6 ___ 11:55PM BLOOD proBNP-140* Imaging: ___ CHEST X-RAY: Low lung volumes, mild cardiomegaly, and central pulmonary vascular congestion. Right apical airspace opacity appears modestly more conspicuous as compared to the prior examination, and could be further evaluated by apical lordotic views if clinically indicated. ___ CHEST X-RAY FINDINGS: The previously described opacity at the right lung apex appears less conspicuous on apical lordotic views. Some of the abnormality is due to deformity of the right clavicular head, and there may be additional bony deformity of the adjacent manubrium. IMPRESSION: No good evidence for clinically significant pulmonary or pleural abnormality at the right apex. Brief Hospital Course: ___ undomiciled man with a history of hepatitis C, opioid use disorder, alcohol abuse who presented to the ED with 1 day history of hematemesis, one week history of R > L bilateral lower extremity edema, rib pain after sustaining rib fractures in assault, and hemoptysis. # Hematemesis vs Hemoptysis Patient did not give a clear history - he reported vomiting up blood, but while inpatient, RN observed hemoptysis. He reports a history of rib fractures secondary to assault. He denies fevers, chills, weight loss, night sweats. Because he also had concomitant R > L lower extremity edema, pulmonary embolism is possible. Pulmonary infection, trauma, malignancy are also possibilities. I discussed this with the patient and ordered lower extremity ultrasound and CTA to evaluate further the source of bleeding. He left the hospital against medical advice before this could be obtained. # Bilateral lower extremity edema, R > L Unclear etiology as well, while there is pulmonary vascular congestion on admission CXR his proBNP is normal and he has no symptoms of CHF. Apparently had recent diagnosis of cellulitis and started treatment with antibiotics prescribed at ___. Patient reports negative LENIs. Severe onycomycosis and excoriations from scratching on bilateral lower extremities predisposing to cellulitis. As above, ordered LENIs, but patient left against medical advice before this could be obtained. # Opioid Use Disorder Unable to confirm methadone dose with Addiction ___ ___ (___) before he left against medical advice. He indicates 73mg Po Daily. Patient reports ongoing daily heroin use, occasionally snorting heroin, despite being enrolled in methadone program. Social work was consulted but was unable to see him before he left against medical advice I had a frank discussion with the patient regarding his ongoing drug abuse - he stated he was interested in drug rehabilitation, and agreed to stay for further workup as outlined above. Shortly after our discussion, he told his nurse he was leaving against medical advice, and he walked out of the hospital before I could re-assess him and have a discussion of risks Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methadone 73 mg PO DAILY (unable to verify with Addiction Treatment ___ - ___, where he reportedly obtains methadone) Discharge Medications: 1. Methadone 73 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: OPIOD USE DISORDER Discharge Condition: LEFT AGAINST MEDICAL ADVICE Discharge Instructions: LEFT AGAINST MEDICAL ADVICE Followup Instructions: ___

{'hematemesis': ['Hematemesis'], 'opioid use disorder': ['Opioid dependence', 'uncomplicated'], 'alcohol abuse': ['Alcohol abuse', 'uncomplicated'], 'homelessness': ['Homelessness'], 'soft tissue disorders': ['Other specified soft tissue disorders'], 'nicotine dependence': ['Nicotine dependence', 'cigarettes', 'uncomplicated']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain, small bowel obstruction Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ year old male with history of Crohn's disease s/p ileocectomy w/ ileostomy and subsequent reversal who has had multiple episodes (>10) of small bowel obstruction who presents with 1 day of crampy abdominal pain consistent w/ previous episodes of SBO. He states he was at a ___ game when he first began to feel the crampy abdominal pain, which worsened by early morning so he came to the ED. He reports he was dehydrated and eating peanuts at the time, but otherwise, leafy green vegetables can sometimes bring out an episode of SBO. They have all been managed conservatively in the past, and an NG tube was used only once. He currently reports improved pain, no fever, chills, chest pain, shortness of breath, headache, dizziness, blood per rectum or dysuria. He last passed gas and had a small BM yesterday evening, but reports none since. Past Medical History: Past Medical History: - Crohn's disease - Hypertension - Obstructive sleep apnea - Gout - Hyperlipidemia ________________________________________________________________ Past Surgical History: - Appendiceal abscess s/p ileocectomy, ileostomy placement (___) - Ileostomy reversal (___) - Repair of abdominal wall diastasis/weakness (___) ________________________________________________________________ Social History: ___ Family History: No family history of inflammatory bowel disease or colon cancer. Physical Exam: ON ADMISSION Vitals: Afebrile, vital signs stable GEN: Alert and oriented, no acute distress, conversant and interactive. HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is clear. NECK: Trachea is midline, thyroid unremarkable, no palpable cervical lymphadenopathy, no visible JVD. CV: Regular rate and rhythm, no audible murmurs. PULM/CHEST: Clear to auscultation bilaterally, respirations are unlabored on room air. ABD: Soft, non distended, mildly tender to palpation diffusely in lower quadrants. No guarding or rebound tenderness. Ext: No lower extremity edema, distal extremities feel warm and appear well-perfused. ON DISCHARGE: VS: T 97.7, HR 58, BP 138/72, RR 18, SaO2 98% RA GEN: No acute distress, alert and cooperative CV: RRR PULM: Easy work of breathing ABD: Soft, nontender, nondistended EXT: Warm, well perfused. Pertinent Results: ___ 03:00AM BLOOD WBC-8.6 RBC-5.00 Hgb-15.4 Hct-45.1 MCV-90 MCH-30.8 MCHC-34.1 RDW-12.3 RDWSD-40.5 Plt ___ ___ 03:00AM BLOOD Neuts-80.2* Lymphs-11.9* Monos-7.3 Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.92* AbsLymp-1.03* AbsMono-0.63 AbsEos-0.01* AbsBaso-0.03 ___ 05:30AM BLOOD Glucose-117* UreaN-8 Creat-0.9 Na-136 K-3.8 Cl-103 HCO3-25 AnGap-12 ___ 03:00AM BLOOD Glucose-126* UreaN-15 Creat-1.0 Na-135 K-4.0 Cl-98 HCO3-25 AnGap-16 ___ 05:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.8 ___ KUB: IMPRESSION: Nonspecific bowel gas pattern with paucity of small bowel gas, though no specific plain radiographic evidence for obstruction. If SBO remains of clinical concern, followup imaging should be considered. ___ CT A/P: IMPRESSION: Mild distention of mid jejunum up to 3 cm with slight surrounding free fluid and two proximal and distal transition points. This could be seen in setting of partial or early small bowel obstruction or possibly enteritis, and is not suggestive of a high-grade obstruction. Brief Hospital Course: Mr. ___ is a ___ year old gentleman with long history of previous small bowel obstructions after ileocectomy, ileostomy, and then reversal. He presented with 1 day of abdominal pain associated with nausea and minimal bowel function. CT findings on arrival to ___ were consistent with small bowel obstruction. He was admitted to ___ ___ monitoring and IV fluids. Overnight, he reports he began to pass flatus and had several bowel movements. His diet was advanced, and he reports his abdominal pain had resolved. He was deemed ready for discharge. He expressed understanding of the plan. We recommended that he follow-up with his gastroenterologist or surgeon if his symptoms are becoming more frequent as this may indicate need for intervention. Medications on Admission: - Sulfasalazine - Atorvastatin - Benicar - Allopurinol - Vitamin B12 - Folic acid - Probiotic - Imodium Discharge Medications: Please resume your medications at home at their usual doses. There are no changes or additions to your medications at home. Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ after experiencing small bowel obstruction associated with abdominal pain and some nausea for 1 day. Overnight, you began passing flatus and having bowel movements, suggesting that your obstruction is not relieved. You have now also tolerated a diet without abdominal pain and are ready to be discharged. Please continue to stay hydrated and monitor your diet. Return to the ED if you have fever, chills, worsening abdominal pain, or are not having bowel movements or passing flatus for several days. Given your history of previous small bowel obstructions, you should continue to follow-up closely with your gastroenterologist as well as surgeon. You may need a surgical repair of the anastomosis where there appears to be a stricture if your small bowel obstructions are becoming more frequent. Thank you for allowing us to participate in your care Followup Instructions: ___

{'Abdominal pain': ['Regional enteritis of unspecified site'], 'Crampy abdominal pain': ['Regional enteritis of unspecified site'], 'Nausea': ['Regional enteritis of unspecified site'], 'Dehydration': ['Regional enteritis of unspecified site'], 'Small bowel obstruction': ['Regional enteritis of unspecified site']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Encephalopathy Traumatic Injury Major Surgical or Invasive Procedure: None History of Present Illness: Unable to obtain history from patient. Predominantly obtained from ___ at ___ Facility and sister ___ . . This is a ___ male with history of EtOH abuse, seizure disorder, and and serious traumatic brain injury with memory deficit who presents after being found altered at the ___. . Per ___ (who found the patient) the patient is normally communicative at baseline. On the eve of ___ however, the patient was not answering the door in his room. The visiting nurse came came in and found the patient altered and vomiting. There was a heavy odor of EtOH in the room. The nurse took the vitals which were okay. They assumed the patient was drunk and left the patient alone. A few hours later the patient was checked on and was seemingly more altered. At that point bruises were noted on the patients back and sides. He vomited again. EMS was called and the patient was brought to ___. . Upon presentation to the emergency department, initial vitals were: T 99.2, HR 76, BP 136/78, RR 16, SaO2 97% 4L NC. Given inability to give history, a trauma scan was done with CT head, neck and torso. The CT head or spine prelim no acute process. CTA chest and CTAP showed no pulmonary embolism, a foci of tree-in ___ in the LLL could be aspiration and fatty liver. CXR with fractures but otherwise clear. He was observed to have marks over lower extremeties. He only answered "yes" to all questions. Urine and blood toxicity were negative. Labs returned with a lactate of 3.1, WBC 7.1. UA negative. He became hypoxic to ___ and required NRB. Weaned to 2L NC and saturating well with oxygen on. On room-air drops to ___. He was given 4L IVF, vancomycin, ceftriaxone and metronidazole for aspiration pneumonia. LP was done and is thus far unrevealing. He was admitted to medicine for further evaluation and management of altered mental status. Past Medical History: 1. EtOH abuse 2. Seizure disorder 3. h/o traumatic brain injury requiring multiple craiectomies in ___ - with memory deficit 4. Subdural hematoma - ___ Social History: ___ Family History: He has a sister who lives in ___ who is well. Otherwise, no family history obtainable from the patient due to memory deficits. Physical Exam: On Admission: VS: T 100.8, BP 142/82, HR 66, RR 20, SaO2 98% RA GENERAL: well-appearing, no apparent distress, lying in bed, not answering questions. HEENT: NC/AT, PERRL, sclerae anicteric, would not open mouth NECK: supple LUNGS: Limited exam. Not cooperating with exam. No clear crackles or wheezes although very small breaths. HEART: RR, nl rate, limited due to positioning. No murmur appreciated ABDOMEN: soft, NT/ND, BS, no rebound or guarding EXTREMITIES: WWP, no edema, 2+ peripheral pulses SKIN: multiple bruises on back and arms. Skin marking ___ - unclear lesion NEURO: awake, A&Ox0 - not answering question, unable to complete exam as patient not participating On Discharge: V: Tm 100.2 Tc 99.0 BP 120-134/62-84s HR ___ RR 18 O2 99RA PE: GENERAL: Adentulous, multiple abrasions over back and LEs, bruise and abrasion under right eye, though no apparent distress, Sitting in chair laughing at TV, making attempts to answer questions with confabulation. HEENT: Abrasion as above, PERRL, sclerae anicteric, adentulous, MMM NECK: supple LUNGS: Diffuse wheezes, good movement of air. HEART: RRR, nml s1s2, no m/r/g. ABDOMEN: Multiple scars on abdomen, prominent scar on RLQ, soft, NT/ND, +BS, no rebound or guarding EXTREMITIES: WWP, no edema, 2+ peripheral pulses SKIN: multiple bruises on back, arms, and legs. NEURO: awake, A&Ox1 - attempting to answer questions, CN II-XII intact. Pertinent Results: On Admission: ___ 07:00PM BLOOD WBC-7.1 RBC-4.14* Hgb-13.1* Hct-38.9* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.4 Plt ___ ___ 07:00PM BLOOD Neuts-89.2* Lymphs-7.9* Monos-2.3 Eos-0.1 Baso-0.5 ___ 07:00PM BLOOD ___ PTT-22.6 ___ ___ 07:00PM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-145 K-4.2 Cl-105 HCO3-25 AnGap-19 ___ 06:50AM BLOOD ALT-203* AST-149* LD(LDH)-235 CK(CPK)-632* AlkPhos-41 TotBili-0.8 ___ 06:50AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.0 Mg-1.7 ___ 07:14PM BLOOD Glucose-122* Lactate-3.1* K-4.1 ___ 06:30AM BLOOD WBC-4.9 RBC-4.01* Hgb-12.8* Hct-37.3* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.3 Plt ___ ___ 06:50AM BLOOD Neuts-76.8* Lymphs-17.0* Monos-5.9 Eos-0.1 Baso-0.2 ___ 06:30AM BLOOD Glucose-122* UreaN-13 Creat-0.7 Na-138 K-3.2* Cl-98 HCO3-28 AnGap-15 ___ 06:30AM BLOOD ALT-191* AST-124* LD(LDH)-267* AlkPhos-43 TotBili-1.2 ___ 06:30AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.9 ___ 06:50AM BLOOD Lipase-27 ___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.___ male with history of EtOH abuse, seizure disorder and history of traumatic brain injury with memory deficit who presented after being found altered at his facility. Altered mental status: Exact etiology unclear. At baseline patient has limited capacity due to prior traumatic brain injury and has a long history of EtOH abuse. Since patient was found vomiting at home concerning for infection, however cultures, Head and CT torso, as well as LP all negative. Chest CT was suggestive of aspiration and patient was empirically started on vancomycin, ceftriaxone, and metronidizole, however this was stopped upon admission as patient did not appear to have a pneumonia clinically. Given patient's seizure history, EEG was performed which was negative for seizure activity. No metabolic or endocrine causes found. Through admission, patient's mental status cleared. Per his sister, he was at his baseline. It was thought patient may have had a seizure in his residence with a prolonged post-ictal period. The true etiology could not be determined. He has close follow up appointments with his PCP and neurologist at ___. # Seizure disorder: Continued home Keppra. EEG performed was negative for seizure activity. # EtOH abuse: EtOH level was negative. Patient does have significant ethanol history. He was placed on thiamine, folate and MVI. # Thrombocytopenia: Remained stable during admission. # Anemia: Remained stable during admission. Medications on Admission: Keppra 1000 BID Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Encephalopathy NOS Hepatitis NOS Secondary: Traumatic brain injury Cognitive and memory impairment Alcohol abuse Seizure disorder Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure caring for you at the ___ from ___ to ___. You were admitted for confusion and vomiting on the evening of ___. You had a very extensive work up that was unrevealing. Everything was negative, and notably your EEG (seizure test) was negative. Over the course of 24 hours your mental status improved to your baseline. Though it is unclear exactly what caused you encephalopathy it improved. We have made appointments with your primary care phycian and your neurologist. We strongly recommend you keep these appointments to insure you continue to improve. You should continue to take your medications as prescribed Followup Instructions: ___

{'Encephalopathy': ['Encephalopathy', 'Late effect of intracranial injury without mention of skull fracture', 'Epilepsy', 'Alcohol abuse', 'Thrombocytopenia', 'Anemia', 'Memory loss', 'Tobacco use disorder', 'Mild cognitive impairment', 'Toxic encephalopathy', 'Acute alcoholic hepatitis'], 'Late effect of intracranial injury without mention of skull fracture': ['Encephalopathy', 'Late effect of intracranial injury without mention of skull fracture'], 'Epilepsy': ['Encephalopathy', 'Epilepsy'], 'Alcohol abuse': ['Encephalopathy', 'Alcohol abuse'], 'Thrombocytopenia': ['Encephalopathy', 'Thrombocytopenia'], 'Anemia': ['Encephalopathy', 'Anemia'], 'Memory loss': ['Encephalopathy', 'Memory loss'], 'Tobacco use disorder': ['Encephalopathy', 'Tobacco use disorder'], 'Mild cognitive impairment': ['Encephalopathy', 'Mild cognitive impairment'], 'Toxic encephalopathy': ['Encephalopathy', 'Toxic encephalopathy'], 'Acute alcoholic hepatitis': ['Encephalopathy', 'Acute alcoholic hepatitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Cats/Dogs / azithromycin Attending: ___. Chief Complaint: Hip pain Major Surgical or Invasive Procedure: ___ THA History of Present Illness: ___ F with long standing hip pain Past Medical History: Malaria ___, low back pain, osteoarthritis both hips with ankylosis, hard of hearing, reactive airway disease exacerbated by cats and dogs, colon adenoma. Tonsillectomy, bilateral mastoidectomy in the 1960s. Social History: ___ Family History: NC Physical Exam: WD F in NAD AAOx3 ___ SILT L3-S1 ___ +DP Inc C/D/I Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior precautions. Ms ___ is discharged to home with services/rehab in stable condition. Medications on Admission: Naproxen 500 mg twice a day, tramadol 50 mg twice a day, vitamin D with calcium 600 mg twice a day, biotin 1000 mg daily for hair loss. Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY DVT Prophylaxsis x 4 weeks RX *enoxaparin 40 mg/0.4 mL 1 injection daily Disp #*28 Syringe Refills:*0 2. Acetaminophen 650 mg PO Q6H standing dose 3. Docusate Sodium 100 mg PO BID 4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN for moderate pain PACU ONLY RX *Dilaudid 2 mg ___ tablet(s) by mouth every ___ hours Disp #*80 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hip osteoarthritis Discharge Condition: Stable Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (___) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. ___ STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently Physical Therapy: WBAT with posterior hip precautions Treatments Frequency: Daily wound check with dry dressing applied. Leave open to air if clean and dry. Cover and protect for soiling or shower. Followup Instructions: ___

{'Hip pain': ['Osteoarthrosis'], 'Long standing hip pain': ['Osteoarthrosis'], 'Low back pain': ['Osteoarthrosis'], 'Osteoarthritis both hips with ankylosis': ['Osteoarthrosis', 'Ankylosis of joint'], 'Hard of hearing': ['Unspecified hearing loss'], 'Reactive airway disease exacerbated by cats and dogs': ['Asthma'], 'Colon adenoma': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfasalazine / Cephalosporins Attending: ___. Chief Complaint: ___ ADMISSION HISTORY AND PHYSICAL . . PCP: ___. ___ . . CC: MENINGITIS . Major Surgical or Invasive Procedure: LUMBAR PUNCTURE IN ER ___ History of Present Illness: ___ old male with h/o remote staph infection in infancy, S-J syndrome to either bactrim/cefixime many years ago, recurrent strep throat is here with headache and fever. Pt has been stressed out due to finals and had some intermittent HA for past couple weeks. However 3days ago he came home from school with severe HA and fever of 102. He went to sleep and felt better the next day. Yesterday afternoon, the HA returned and was very severe. Described as head fullness worse than he has ever had (has had mild HA with fevers in past) and also had eye pain (with movement, not photophobia). Also had fever again yesterday to 101-102. Had mild sore throat but nothing like his usual strep symptoms. Took tylenol and went to bed. Woke up this am with persistant HA and fever so came to ER. No sick contacts. No neck stiffness. No confusion/lethargy. No travel. No skin rash or joint complaints. No sore throat or cough today. Other than HA and fever, no other complaints. Called PCP this am, ___ to ER for LP . In ER, underwent LP, c/w viral meningitis. Started on Abx for concern for early bacterial meningitis as well. Given possible Cephalosporin/sulfa allergies, given Vanc/Doxy with plan to add chloramphenicol. Is sad about missing school and review for his finals. Past Medical History: staph skin infection in infancy S-J syndrome to either bactrim or cefixime recurrent strep throat ___ Social History: ___ Family History: no FH of recurrent infections Physical Exam: Physical Exam: Vitals on arrival to ER: 97.7 111/62 80 18 100%RA Vitals on arrival to floor: 97.8 ___ 64 16 98%RA Gen: pleasant, thin male, in NAD Eyes: EOMI, anicteric ENT: o/p clear w/o exudates, mmm Neck: no LAD CV: RRR, no m, nl S1, S2 Resp: CTAB, no crackles or wheezes Abd: soft, nontender, nondistended, +BS, no HSM Lymph: no cervical, axillary, inguinal LAD Ext: no edema, good peripheral pulses, no cyanosis Neuro: A&OX3, CNII-XII intact, normal gait, strength equal b/l ___, intact sensation, reflexes 2+ ___, neg Kernig/neg Brudzinski Skin: warm, NO rashes and no petechia psych: appropriate . . On discharge Vitals:Tm 99.4 Tc 97.9 ___ 18 98%RA Pain: ___ eye pain Access: PIV Gen: nad HEENT: anicteric, o/p clear, mmm Neck: no LAD CV: RRR, no m Resp: CTAB, no crackles or wheezing Abd; soft, nontender, +BS, no HSM Ext; no edema Neuro: A&OX3, remains at baseline-nonfocal Skin: no rash psych: appropriate . Pertinent Results: wbc 5.8 wiht 64%N hgb ___ plt 158 . Chem: BUN/creat ___ LFTs wnl . INR 1.4 . LP wbc 110, 90 with 8%PMN, 84%Lymph, 8% Mono RBC 3, 3 Gluc 51 T pro 50 Lyme pending*** CSF ___ neg CSF Cx NTD Blood CX X2 NTD . . Imaging/results: NONE Brief Hospital Course: ___ old male admitted with 3days of HA and fever. Underwent LP in ER with findings of meningitis. LP showed lymphocytic predominence and patient clinically looked very well so likely aseptic meningitis. However, there was concern that this could also represent early bacterial meningitis, thus he was covered empirically with Abx. Pt had a h/o severe allergy (S-J syndrome) to either cefexime/bactrim so after discussion with ID, we covered for bacterial meningitis with vanc, doxy PO, chloramphenicol IV q6. No evidence of encephalitis so less likely HSV so acyclovir not started (and we did not check for this). The ER sent off lyme serologies in CSF fluid and this is PENDING at time of discharge (communicated to PCP). Our suspicion for this was low. After the cultures were negative for 48hours, these were stopped. Pt was told to continue supportive care for his Aseptic Meningitis with rest, fluids, tylenol. He remained afebrile here. He had a mild HA that was better with tylenol and mild eye pain w/o evidence of conjunctivits/episcleritis. He was discharged in good condition. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained by Patient. 1. Acetaminophen 650 mg PO Q6H:PRN fever Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever Discharge Disposition: Home Discharge Diagnosis: Aseptic meningitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for fevers and headache that ocurred over a couple days. You underwent Lumbar puncture which showed you had meningitis. Initially we covered you with IV antibiotics in the case this was early bacterial meningitis (which can be dangerous). However, your cultures from the spine fluid and blood remained negative for 48hours, so this was more likely ASEPTIC (aka Viral) meningitis. This is treated with supportive care like any viral illness with rest, fluids, tylenol as needed. You will not be discharged on any antibiotics Followup Instructions: ___

{'headache': ['Unspecified viral meningitis'], 'fever': ['Unspecified viral meningitis'], 'eye pain': ['Unspecified viral meningitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine Attending: ___. Chief Complaint: HMED Admission Note ___ cc: abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old F with Chron's disease since ___ here with weight loss, fever, nausea, and diarrhea. Pt with recent colonoscopy this month showing active disease in most of her colon with rectal sparing. CMV testing showed negative stain but cultures pending. Pt also with history of latent TB and completed treatment course with rifampin a few months ago. Pt started on prednisone for her active disease but unable to tolerate medication (did not like taste). She saw Dr ___ and was noted to have significant abdominal pain dehydration with nearly 30 lb weight loss in the past month, fevers, and diarrhea with any PO intake so she was directly admitted from clinic. Says diarrhea is watery and foul smelling. Some dry heaving. Reports subjective fevers at home but has not been taking temps, reports pain in knees without swelling or inflammation. ROS: negative except as above Past Medical History: #Chrons - diagnosed in ___, never on biologics, h/o fistula/abscess #HTN Social History: ___ Family History: No family history of Chron's. Physical Exam: Vitals: 100.2 117/63 127 16 100%RA Gen: NAD, thin HEENT: white material caking tongue but not orl mucosa, small ulcers in oropharynx CV: tachy, regular, no rmg Pulm: clear bl Abd: quiet bowel sounds but present, soft, tenderness in RLQ with no rebound Ext: no edema Neuro: alert and oriented x 3 Pertinent Results: ___ 04:20PM WBC-19.3* RBC-4.63 HGB-9.9* HCT-33.2* MCV-72* MCH-21.4* MCHC-29.7* RDW-16.3* ___ 04:20PM PLT COUNT-701*# ___ 04:20PM GLUCOSE-82 UREA N-17 CREAT-1.0 SODIUM-138 POTASSIUM-3.5 CHLORIDE-88* TOTAL CO2-28 ANION GAP-26* ___ 04:20PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-90 ___ 04:20PM ALBUMIN-3.6 ___ 04:20PM CRP-199.5* Brief Hospital Course: ___ yo F with Crohn's disease here with likely flare. We initially kept her NPO and started her on steroids with improvement. Given concern for leukocytosis and lesions noted on colonoscopy, we obtained CMV viral titers and IgM/IgG all of which were negative. We switched her from IV steroids to PO liquid prednisone to be continued at home. We started her on nystatin for possible oral ___ will see her in follow up for remicaide infusion an outpatient (costs for starting remicaide inpatient were prohibitive). Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. FoLIC Acid 1 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Hydrocortisone Enema 100 mg PR QHS:PRN chrons 6. lidocaine HCl-hydrocortison ac ___ % rectal TID:PRN pain Discharge Medications: 1. Nystatin Oral Suspension 10 mL PO QID:PRN thrush RX *nystatin 100,000 unit/mL 10 mL by mouth three times a day Refills:*1 2. predniSONE 30 mg ORAL BID RX *prednisone 5 mg/5 mL 6 mL by mouth twice a day Refills:*1 3. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. FoLIC Acid 1 mg PO DAILY 6. Hydrocortisone Enema 100 mg PR QHS:PRN chrons 7. lidocaine HCl-hydrocortison ac ___ % rectal TID:PRN pain 8. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Crohn's disease flare 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 a Crohn's flare - we started you on steroids. You will need to see Dr ___ in follow up - she will call you with an appointment - she will also be scheduling you for Remicaide dosing as an outpatient sometime next week. We also tested you for infection (CMV) which was negative. Followup Instructions: ___

{'abdominal pain': ['Regional enteritis of small intestine with large intestine'], 'diarrhea': ['Regional enteritis of small intestine with large intestine'], 'fever': ['Regional enteritis of small intestine with large intestine'], 'nausea': ['Regional enteritis of small intestine with large intestine'], 'weight loss': ['Regional enteritis of small intestine with large intestine'], 'knee pain': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine / Indocin / Nafcillin Attending: ___. Chief Complaint: SOB A-fib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of ischemic cardiomyopathy EF ___, CAD (2VD with chronic total occlusions), tachy-brady syndrome, A-fib initially evaluated at the ___. She is now being transferred for exertional RVR that was difficult to control with escalating doses of of beta blockade for consideunstable angina who presented to ___ with unstable angina. Per report, she has a history of unstable angina for which she takes nitroglycerin, and took 3 doses prior to presentation toration of PPM or AICD (given low EF). Her hospital course was notable for decompensated systolic heart failure and her lasix was increased from her home dose of 60 mg daily to 80 mg daily. ECHO at ___ revealed EF ___ with multiple regional wall motion abnormalities. Her metoprolol was increased from 100mg XL daily to 100 mg BID, though HR still escalate to 130s with any exertion and sustained. Coumadin was held at ___ in case any procedures are planned. Of note, her long acting nitrates were recently discontinued by her outpatient cardiologist. Vitals on transfer: 97.4 HR 72 ___nd 130 w/ movement, resp ___, 133/66, 97% ra. On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Hypertension 2. CARDIAC HISTORY: # Atrial fibrillation (on coumadin) # Coronary artery disease # ___ with EF 40% -PERCUTANEOUS CORONARY INTERVENTIONS: cardiac catheterization at ___ in ___ showing "small vessel disease", cardiac cath in ___ showing two vessel disease without any intervention 3. OTHER PAST MEDICAL HISTORY: # History of Non-Hodgkin's lymphoma # Multinodular Goiter # Chronic Low Back Pain # s/p hysterectomy # s/p bilateral knee replacements # s/p bilateral eye surgery Social History: ___ Family History: Diabetes; Grandmother died of MI at ___. Father: MI in ___, Mother: died before her ___ of "heart condition that was undiagnosed" Physical Exam: General: elderly female resting in bed, NAD HEENT: NCAT, scleric anicterus Neck: Elevated JVP 7cm above sternal angle. Neck supple CV: Irregularly irregular. Normal S1/S2, no murmurs. Lungs: CTABL Abdomen: soft, NT/ND Ext: Warm, dry. No ___: alert, oriented PULSES: 1+ peripheral pulse. Pertinent Results: ___ 04:53AM BLOOD WBC-7.7 RBC-4.33 Hgb-12.6 Hct-38.1 MCV-88 MCH-29.2 MCHC-33.1 RDW-14.7 Plt ___ ___ 04:53AM BLOOD Glucose-145* UreaN-27* Creat-1.4* Na-143 K-3.6 Cl-103 HCO3-28 AnGap-16 ___ 04:53AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.___-fib with RVR: ___ with ischemic cardiomyopathy EF ___, CAD with 2VD with chronic total occlusion, tachy-brady syndrome, and A-fib who was transferred to ___ from ___ for exertional RVR that was difficult to control with high dose beta-blockers, decompensated CHF, and evaluation for potential pacemaker. Her metoprolol XL was recently increased from 100mg daily to 100mg BID at the OSH. Her heart rate remained well-controll <100 during her hospitalization at ___ even with ambulation. We ultimately adjusted her metoprolol XL to 150mg daily. Her HR and BP remained under well-controlled on this new dosage. At this time, pacemaker is not warranted as her HR is well-controlled with pharmacologic agents. Her coumadin was restarted and INR was in therapeutic range prior to discharge. ___ pharmacist reviewed patient's medications prior to discharge. # CHF exacerbation: Pt's SOB is partly contributed by volume overload ___ ischemic cardiomyopathy. Her home lasix was increased from 40mg BID to 80mg BID. Lytes remained stable prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Digoxin 0.125 mg PO DAILY 3. Gabapentin 300 mg PO BID 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN Chest pain 6. Pantoprazole 40 mg PO Q24H 7. Simvastatin 20 mg PO DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg ORAL TID:PRN pain 10. Furosemide 40 mg PO DAILY 11. Warfarin 5 mg PO DAILY16 Atrial fibrillation 12. Detemir 40 Units Breakfast Detemir 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 14. Potassium Chloride 10 mEq PO DAILY 15. Aspirin 81 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY 17. Docusate Sodium 100 mg PO BID 18. Senna 17.2 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Digoxin 0.125 mg PO DAILY 4. Furosemide 80 mg PO BID RX *furosemide 80 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*3 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth once daily Disp #*45 Tablet Refills:*3 7. Pantoprazole 40 mg PO Q24H 8. Warfarin 5 mg PO DAILY16 Atrial fibrillation 9. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once nightly Disp #*30 Tablet Refills:*3 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 11. Docusate Sodium 100 mg PO BID 12. Nitroglycerin SL 0.4 mg SL PRN Chest pain 13. Percocet (oxyCODONE-acetaminophen) 7.5-325 mg ORAL TID:PRN pain 14. Potassium Chloride 10 mEq PO DAILY Hold for K > 4.5 15. Senna 17.2 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY 17. Detemir 40 Units Breakfast Detemir 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 18. Gabapentin 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: A-fib, heart rate controlled Decompensated CHF 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: Ms ___: It was a pleasure taking care of you. You were transferred to us from ___ due to fast heart rate associated with your A-fib and for evaluation of potential pacemaker. You were monitored on a continuous heart monitor during hospitalization, which revealed that your heart rate was very well-controlled with the new dose of metoprolol (150mg daily). We reviewed your studies very carefully and determine that a pacemaker will NOT be beneficial at this time. Your coumadin was held at the outside hospital in anticipation for potential procedure. You were restarted on coumadin at ___ ___ and your INR was in therapeutic range prior to discharge. For your shortness of breath, we believe it is due to volume overload secondary to decompensated heart failure. You will be discharged on a higher dose of lasix. Please Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___

{'SOB': ['Atrial fibrillation', 'Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease'], 'A-fib with RVR': ['Atrial fibrillation', 'Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease'], 'Decompensated CHF': ['Acute on chronic diastolic heart failure', 'Congestive heart failure', 'unspecified', 'Coronary atherosclerosis of native coronary artery', 'Unspecified essential hypertension', 'Mitral valve disorders', 'Other and unspecified angina pectoris', 'Long-term (current) use of anticoagulants', 'Other specified forms of chronic ischemic heart disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Facial pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M transferred For trauma evaluation after a fall. Patient poorly fell down a flight of stairs. Had imaging which showed a facial fractures as well as a small cerebral contusion. Here patient complains of pain to his head and neck. Denies other injuries. Past Medical History: PMHx: CAD, angina, MI, GERD, HCV, HL, migraines, OSA, atrophic L kidney PSHx: appendectomy, carpal tunnel release, spine surgery (cervical) Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Temp: 97.2 HR: 86 BP: 134/75 Resp: 18 O(2)Sat: 96 Normal Constitutional: Constitutional: Lying in bed, protecting airway Head / Eyes: NC, PERRL, EOMI, Left periorbital ecchymosis ENT: OP WNL Resp: CTAB Cards: RRR. Abd: S/NT/ND Pelvis stable Skin: no rash, warm and dry Ext: No c/c/e Neuro: speech fluent Psych: normal mood DISCHARGE PHYSICAL EXAM: Gen: awake, alert, pleasant and interactive. CV: rrr PULM: Clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended. active bowel sounds EXT: Warm and dry. 2+ ___ pulses. Pertinent Results: ___ 03:22AM BLOOD WBC-5.6 RBC-4.32* Hgb-11.7* Hct-35.7* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.3 RDWSD-42.6 Plt Ct-96* ___ 03:22AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-139 K-4.5 Cl-98 HCO3-30 AnGap-11 ___ 01:30AM BLOOD ALT-26 AST-45* AlkPhos-102 TotBili-0.6 ___ 03:22AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 ___ 01:43AM BLOOD Lactate-1.3 Brief Hospital Course: Mr. ___ is a ___ yo M who presented to emergency department after reportedly a fall down a flight of stairs sustaining left sided facial trauma. He was hemodynamically stable. CT head negative for acute intracranial process. Imaging reveals a small left zygomatic arch fracture, left orbital floor fracture, and lateral orbital wall fracture. The patient was seen and evaluated by plastic surgery who recommended non-operative management of his fractures. the patient was evaluated for ophthalmology for eye injury/muscle entrapment which there was none. He was admitted to the surgical floor for observation and pain control. Pain medication were titrated with good effect. On HD4 he was discharged to home on sinus precautions, doing well, afebrile and hemodynamically stable. The patient was tolerating a 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. NIFEdipine (Extended Release) 30 mg PO DAILY 2. Simvastatin 80 mg PO QPM 3. Terazosin 2 mg PO QHS 4. FLUoxetine 60 mg PO DAILY 5. Sumatriptan Succinate 6 mg SC ONCE:PRN headache 6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 7. Omeprazole 20 mg PO DAILY 8. HYDROmorphone (Dilaudid) 4 mg PO TID pain 9. Diazepam 10 mg PO QHS anxiety 10. Gabapentin 300 mg PO TID 11. Morphine SR (MS ___ 120 mg PO Q12H Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild do not exceed 4000 mg Tylenol/ 24 hours. 2. Docusate Sodium 100 mg PO BID 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Alternate with Tylenol. 4. Omeprazole 20 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Senna 8.6 mg PO BID:PRN constipation 7. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN Pain - Severe 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 9. Diazepam 10 mg PO QHS anxiety 10. FLUoxetine 60 mg PO DAILY 11. Gabapentin 300 mg PO TID 12. Morphine SR (MS ___ 120 mg PO Q12H 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Simvastatin 80 mg PO QPM 15. Sumatriptan Succinate 6 mg SC ONCE:PRN headache 16. Terazosin 2 mg PO QHS 17. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This medication was held. Do not restart NIFEdipine (Extended Release) until instructed by primary care provider. Discharge Disposition: Home Discharge Diagnosis: Left comminuted Maxillary sinus fracture- both walls Small Left zygomatic arch fracture Small Left orbital floor fracture Small lateral orbital wall fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the Acute Care Trauma Surgery service on ___ after a fall sustaining multiple facial injuries. You were seen by the plastic surgery team who evaluated your facial fractures and recommended non-operative management at this time and follow up in outpatient clinic to determine if further surgery is needed. Please continue to follow sinus precautions (no nose blowing, sneeze with your mouth open, no drinking through straws). You were evaluated by the ophthalmology team who determined there are no injuries to your eyes that require intervention at this time. Please follow up in clinic to re-evaluate your vision and assess for worsening symptoms. You are now doing better, tolerating a regular diet, and ready to be discharge to home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___

{'Facial pain': ['Maxillary fracture', 'Fracture of orbital floor', 'Zygomatic fracture'], 'Fall down stairs': ['Fall (on) (from) unspecified stairs and steps'], 'Head and neck pain': ['Maxillary fracture', 'Fracture of orbital floor', 'Zygomatic fracture'], 'Cerebral contusion': ['Cerebral contusion']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___- Diagnostic Angiogram- Negative History of Present Illness: ___ year old male who presented to OSH with left sided frontal headache x 5 days after working out at the gym. The patient reports he generally doesn't have trouble with headaches, and states he took some Tylenol initially with relief although reports over the course of several days Tylenol was no longer relieving his headache therefore he presented to ___ on ___ for further evaluation. A NCHCT was performed and was negative for hemorrhage therefore he was discharged to home. The patient returned the following day as headache symptoms persisted. He underwent an MRI/MRA which revealed no acute intracranial process, however there is a note of minute focus of relatively nodular signal in the region of the anterior communicating artery on MR angiography which measures approximately 2mm and could represent prominent infundibulum at the origin of the anterior communicating artery from left A1. A 2 mm Microaneurysm is possible here. He also underwent an LP which revealed 120 RBS in tube 1 with 1 WBC and 120 RBCs in Tube 3 with less than 1 WBC. The patient was then transferred to ___ for further Neurosurgical evaluation and diagnostic angiogram with possible intervention. Past Medical History: BPH, Appendicitis requiring appendectomy, Hernia repair Social History: ___ Family History: No history of aneurysms. Physical Exam: On Discharge ___: Eyes open spontaneously, Aox3, PERRL ___ bilaterally, face symmetric, tongue midline, no pronator drift. Speech clear and comprehension intact. Moves all extremities with full strength ___. Right groin dressing clean dry and intact. Groin soft, no hematoma. Distal pulses intact to bilateral lower extremities. Pertinent Results: CAROTID/CEREBRAL BILAT Study Date of ___ 1:58 ___ IMPRESSION: 1. Diagnostic cerebral angiogram within normal limits, with fenestration of the A-comm. RECOMMENDATION(S): 1. Neurology consultation for headaches management. Brief Hospital Course: ___ year old male with 5 days of headaches who was transferred from OSH with concern of 2mm ACA aneurysm. #Headaches: The patient was taken for a diagnostic angiogram upon arrival to ___. It was within normal limits, and demonstrated a fenestration of the A-comm. The patient recovered in the PACU and was transferred to the ___ when stable. On Post-operative check he was neurologically intact and his right groin was soft and there was no concern for hematoma. Distal pulses were intact. Neurology was consulted to assess for further causes of headaches. Notes and lab results were obtained from outside hospital Neurology consult for interpretation by the Neurology team. It was determined by Neurology that the patients headaches were caused by Occipital Neuralgia. It was recommended that he was to be started on Gabapentin 300 mg po Q HS. Detailed instructions were given to him for management of pain and when to stop gabapentin as well as when to follow up as an outpatient. This was all listed in his discharge information. The patient was cleared for safe discharge to home by the Neurosurgery service. He was given prescriptions and follow up information. Medications on Admission: None Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain - Moderate RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ capsule(s) by mouth every eight (8) hours Disp #*40 Capsule Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO QHS As instructed on discharge instructions RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Headache Occipital Neuralgia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ ___ • You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. • Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. • You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. • Do not go swimming or submerge yourself in water for five (5) days after your procedure. • You make take a shower. Medications • Resume your normal medications and begin new medications as directed. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Please do not take this with Fioricet as this contains acetaminophen. Please do not exceed greater than 4 grams of acetaminophen in 24 hours. • If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site • You will have a small bandage over the site. • Remove the bandage in 24 hours by soaking it with water and gently peeling it off. • Keep the site clean with soap and water and dry it carefully. • You may use a band-aid if you wish. What You ___ Experience: • Mild tenderness and bruising at the puncture site (groin). • Soreness in your arms from the intravenous lines. • Fatigue is very normal. When to Call Your Doctor at ___ for: • Severe pain, swelling, redness or drainage from the puncture site. • Fever greater than 101.5 degrees Fahrenheit • Constipation • Blood in your stool or urine • Nausea and/or vomiting 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 Occipital Neuralgia • You were seen and evaluated by the Neurology service while at ___ for further evaluation of your headaches. It was determined that you are currently suffering from Occipital Neuralgia. • Please begin taking Gabapentin 300 mg by mouth every night at bedtime. You have been given a prescription for this medication at the time of discharge. • If you experience relief of headache with the Gabapentin please continue to take this medication for an additional 4 weeks AFTER your headache symptoms have resolved. • If you do not have relief of headache after ___ weeks please follow up with the local pain clinic or you may follow up with Dr. ___ Neurology at ___ for a possible occipital nerve block. Dr. ___ phone number is ___. Followup Instructions: ___

{'headache': ['Occipital neuralgia'], 'tenderness': ['Occipital neuralgia'], 'bruising': ['Occipital neuralgia'], 'soreness': ['Occipital neuralgia'], 'fatigue': ['Occipital neuralgia'], 'pain': ['Occipital neuralgia'], 'swelling': ['Occipital neuralgia'], 'redness': ['Occipital neuralgia'], 'drainage': ['Occipital neuralgia'], 'fever': ['Occipital neuralgia'], 'constipation': ['Occipital neuralgia'], 'blood in stool or urine': ['Occipital neuralgia'], 'nausea and/or vomiting': ['Occipital neuralgia'], 'numbness or weakness in the face, arm, or leg': ['Occipital neuralgia'], 'confusion or trouble speaking or understanding': ['Occipital neuralgia'], 'trouble walking, dizziness, or loss of balance or coordination': ['Occipital neuralgia'], 'severe headaches': ['Occipital neuralgia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: decreased ostomy output Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p subtotal colectomy w/ end ileostomy for ulcerative colitis in ___. Followed closely by gastroenterology for inflammatory bowel disease. Post-operatively, dealing with constant lower abdominal pain described as muscle spasms which wraps around the lower edge of his stoma. There episodes occur t/o day and he is treated with oxycodone. Now reports one day history of decreased ostomy output. Has not changed his ostomy yet from normal ___. Fairly nauseous o/n with several episodes of non-bloody, non-bilious emesis. Still nauseous but no vomiting since this AM. Currently symptoms resolved with medication (morphine, ativan, zofran) in the ED. Past Medical History: PMH: UC, pain control issues PSH: abd colectomy, end ileostomy Social History: ___ Family History: non-contributory Physical Exam: Vitals: 97.0 88 146/62 18 100 Gen: NADS, AAOx3 Lungs: CTA Cardio: RRR Abd: soft, midline incision, tenderness (baseline) to lower abdomen, hypoact BS, end ileostomy stoma patent, digitized and normal feeling Ext: no c/c/e Pertinent Results: ___ 11:00AM WBC-5.9 RBC-3.94* HGB-6.0* HCT-24.6* MCV-63* MCH-15.3* MCHC-24.5* RDW-18.4* ___ 11:00AM NEUTS-83.7* LYMPHS-12.1* MONOS-3.8 EOS-0 BASOS-0.4 ___ 11:00AM GLUCOSE-121* UREA N-11 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 ___ 11:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG CT AP: 1. Dilated small bowel in the right lower quadrant proximal to the ileostomy with two apparent points of transition with a closed loop obstruction. Internal hernia in this patient with prior subtotal colectomy. Lack of enteric contrast does limit the evaluation. 2. Hypodensities in the liver and kidney may represent cysts but several are too small to accurately characterize. 3. Enlarged Prostate. Correlate with PSA. Brief Hospital Course: Mr. ___ presented with decreased ostomy output and nausea and CT consistent with small bowel obstruction. He was treated nonoperatively with a nasogastric tube and IV fluids with ultimate resolution of his small bowel obstruction. As he began to have ostomy output and decreased NG output, the NG tube was removed and his diet was advanced. He is being discharged afebrile, with stable vital signs, tolerating an oral diet and with pain controlled on oral medications. His home pain medications of oxycodone and oxazepam were stopped and he was given intermittent ativan for anxiety and help sleeping. He was discharged on this with follow up to his primary care physician and to the ___. Medications on Admission: ___: oxycodone and oxazepam for sleep Discharge Medications: 1. Oxycodone Oral 2. Oxazepam Oral 3. Ativan 0.5 mg Tablet Sig: ___ Tablets PO at bedtime as needed for insomnia for 10 days. Disp:*30 Tablet(s)* Refills:*0* 4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 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. Followup Instructions: ___

{'lower abdominal pain': ['Ulcerative colitis'], 'nausea': ['Ulcerative colitis', 'small bowel obstruction'], 'vomiting': ['Ulcerative colitis', 'small bowel obstruction'], 'decreased ostomy output': ['small bowel obstruction'], 'muscle spasms': ['Ulcerative colitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R wrist decreased AROM Major Surgical or Invasive Procedure: TENDON TRANSFER RIGHT WRIST EXTENSOR DIGITORUM CARPIALIS ___ TO ___ DIGIT; EXTENSOR CARPIALIS RADIALIS BREVIS TO EXTENSOR CARPIALIS ULNARIS, EXTENSOR DIGITORUM QUINTI TO EXTENSOR CARPI ULNARIS ___ DIGIT; ___ EXTENSOR CENTRAL SLIP REPAIR; TENOLYISIS EXTENSOR DIGITORUM CARPIALIS TENDONS; ? REVISION DORSAL FOREARM 8 X 3 CM EXTENSOR POLLICUS LONGUS REPAIR WITH TENDON ALLOGRAFT History of Present Illness: Mr. ___ is a ___ male who sustained an open crush injury to the right forearm in a lathe. This is associated with right radial fracture. He underwent fasciotomies initially as well as ORIF of his distal radius fracture and carpal tunnel release. His debridement unfortunately required dissections of the ECU and EPL tendons be taken. Since surgery, his postoperative course has been complicated by pain requiring gabapentin use three times a ___ as well as ongoing Vicodin use now over 10 weeks out from surgery. He reports that he is still making progress with physical therapy and the physical therapist has sent a note along with him today, which documents his MCP joint motion at the index finger is from -9 to 66, The middle finger is ___, ring finger is 0 to 65 and small finger is 0 to 50. At the PIP joint of the index -___ to 90 degrees, middle finger -5 to 96 degrees, ring finger -10 to 95 degrees and small finger -30 to 86 degrees. At the DIP joint for the index finger -15 to 59 degrees, middle finger is 0 to 62 degrees, ring finger -10 to 63 degrees and small finger -4 to 55 degrees, the thumb MP joint from -25 to 50 degrees, PIP joint 10 to 30 degrees with only 56 degrees of palmar abduction. The patient also indicates that he for the last several weeks has had lateral epicondylitis of the left elbow and pain in the anterior right shoulder consistent with bicipital tendonitis. Though it was recommended at his last visit with us that he consult with a psychologist or psychiatrist in around his pain issues and coping issues from surgery, he has not been interested so far in pursuing that. Past Medical History: GERD, Gout Social History: ___ Family History: Non-contributory Physical Exam: GEN: Well appearing, NAD AVSS RUE: Splint c/d/i EPL/FDS/FDP/DIO fire SLT m/r/u Fingers WWP Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: Otherwise, pain was initially controlled with oral pain medications with IV for breakthrough pain. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is non weight bearing in splint until follow up. Mr ___ is discharged to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 3. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: R arm crush injury 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 your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your splint clean and dry until follow up. You can shower, but make sure to keep your splint dry. 7. Please call Dr ___ office at ___ upon discharge to schedule a follow up for ___ days after surgery. 12. ACTIVITY: Non weight bearing in splint until follow up Followup Instructions: ___

{'R wrist decreased AROM': ['Late effect of crushing'], 'pain': ['Pain in limb', 'Late effects of other accidents'], 'lateral epicondylitis': ['Pain in limb'], 'bicipital tendonitis': ['Pain in limb']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RLL nodule Major Surgical or Invasive Procedure: Video-assisted Right lower lobe wedge resection on ___ History of Present Illness: Mr ___ is a ___ year old man with a RLL pulmonary nodule noted as incidental finding on T spine CT ___. It was measured at 11x15mm at that time. A follow-up Chest CT ___ noted that the nodule was 22x14mm. There were other smaller indeterminate nodules. His Pet-CT ___ showed FDG avidity of the nodule with SUV 15.2. He denies any respiratory or infectious symptoms such as dyspnea, cough, hemoptysis, purulent sputum, fevers, chills, or sweats. He is quite active and has not noticed any changes in energy level. He denies new aches or pains, new neurologic symptoms, or weight loss. He presents today for wedge resection and possible lobectomy if the nodule turns out to be a primary lung cancer. Past Medical History: Carotid stenosis: right ICA near 40% stenosis and a left ICA 60% to 69% stenosis (followed by Dr ___ CRI HLD depression s/p RIH repair x ___ s/p LIH repair Benign prostatic hypertrophy. Increased prostate-specific antigen. Perforated diverticulitis with temporary colostomy s/p reversal ___ s/p appendectomy. s/p Back surgeries x4, most recently anterior-posterior fusion of ___ s/p bilat RCR s/p foot surg s/p pilonidal cystectomy s/p melanoma excision L shoulder ___ Social History: ___ Family History: non-contributory Physical Exam: BP: 138/92. Heart Rate: 96. Weight: 200. Height: 73. BMI: 26.4. Temperature: 98.3. O2 Saturation%: 96. GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [x] No rashes/lesions/ulcers [x] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: ___ 07:50AM BLOOD WBC-12.8* RBC-5.05 Hgb-13.2* Hct-42.4 MCV-84 MCH-26.2* MCHC-31.2 RDW-14.5 Plt ___ ___ 07:50AM BLOOD UreaN-19 Creat-1.3* Na-135 K-4.5 Cl-100 ___ 07:50AM BLOOD Mg-1.7 ___ CXR The right chest tube has been removed. No pneumothorax is present. Atelectasis at the right lower lobe is present. Subcutaneous emphysema is seen on the right. Brief Hospital Course: Mr. ___ was taken to the operating room on ___ for a VATS RLL wedge resection vs lobectomy. The frozen section pathology of the nodule showed spindle cell proliferation, consistent with melanoma (given his history), and therefore only a wedge and not formal lobectomy was performed. He tolerated the procedure well and was extubated to the PACU. He was noted to have some PVCs and so electrolytes and hemoglobin were obtained. Electrolytes were repleted as needed. He was transferred to the surgical floor hemodynamically stable. His diet was advanced as tolerated. His chest tube was kept to water seal overnight. On POD1 his chest tube was removed, and a post-pull film showed no evidence of pneumothorax. His foley catheter was also discontinued on POD1 however he failed to void spontaneously. Foley was replaced and discontinued again at midnight on POD2, after which he did void spontaneously. He remained hemodynamically stable and afebrile throughout his hospital stay, and his pain was well controlled on an oral regimen. He was discharged home on POD2 with instructions to arrange follow-up with Dr. ___ 2 weeks from discharge. TRANSITIONAL ISSUES: - Patient to follow-up in Thoracic Surgery Clinic 2 weeks from discharge with CXR. - Final pathology report unavailable at time of discharge. Medications on Admission: butran transdermal 10 mcg/hr patch, cymbalta ___ 90 mg ___, nexium 40 mg ___ ___ 5 mg ___, gabapentin 400 mg TID, lorazepam 0.5-1 mg qhs, oxycodone ___ mg TID PRN pain, oxycontin 10 mg bid, simvastatin 20 mg, terazosin 5 mg ___ 81, Ca-Vit D, glucosamine, senna Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 650 mg 1 tablet(s) by mouth Q ___ hours Disp #*40 Tablet Refills:*0 2. Gabapentin 400 mg PO Q8H 3. Oxycodone SR (OxyconTIN) 10 mg PO BID pain 4. Simvastatin 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Terazosin 5 mg PO HS 7. Lorazepam 0.5 mg PO HS:PRN insomnia 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 10 mg ___ tablet(s) by mouth q ___ hours Disp #*30 Tablet Refills:*0 9. Duloxetine 90 mg PO DAILY 10. Finasteride 5 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: right lower lobe lung nodule 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 lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol ___ mg every 6 hours in between your narcotic. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: ___

{'RLL pulmonary nodule': ['Secondary malignant neoplasm of lung'], 'Carotid stenosis': ['Chronic kidney disease', 'unspecified'], 'HLD': ['Other and unspecified hyperlipidemia'], 'depression': [], 's/p RIH repair': [], 's/p LIH repair': [], 'Benign prostatic hypertrophy': [], 'Increased prostate-specific antigen': [], 'Perforated diverticulitis with temporary colostomy s/p reversal': [], 's/p appendectomy': [], 's/p Back surgeries': [], 's/p bilat RCR': [], 's/p foot surg': [], 's/p pilonidal cystectomy': [], 's/p melanoma excision L shoulder': ['Personal history of malignant melanoma of skin'], 'Dyspnea': [], 'cough': [], 'hemoptysis': [], 'purulent sputum': [], 'fevers': [], 'chills': [], 'sweats': [], 'energy level': [], 'aches or pains': [], 'neurologic symptoms': [], 'weight loss': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: R foot ulcer Major Surgical or Invasive Procedure: ___: R ___ digit arthroplasty History of Present Illness: This patient is a ___ year old male with PMH significant for uncontrolled type II diabetes and hypertension with a right fourth to infection. Patient recalls doing yard work on ___ when he dropped a heavy object on his foot. He then travelled to ___ for a business trip and a on ___ noticed an ulcer with increasing redness and drainage on his right fourth toe. He presented to an emergency room in ___, where he was admitted for IV antibiotics. Surgical intervention was discussed during his admission, but an infectious disease physician recommended he fly home to ___ and be seen immediately. He was discharged on a course of Augmentin which he has been taking and states some of the redness has improved. Patients admits to being diabetic and that his blood sugars have been under poor control. His most recent HbA1c was 12.3%. He denies any recent nausea, vomiting, fever, chills, shortness of breath, or chest pain. Past Medical History: HTN, DMII Social History: ___ Family History: Significant for diabetes and heart disease Physical Exam: Admission Physical Examination General: Awake, alert, oriented x3. No acute distress HEENT: MMM, neck supple, NTAC Cardiac: extremities well perfused Lungs: No respiratory distress Abd: Soft, non-tender, non-distended Lower extremity exam: ___ pulses palpable b/l. Capillary refill time < 3 seconds to the digits b/l. Skin temperature warm to cool from proximal tibia to distal digits bilaterally. Protective sensation diminished b/l. Ulcer noted to the lateral aspect of the fourth digit that probes deeply. Scant amount of purulent drainage expressed from the fourth digit ulcer. Right fourth digit appear erythematous and edematous with sloughing skin. Erythema note to the right fourth toe extending to the right dorsal foot, outline by previous hospital. Distal aspect of the fourth digit appears dusky in color without capillary refill. Mild tenderness with palpation of the right fourth digit. Discharge Physical Exam: Pertinent Results: ___ 09:29PM BLOOD WBC-7.3 RBC-4.15* Hgb-12.5* Hct-35.7* MCV-86 MCH-30.1 MCHC-35.0 RDW-11.5 RDWSD-36.1 Plt ___ ___ 09:29PM BLOOD Neuts-58.1 ___ Monos-9.2 Eos-1.8 Baso-0.1 Im ___ AbsNeut-4.25 AbsLymp-2.23 AbsMono-0.67 AbsEos-0.13 AbsBaso-0.01 ___ 09:29PM BLOOD Plt ___ ___ 09:29PM BLOOD Glucose-286* UreaN-17 Creat-0.8 Na-136 K-4.1 Cl-99 HCO3-24 AnGap-17 ___ 09:29PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8 ___ 09:29PM BLOOD CRP-18.7* Right foot radiograph ___: FINDINGS: Soft tissue swelling at the fourth toe is present. No overt bone destruction or periosteal reaction. Mild degenerative changes are seen at the first MTP joint, fourth TMT joint, first TMT joint. Plantar and posterior calcaneal spurs are seen. Bipartite lateral sesamoid at first MTP. IMPRESSION: Soft tissue swelling at the fourth toe. No overt evidence of osteomyelitis. Additional findings as above. Brief Hospital Course: The patient was admitted to the podiatric surgery service from clinic on ___ for a R foot infection. On admission, he was started on broad spectrum antibiotics. The patient was brought to the operating room on ___ for a Right ___ digit arthoplasty, which the patient tolerated well. For full details of the procedure, please see the separately dictated operative report. The patient was taken to the PACU in stable condition and was transferred back to the floor after satisfactory recovery from anesthesia. Throughout his hospital stay, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on broad spectrum antibiotics while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient had hyperglycemia throughout his stay, and was seen by a member of the ___ Diabetes Team and his blood glucose levels improved. The patient was subsequently discharged to home on POD 2 with vital signs stable and vascular status intact to right foot. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Metformin 1000mg BID 2. Lisinopril 40mg 3. Simvastatin 40mg Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Glargine 30 Units Dinner Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 30 Units before DINR; Disp #*1 Syringe Refills:*0 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: R foot ulcer 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 to the Podiatric Surgery service for your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weight bearing to your R heel in a surgical shoe until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___

{'ulcer': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'redness': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'drainage': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'infection': ['Type 2 diabetes mellitus with foot ulcer', 'Other acute osteomyelitis, right ankle and foot'], 'uncontrolled diabetes': ['Type 2 diabetes mellitus with other specified complication', 'Type 2 diabetes mellitus with hyperglycemia'], 'hypertension': ['Essential (primary) 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: abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: ___ presents with abdominal pain. Pt reports pain started a few weeks ago, was intermittent, epigastric, worse with food. Associated nausea, no emesis or diarrhea. Pain has been increasing and today became constant, more severe. Patient denies any fevers/chills. Went to ___ where he had CT scan which showed 2.6cm stone in his distal CBD, mild duct dilatation, bili 2.6. Pt transferred to BIDED for ERCP. In ED pt given morphine and then dilaudid for pain. ROS: +as above, otherwise reviewed and negative Past Medical History: None Social History: ___ Family History: No GB disease Physical Exam: Admission: Vitals: T:97.5 BP:110/69 P:61 R:16 O2:100%ra PAIN: 2 General: nad EYES: anicteric Lungs: clear CV: rrr no m/r/g Abdomen: bowel sounds present, soft, mildly tender RUQ Ext: no e/c/c Skin: no rash Neuro: alert, follows commands Discharge: No distress 98.1, 107/59, 58, 16, 100% RA Pain: ___ Anicteric, MMM CTAB RR, nl rate, no murmur soft, nontender, nondistended, pos bowel sounds no rash alert, oriented, ambulates without difficulty Pertinent Results: Admission Exam: ___ 06:34PM GLUCOSE-80 UREA N-11 CREAT-0.8 SODIUM-142 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18 ___ 06:44PM LACTATE-0.7 ___ 06:34PM ALT(SGPT)-244* AST(SGOT)-138* ALK PHOS-99 TOT BILI-2.3* ___ 06:34PM LIPASE-36 ___ 06:34PM ALBUMIN-4.3 ___ 06:34PM WBC-7.6 RBC-4.90 HGB-15.4 HCT-43.2 MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 ___ 06:34PM NEUTS-60.7 ___ MONOS-4.8 EOS-4.4* BASOS-0.5 ___ 06:34PM PLT COUNT-220 ___ 06:34PM ___ PTT-29.8 ___ ___ 06:34PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG Discharge Exam: ___ 06:00AM BLOOD WBC-6.6 RBC-4.62 Hgb-14.3 Hct-40.8 MCV-88 MCH-31.0 MCHC-35.1* RDW-12.5 Plt ___ ___ 05:50AM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-139 K-4.5 Cl-110* HCO3-21* AnGap-13 ___ 05:50AM BLOOD ALT-184* AST-79* AlkPhos-88 TotBili-3.1* ___ 06:00AM BLOOD ALT-141* AST-47* AlkPhos-89 TotBili-2.6* ERCP: The scout film was normal. During biliary cannulation, the pancreatic duct was partially filled with contrast and visualized proximally. The course and caliber of the duct was normal with no evidence of filling defects, masses, chronic pancreatitis or other abnormalities. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. The CBD was 8mm in diameter. One filling defect consistent with a stone was identified in the distal CBD. Opacification of the gallbladder was incomplete. The left and right hepatic ducts and all intrahepatic branches were normal. A biliary sphincterotomy was made with a sphincterotome. There was no post-sphincterotomy bleeding. The biliary tree was swept with a balloon starting at the bifurcation. One stone was removed. The CBD and CHD were swept repeatedly until no further stones were seen. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Overall, successful ERCP with sphincterotomy and stone extraction. Brief Hospital Course: ___ with abdominal pain due to choledocholithiasis. # Choledocholithiasis: He presented with abdominal pain and found to have choledocholithiasis and transaminitis. He had ERCP with stone extraction and sphincterotomy. He was given 5 days of cipro to prevent infection. Afterwards, his diet was advanced and he did well. He was pain free and without nausea at discharge. He was warned of bleeding and pancreatitis complications. He did not have evidence of cholelithiasis. CCY may still be indicated. He was urged to discuss this with his PCP at follow up. In addition, we recommended trending LFTs until resolution (this was discussed with the patient). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Transaminitis Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain. You were found to have a gall stone in your bile duct. You had a procedure to remove this. We set you up with a follow up appointment at ___. It is important to keep this to #1 get repeat labs to make sure your liver function tests return to normal and #2 to discuss a possible cholecystectomy (gall bladder removal). Please avoid medications like aspirin or NSAIDs (ie ibuprofen) for the next 4 days. You were started on an antibiotic to prevent an infection in the area. Followup Instructions: ___

{'abdominal pain': ['Choledocholithiasis'], 'epigastric': ['Choledocholithiasis'], 'nausea': ['Choledocholithiasis'], 'transaminitis': ['Choledocholithiasis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Darvon / Penicillins / Codeine / Motrin Attending: ___. Chief Complaint: Pain at ___ Site Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M PMH significant for HIV, HCV, low back pain on chronic narcotics, urinary retention s/p foley placement who has had numerous admissions this month in relation to the foley now found to have complicated UTI. The patient was discharged from the ED, the morning of admission and returned because he was having discomfort at the site of the foley. He was told by his ___ that he should go to the ED. He reports that he may have been having fevers, but is unclear. Denies chills, chest pain, SOB, Nausea, vomiting, abdominal pain. In the ED, initial vitals: 97.4 67 154/58 18 94% RA. Patient's labs were ntoable for Chem 7, CBC WNL. UA showed large # WBC, + leukocytes, + nitrates. Lactate 1.1. Blood cultures were sent. He received actemainophen, ciprofloxacin, phenazopyridine, vancomycin (given that previous urine culture positive for corynebactermium) and oxycodone. He failed a voiding trial in ED and foley was placed. Vitals prior to transfer: 98.0 73 152/83 18 98% RA Currently, Patient reports that he has ___ back pain. ROS: per HPI, 10 pt ROS neg except for above. Of note, +pain at ___ site. Past Medical History: Depression ? mild dementia HIV on HAART Hepatitis C, reportedly s/p interferon treatment self-administered for ___ year Hypertension Lumbar Stenosis s/p spinal fusion in ___ for back pain Sciatica BPH urinary retention anxiety B12 deficiency Social History: ___ Family History: As per OMR: Father was an alcoholic and died of complications, unsure of how mother died Physical ___: ADMISSION PHYSICAL EXAM: ======================== Vitals- 98.3 170/64 82 20 97%RA General- AOx3 no NAD HEENT- Sclera anicteric, MMM, oropharynx clear, Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding GU- + foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, fluent speech DISCHARGE PHYSICAL EXAM: ======================== Vitals- 98.5 149/68 74 18 98%RA General- AOx3 no NAD HEENT- Sclera anicteric, MMM, oropharynx clear, Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present GU- + foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, fluent speech Pertinent Results: ADMISSION LABS: ===================== ___ 04:00PM BLOOD WBC-10.1 RBC-4.03* Hgb-12.5* Hct-37.9* MCV-94 MCH-30.9 MCHC-33.0 RDW-13.5 Plt ___ ___ 04:00PM BLOOD Glucose-113* UreaN-10 Creat-0.9 Na-139 K-3.5 Cl-98 HCO3-30 AnGap-15 IMAGING: =========== None MICRO: ============ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: =================== ___ 06:10AM BLOOD WBC-7.9 RBC-3.70* Hgb-11.6* Hct-34.2* MCV-92 MCH-31.5 MCHC-34.1 RDW-14.0 Plt ___ ___ 04:00PM BLOOD Glucose-113* UreaN-10 Creat-0.9 Na-139 K-3.5 Cl-98 HCO3-30 AnGap-___ y/o M PMH significant for HIV, HCV, low back pain on chronic narcotics, urinary retention s/p foley placement who has had numerous admissions this month in relation to the foley now found to have complicated UTI. ACTIVE ISSUES: =================== # Complicated UTI: foley removed in ED, failed voiding trial. Therefore another foley was placed in the ED. The patient had a positive UA and given that patient is symptomatic with pain at the foley, it was determined to treat for complicated UTI. Given that he had previously had a urine culture with corynebacterium he was started on vancomycin/cipro while cultures were pending. His cultures revealed E.coli with variable sensitivities, but resistant to ciprofloxacin. The patient was switched to bactrim with a plan treatment duration of 7 days with the last day being on ___. His foley was removed given that his E.coli was not being treated with ciprofloxacin and he passed the voiding trial. # Urinary Retention requiring foley. Failed voiding trial in ED. He was continued on finasteride and tamsulosin was not started given the interactions with ritonavir. He passed the voiding trial on the floor and the patient was discharged without a foley catheter. CHRONIC ISSUES: ================== # Low Back Pain/sciatica:Patient was continued on oxycontin 10mg q12h and oxycodone. # HIV: Patient was continued on darunavir, emtricitabine, ritanovir, raltegravir, and acyclovir. # HTN: He was continued on amlodipine, metoprolol. # GERD: He was continued on omeprazole. TRANSITIONAL ISSUES: ======================== # Urinary retention: he was discharged without a foley Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Zolpidem Tartrate 5 mg PO HS 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Amlodipine 10 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Cyanocobalamin 1000 mcg IM/SC ONCE 6. Acyclovir 400 mg PO Q12H 7. LOPERamide 2 mg PO QID:PRN diarrhea 8. Finasteride 5 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO BID 11. Darunavir 600 mg PO BID 12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 14. Raltegravir 400 mg PO BID 15. Emtricitabine 200 mg PO Q24H 16. RiTONAvir 100 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Amlodipine 10 mg PO DAILY 3. Darunavir 600 mg PO BID 4. Emtricitabine 200 mg PO Q24H 5. Finasteride 5 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 10. Raltegravir 400 mg PO BID 11. RiTONAvir 100 mg PO BID 12. Zolpidem Tartrate 5 mg PO HS 13. Cyanocobalamin 1000 mcg IM/SC ONCE 14. Fish Oil (Omega 3) 1000 mg PO BID 15. LOPERamide 2 mg PO QID:PRN diarrhea 16. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 17. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Complicated UTI Secondary: HIV, HTN, Chronic low back pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you here at ___ ___ ___. You came to the hospital because you were having pain at the location of your foley. This most likely was caused by a urinary tract infection. You were given antibiotics called bactrim that you will need to take for a total of 7 days with your last day being on ___. Your foley catheter was removed and you were able to urinate afterwards. Our physical therapists evaluated you and believed you were safe to go home with physical therapy at home. Followup Instructions: ___

{'Pain at ___ site': ['Urinary tract infection', 'Other chronic pain'], 'Fever': ['Urinary tract infection'], 'Discomfort at the site of the foley': ['Urinary tract infection'], 'Back pain': ['Other chronic pain'], 'Low back pain': ['Other chronic pain'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'HCV': ['Chronic hepatitis C without mention of hepatic coma'], 'Hypertension': ['Unspecified essential hypertension'], 'GERD': ['Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: Darvon / Penicillins / Codeine / Motrin Attending: ___. Chief Complaint: BENIGN PROSTATIC HYPERTROPHY WITH URINARY RETENTION, INCOMPLETE BLADDER EMPTYING, REQUIRING CLEAN INTERMITTENT CATHETERIZATION. Major Surgical or Invasive Procedure: BIPOLAR TRANSURETHRAL RESECTION OF PROSTATE History of Present Illness: Mr. ___ is a ___ year old male who presents for transurethral resection of prostate. Past Medical History: Depression ? mild dementia HIV on HAART Hepatitis C, reportedly s/p interferon treatment self-administered for ___ year Hypertension Lumbar Stenosis s/p spinal fusion in ___ for back pain Sciatica BPH urinary retention anxiety B12 deficiency Social History: ___ Family History: Father was an alcoholic and died of complications, unsure of how mother died Physical ___: WDWN male, nad, avss abdomen soft, nt/nd extremities w/out edema, pitting, pain. foley has been removed Pertinent Results: ___ 09:05AM BLOOD Glucose-101* UreaN-10 Creat-1.0 Na-136 K-3.5 Cl-100 HCO3-28 AnGap-12 ___ 02:24PM BLOOD Glucose-94 UreaN-16 Creat-1.5* Na-135 K-3.9 Cl-99 HCO3-27 AnGap-13 ___ 02:24PM BLOOD Calcium-9.2 Phos-3.8# Mg-1.8 Brief Hospital Course: Mr. ___ was admitted to Urology 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 complicated only by delayed return to baseline respiratory status. He received intravenous antibiotics and continuous bladder irrigation overnight. On POD1 the CBI was discontinued and Foley catheter was removed. He passed his voiding trial but as stated, it took two additional days of aggressive pulmonary toileting before he was able to maintain room air oxygen saturation at above 92%. Mr. ___ to 87% on room air while ambulating (remained asymptomatic) however he was mobilizing safely and independently at the time. On room air Mr. ___ ___ hovered around 90% for hospital days 0 to 2. He was noted at 95% at PREOP pre-admission testing and notes from Pysical therapy eval in ___ reflect room air sats, at rest, around 94%. Mr. ___ feels he is at his baseline. On discharge he was maintaining 94-95% on room air. His urine was clear and without clots. He remained a-febrile throughout his hospital stay. At discharge, the patient had pain well controlled with oral pain medications, was tolerating regular diet, ambulating with assistance. He was given oral pain medications on discharge and a course of antibiotics along with explicit instructions to follow up in clinic. He will resume visiting nurse services and home ___ on discharge home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Acyclovir 400 mg PO Q12H 3. Amlodipine 10 mg PO DAILY 4. Darunavir 600 mg PO BID 5. Emtricitabine 200 mg PO Q24H 6. Gabapentin 1200 mg PO BID 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Paroxetine 40 mg PO HS 10. Raltegravir 400 mg PO BID 11. RiTONAvir 100 mg PO BID 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Cyanocobalamin 1000 mcg IM/SC Q1MO Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Amlodipine 10 mg PO DAILY 3. Darunavir 600 mg PO BID 4. Emtricitabine 200 mg PO Q24H 5. Finasteride 5 mg PO DAILY 6. Gabapentin 1200 mg PO BID 7. LOPERamide 2 mg PO QID:PRN diarrhea 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Paroxetine 40 mg PO HS 11. Raltegravir 400 mg PO BID 12. RiTONAvir 100 mg PO BID 13. Cyanocobalamin 1000 mcg IM/SC Q1MO 14. Acetaminophen 650 mg PO Q6H:PRN pain 15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg Half to ONE full tablet(s) by mouth Q6hrs Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Benign prostatic hypertrophy with incomplete bladder emptying requiring clean intermittent catheterization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge 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 -ALWAYS follow-up with your PCP to review your post-operative course, medications and disposition. You will also need to follow up regarding your potential need of supplemental oxygen, especially overnight. -Resume all of your pre-admission medications -Complete a course of antibiotics IF prescribed. -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). If you go home with a Foley catheter: -You will return in one week to allow more healing time and then you will repeat the trial of void. DO NOT RESUME clean intermittent catheterization (CIC) unless advised to do so. -You will resume your pre-admission visiting nurse services and home ___. Continue with regular "timed" voids to promote effective bladder emptying. Followup Instructions: ___

{'urinary retention': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)'], 'incomplete bladder emptying': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)'], 'depression': ['Depressive disorder, not elsewhere classified'], 'dementia': ['Dementia, without behavioral disturbance'], 'B12 deficiency': ['Other B-complex deficiencies'], 'anxiety': ['Anxiety state, unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: Verapamil / Compazine Attending: ___. Chief Complaint: "embarassed" (Presented to ED with suicidality) Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ with a history of depression who presents with suicidal ideation and plan to overdose on percocet in the setting of multiple psychosocial stressors. Patient states that yesterday, she went to visit her family cemetary site as it was the ___ year anniversary of her father's death. Afterwards, she was sitting in her car at the train tracks and a train was coming. She considered driving up onto the tracks. She says everyone would think it was an "accident." Despite these thoughts, she did not move her car forward. She then met her brother for lunch and a drink. She had not been drinking recently as she gave up EtOH for lent, but had ___ drinks. In the evening, she knew she could not drive home because of her intoxication, so her kids picked her up. She admits that she had drank too much and as a result told her kids something that she had been hiding from them; that she had an emotional affair with another man and that her relationship with their father was having difficulty. The kids reassured her. Then at approximately 3 in the morning, she was contemplating taking percocets or oxycodone. She had a bottle left over from after a surgery. She opened the bottle and got some water to take the pills, but then thought that if she overdosed her kids would find her. She did not want to put that on her children, so she called her friend ___ instead. With ___ support, she called her PCP ___ referred her to the ED. At some point she wrote a note: "I love the 3 of you with all of my heart - I can't stand my failures - I don't know why my brain broke. Be happy please. I want to move. Start over. Live differently." She has multiple stressors in her life: - Work: ___ - Personal: Father's death ___ years ago (refers to him as her best friend). ___ affair with an older man, which her husband found out about. Now there is marital stress; they are in couples counseling, and they are "staying together for the children." Past Medical History: PAST PSYCHIATRIC HISTORY: Diagnoses: Depression Hospitalizations: Denies. Current treaters and treatment: Denies current treaters. Previously saw ___ for ___ year, stopped in ___ (___). Was referred to a psychiatrist, but only saw him once or twice. Medication and ECT trials: Citalopram (___), Fluoxamine (___) Self-injury: Denies. Harm to others: Denies. Access to weapons: Denies. PAST MEDICAL HISTORY: PCP: Dr. ___ of pyelonephritis with left renal calculus Bell's Palsy History of recurrent bronchitis Malrotated slightly atrophic right kidney Uterine fibroids Left ECU tenosynovitis s/p synovectomy Denies history of seizures and head injuries. Social History: SUBSTANCE ABUSE HISTORY: EtOH: Recently gave up EtOH for lent. Drank ___ beverages yesterday. Normally drinks ___ beverages upon occassion. Husband may have said to drink less EtOH rarely after she said something embarrassing. Vomited from EtOH as a teen. Denies withdrawal symptoms. Tobacco: As a teenager. MJ and cocaine: Tried once ___ years ago. Denies other substances or misusing pills. SOCIAL HISTORY: ___ Family History: People have had periods of feeling a little depressed, but never diagnosed with anything. No familial suicide attempts. Brother drank to much when he was younger. Physical Exam: EXAM: *VS: T 98.6 P 78 BP 142/76 RR 18 SpO2 100% Neurological: *station and gait: Normal station and gait. *tone and strength: Normal tone. ___ strength. cranial nerves: Intact; facial droop not noted. abnormal movements: None noted. FNF intact. No tremor. Cognition: Wakefulness/alertness: Alert, *Attention: MOYB intact. *Orientation: Oriented to self, BI ED and ___. *Memory: ___ registration and recall. Recalls past 3 presidents. *Fund of knowledge: ___ and ___ as ___ plays. Calculations: 7 quarters in $1.75. Abstraction: Apples/Orange: Fruit Apple/Fall/Tree: "People often are a product of their environment." *Speech: Regular volume, rate, tone. *Language: Intact. Naming of glasses, clipboard, pen. Mental Status: *Appearance: Thin caucasian female in sweatpants and sweatshirt sitting in bed. Behavior: Frequently crying, fair eye contact, no PMR/PMA. *Mood: "Embarrassed" "Lonely" Affect: Distressed and tearful. Congruent. No lability. *Thought process / *associations: Goal directed. At times tangential when speaking of stressors. No loosening of associations. *Thought Content: SI with plan at presentation; currently with passive SI. Denies HI, AVH. Multiple stressors (family, work, anniversay of father's death), concern for people's perception of her changing. *Judgment and Insight: Insight into her depression and that she needs help. Showed good judgement in seeking help from friend. Pertinent Results: ___ 06:45AM BLOOD WBC-12.2*# RBC-4.35 Hgb-13.8# Hct-40.6 MCV-94 MCH-31.7 MCHC-33.9 RDW-12.4 Plt ___ ___ 06:45AM BLOOD Neuts-83.1* Lymphs-13.7* Monos-2.4 Eos-0.3 Baso-0.5 ___ 06:45AM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-144 K-3.3 Cl-102 HCO3-25 AnGap-20 ___ 06:45AM BLOOD TSH-0.58 ___ 06:45AM BLOOD T4-8.8 ___ 06:45AM BLOOD ASA-NEG Ethanol-26* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: #) Psychiatric At admission Ms ___ was found to be exceedingly dysphoric with overwhelming tearfulness and sense of hopelessness, and ambivalence around her hospitalization. On the unit she again endorsed the numerous depressive symptoms such as insomnia, decreased energy, guilt, and prior suicidality though seemed prone to minimizing the severity of the episode, especially early on. She also agreed that recent escalating alcohol use likely contributed to her acute change and need for presentation. For her apparent major depressive episode she was started on bupropion SR 100mg BID, which she tolerated and was increased to 150mg BID and continued through discharge. Trazodone at 25mg was also used for insomnia on a PRN basis with good effect. She experienced fair improvement in her mental status with decreased mood reactivity and tearfulness and better interpersonal engagement with the team later in her course. Over her short hospitalization she was consistently visible on the unit milieu and in groups with positive interactions with other patients. She consistently denied any further lingering suicidal ideations after her initial eval in the ED. Her insight into the severity of the episode and need for multi-faceted treatment also improved closer to discharge. #) Alcohol History suggests and the patient agrees that alcohol misuse likely played a role in the decompensation and presentation leading to this admission. She agreed that eliminating this as a contributing agent would be a good idea. Does likely meet criteria for abuse though not full dependence. #) Medical Her home diuretic and hormone replacement were continued and no particular intervention was required. She noticed a mild headache and question of asymmetry of the facial musculature at one point though neuro exam was negative and the HA resolved with ibuprofen. #) Legal Ms ___ signed in voluntarily and remained as such for the duration of her course. #) Social/Dispo: Ms ___ immediate family was involved as she wished for treatment and discharge planning. Husband ___ came to visit over weekend and again for collective meeting with the team day prior to d/c. She will return home and pick up care with new outpatient providers including, briefly, the ___ ___ immediately after discharge. #) Risk assessment: Ms ___ carries a small number of chronic risk factors for poor outcome like self-harm or suicide, namely her limited insight and willingness to participate in mental health treatment. Acute risk factors which have been addressed include major depressive episode, alcohol misuse behaviors, and lack of outpatient treatment outreach. She remains protected by her education and work motivation with good future orientation, sex, lack of major substance dependence, lack of access to weapons, and dependent children. This profile suggests the outpatient setting will be the least restrictive sufficient environment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiloride HCl 5 mg PO DAILY 2. Hydrochlorothiazide 50 mg PO DAILY 3. Necon ___ (28) *NF* (norethindrone-ethin estradiol) ___ mg-mcg Oral Daily Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO BID RX *bupropion HCl [Wellbutrin SR] 150 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 2. traZODONE 25 mg PO HS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*15 Tablet Refills:*0 3. Amiloride HCl 5 mg PO DAILY 4. Hydrochlorothiazide 50 mg PO DAILY 5. Necon ___ (28) *NF* (norethindrone-ethin estradiol) ___ mg-mcg Oral Daily Discharge Disposition: Home Discharge Diagnosis: Axis I: Major depressive disorder Axis II: deferred Axis III: History of pyelonephritis with left renal calculus Bell's Palsy History of recurrent bronchitis Discharge Condition: VS: 98.3 71 124/81 16 99%RA MSE: Appearance: blonde woman appears stated age wearing t-shirt and sweatpants, clean and brushed hair, some makeup, medium build Gait/tone: both appear normal Behavior: generally calm and cooperative, seated comfortably in interview room, no PMR/PMA observed, no adventitious mvmts Speech: grossly normal rate/tone/prosody, no slurring/dysarthria Mood: 'better' Affect: reactive though less so from ___, more euthymic overall, remains mood- and content-congruent Thought Process: generally logical and goal-directed though some perseveration around leaving the hospital and her rights being removed (nonpsychotic) Thought Content: no prominent delusions/paranoia Perceptions: denies Auditory/Visual/Somatic hallucinations; not appearing to respond to internal stim Suicidality/Homicidality: denies both currently Insight/Judgment: both somewhat limited into the nature and severity of her depressive symptoms and need for tx, though appear improved from last wk Cognitive Exam: awake and alert, oriented to place, date, person, situation; memory, concentration, attention grossly intact during interview but not formally tested Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you felt unstable and suicidal. You improved while in the hospital. It has been a pleasure taking care of you. We wish you good luck in your recovery! -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. Followup Instructions: ___

{'suicidal ideation': ['Major depressive affective disorder', 'Suicidal ideation'], 'alcohol abuse': ['Alcohol abuse'], 'family disruption due to death of family member': ['Family disruption due to death of family member'], 'anxiety state': ['Anxiety state'], 'insomnia': ['Insomnia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: L hip OA Major Surgical or Invasive Procedure: L THR History of Present Illness: ___ with L hip OA Past Medical History: R shoulder rotator cuff tear s/p surgical repair, hypertension, chronic LBP Social History: ___ Family History: Family history is noncontributory. Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema ___ intact SILT distally Pertinent Results: ___ 06:20AM BLOOD WBC-7.9 RBC-2.49* Hgb-8.2* Hct-23.8* MCV-96 MCH-32.9* MCHC-34.4 RDW-12.5 Plt ___ ___ 06:10AM BLOOD WBC-7.0 RBC-2.90*# Hgb-9.7* Hct-27.8* MCV-96 MCH-33.3* MCHC-34.8 RDW-12.4 Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-106* UreaN-7 Creat-0.9 Na-139 K-3.4 Cl-106 HCO3-29 AnGap-7* ___ 06:10AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7 Brief Hospital Course: The patient was admitted on ___ and, later that day, was taken to the operating room by Dr. ___ L THR without complication. Please see operative report for details. Postoperatively the patient did well. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services in a stable condition. The patient's weight-bearing status was WBAT. Medications on Admission: cymbalta, neurontin, topamax, verapamil, vit D Discharge Medications: 1. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 7. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: Do not drink, drive or operate heavy machinery while taking this medication. Disp:*80 Tablet(s)* Refills:*0* 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 10. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks: To be followed by aspirin 325mg twice daily for 3 weeks. Disp:*21 syringe* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L hip OA Discharge Condition: Stable Discharge Instructions: 1. Please return to the emergency department or notify MD if you experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by ___ in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT Treatments Frequency: Physical therapy. Lovenox injections. Wound checks. ___ to remove staples at 2 weeks. Followup Instructions: ___

{'L hip OA': ['Osteoarthrosis', 'pelvic region and thigh'], 'hypertension': ['Unspecified essential hypertension'], 'chronic LBP': ['Lumbago'], 'smoking history': ['Tobacco use disorder'], 'GERD': ['Esophageal reflux'], 'L THR': ['Hip joint replacement']}

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: preterm premature rupture of membranes Major Surgical or Invasive Procedure: Dilation and Evacuation History of Present Illness: ___ G1P0 @ 18w6d by LMP presenting after she felt a gush of clear fluid yesterday that has continued intermittenly and required her to wear a pad since. She denies VB and ctx. She has not felt sick: no fevers/chills, no urinary or vaginal symptoms, regular bowel movements, no rashes, no N/V. Reports mild abdominal discomfort in LLQ that feels like "a muscle pull" that started 2 days ago. Feels the discomfort w/ movement and palpation. Has been feeling stressed and tired secondary to a recent move. Pregnancy uncomplicated other than bleeding from a cervical polyp earlier in the pregnancy. The patient is s/p coloscopy ___ which was technically unsatisfactory, no features of premalignant dz - recommendation for f/u in 2 months. Past Medical History: POBHx: -G1 PGynHx: -Denies STDs (husband w/ hx of chlamydia) -pap ___ ASC-US, negative HPV -Colpo ___: technically unsatisfactory, large vascular endocervical polyp without features of premalignant disease. Rec: f/u for repeat evaluation of polyp in 2 months PMH: -ulcerative colitis dx ___ ago, currently in remission, no sxs, no meds, last hospitalized for flare ___ PSH: -none Social History: ___ Family History: Non-contributory Physical Exam: PE: T 98.4 HR 89 BP 108/69 O2 100% RA NAD CTA bilaterally RRR Abd soft, gravid, mildly tender to deep palpation in the left lower quadrant. SVE: cervix closed SSE: approx. 1cm friable appearing endocervical polyp, os appears closed, gush of fluid visible from cervix, +pooling, +nitrazine, +ferning Pertinent Results: ___ 05:40PM ___ PTT-23.5 ___ ___ 11:25AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 11:25AM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 10:55AM WBC-11.0 RBC-3.68* HGB-12.0 HCT-32.6* MCV-89 MCH-32.5*# MCHC-36.7*# RDW-13.4 ___ 10:55AM NEUTS-85.0* LYMPHS-9.6* MONOS-4.6 EOS-0.5 BASOS-0.3 ___ 10:55AM PLT COUNT-282 Brief Hospital Course: Ms. ___ was admitted to the gynecology service after being found to have preterm premature rupture of membranes at approximately 19 weeks gestational age. There was nothing in the patient's history or evaluation to suggest an etiology for PPROM. Options for management were discussed with the patient and her husband and they elected for a dilation and evacuation procedure. Laminaria were placed for cervical dilation. She was admitted overnight for pain control as well as intravenous antibiotics for prevention/treatment of chorioamnionitis. On HD#2 the patient underwent an uncomplicated D&E. For full details of the procedure please see Dr. ___ report. The patient recovered well from the procedure and was discharged home on POD#0/HD#2, ambulating, eating a regular diet, voiding, with pain controlled on oral medication with instructions to follow up with her primary Ob/Gyn. She was given a prescription for a course of Doxycycline to finish a total of 7 days of antibiotic treatment. Medications on Admission: prenatal vitamin Discharge Medications: 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 6 days. Disp:*12 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: preterm premature rupture of membranes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please take your medications as prescribed. Do not drink alcohol or operate machinery while taking percocet. Do not take a shower for 24hrs. Do not take a tub bath or swim for 1 week. Nothing in the vagina (no tampons/intercourse) for 2 weeks. Followup Instructions: ___

{'abdominal discomfort': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'clear fluid': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'feeling stressed': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'tired': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'mild abdominal discomfort': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'muscle pull': ['Spontaneous abortion', 'without mention of complication', 'incomplete']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ w/ h/o CLL and systolic murmur who presents s/p syncope and fall from standing. She had a mechanical fall approximately one week ago due to loss of balance, but did not black out. Today, she was in the kitchen cooking when she felt a bit weak, went and sat down for a brief period. Later, she felt better and resumed cooking. She felt weak again, blacked out and awoke on the floor. She pushed her med alert button, and EMS transported to ___. She does not believe that she hit her head, but was unconscious at the time of impact with the ground. The patient denies any chest pain, dizziness or dyspnea, and no history of these. She denies dysuria, cough, fevers, chills, diarrhea, pain or changes in vision. She does have intermittent constipation. In the ED, initial VS were:97 72 122/57 18 100% Chem 7 unremarkable. CBC remarkable for Hct of 27.7 and plt 19. On arrival to the floor, patient has no complaints and has no areas of pain from the fall. REVIEW OF SYSTEMS: (+) occasional constipation (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: CHRONIC LYMPHOCYTIC LEUKEMIA (cycle 1 of rituxin in ___, previously attempted one cycle of bendamustine; recent bone marrow biopsy approx a week ago) MDS GOUT HYPERLIPIDEMIA HYPERTENSION PERIPHERAL VASCULAR DISEASE VERTIGO Social History: ___ Family History: She thinks her father might have had prostate cancer. There are no other known cancers in the family. No blood disorders. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.4 150/54 64 18 100%RA GENERAL - well-appearing, in NAD, comfortable, appropriate, quite pleasant HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, JVP 9cm H2O LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, III/VI systolic murmur heard best in RUSB with radiation to carotids ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions; no traumatic injuries appreciated on exam LYMPH - no cervical, or supraclavicular LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Discharge Exam VS - 98.4 127/42 66 18 98%RA lying: 128/60 standing: 118/58 Tele: ___ few PVCs GENERAL - well-appearing female, in NAD, comfortable, appropriate, quite pleasant HEENT - NCAT, PERRL, EOMI, crusting around left eye with erythema and purulence in nasal portion of left conjunctiva, MMM, OP clear NECK - supple, LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, III/VI systolic murmur heard best in RUSB & radiates to carotids ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, or supraclavicular LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: Admission Labs: ___ 08:20PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:20PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE EPI-0 ___ 05:48PM GLUCOSE-110* UREA N-22* CREAT-0.8 SODIUM-139 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15 ___ 05:48PM estGFR-Using this ___ 05:48PM CK(CPK)-121 ___ 05:48PM CK-MB-4 cTropnT-<0.01 ___ 05:48PM WBC-4.3 RBC-2.56* HGB-9.6* HCT-27.7* MCV-108* MCH-37.6* MCHC-34.8 RDW-25.1* ___ 05:48PM NEUTS-64.4 ___ MONOS-5.5 EOS-2.7 BASOS-0.3 ___ 05:48PM PLT COUNT-19*# Imaging: CT HEAD W/O CONTRAST (___): No acute intracranial process CXR (___): IMPRESSION: 1. No focal consolidation. Slight blunting of the posterior right costophrenic angle may be artifactual, although trace pleural effusion not excluded. 2. Hiatal hernia. 3. Persistent cardiomegaly without overt pulmonary edema. TTE (___): The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Preserved biventricular systolic function. Moderate-severe tricuspid regurgitation with moderate pulmonary artery systolic hypertension. Discharge Labs: ___ 06:30AM BLOOD WBC-5.4 RBC-2.55* Hgb-9.7* Hct-27.8* MCV-109* MCH-37.9* MCHC-34.7 RDW-25.1* Plt Ct-21* ___ 06:30AM BLOOD Glucose-100 UreaN-23* Creat-1.1 Na-139 K-4.0 Cl-102 HCO3-29 AnGap-12 ___ 06:30AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ with a history of chronic lymphocytic leukemia, anemia, and thrombocytopenia who presents s/p syncopal episode today and was found to have a systolic murmur. Active Issues: # Syncope: Pt with single syncopal episode. No traumatic injuries on exam. CT head was unremarkable. The patient's infectious work up has been unrevealing. Patient has not had any chest pain or dyspnea, but considering pt's murmur and age, may have significant AS lesion. Syncope work up was negative revealing negative cardiac enzymes x2, no significant arrhythmias on telemetry, echo showed TR and PR but not AS, and orthostatic vitals were within normal limits. It is unlikely that patient had a stroke given no focal neurologic deficits or seizure since there was no reports of tongue biting, urinary incontinence, or shaking. Pt symptoms could be from her anemia, although her H/H were at her baseline. On discharge pt no longer was dizzy or lightheaded. # Anemia: Patient's anemia likely secondary to CLL and treatment effects. Her H/H is consistent with prior recent values, if not a bit higher. We trended her lab values and they were stable. # Thrombocytopenia: pt with profound thrombocytopenia with plts 19K. Again, consistent w/ recent priors, and likely secondary to known CLL and treatment effects. Pt did not have any signs of significant hematoma from her fall. # CLL: Pt is s/p 1 cycle of Rituxan and a BM biopsy 1 week ago with results of this pending. I notified pt oncologist Dr. ___ her admission as well as the hematology-oncology felllow. Pt will follow up with Dr. ___ as an outpatient for results of BM biopsy and next step in treatment plan. # Conjunctivitis: Pt developed redness and crusting of her left eye while in hospital. This appeared to be a conjunctivitis which was treated initially with erythromycin ointment. On discharge pt was given prescription for trimethoprim-polymixin eye drops for the remainder of 7 days of treatment. Pt eye should be re-evaluated at her post hospitalization PCP ___. Chronic Issues: # HTN: mildly hypertensive 150/54 on arrival. We initially held pt hypertension medications given her syncopal episode. We then continue enalapril, amlodipine, and atenolol and pt remained normotensive. # GERD: Pt was asymptomatic so we continued omeprazole. Transitional Issues: 1. Pt will need left eye re-evaluated s/p 7 days of antibiotic eye drops for conjunctivitis. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Polyethylene Glycol 17 g PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Atorvastatin 10 mg PO DAILY 4. Amlodipine 5 mg PO DAILY 5. Moexipril 15 mg PO DAILY 6. Allopurinol ___ mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Magnesium Oxide 400 mg PO TID 10. Omeprazole 10 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea 12. Prochlorperazine 5 mg PO Q6H:PRN nausea 13. Senna 1 TAB PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Moexipril 15 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Senna 1 TAB PO DAILY 10. Magnesium Oxide 400 mg PO TID 11. Ondansetron 8 mg PO Q8H:PRN nausea 12. Prochlorperazine 5 mg PO Q6H:PRN nausea 13. Omeprazole 10 mg PO DAILY 14. Artificial Tears ___ DROP LEFT EYE Q4H:PRN dry eye RX *peg 400-hypromellose-glycerin [Artificial Tears] 1 %-0.2 %-0.2 % ___ drops in each eye Q4H:PRN dry eye Disp #*1 Bottle Refills:*0 15. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B) 0.1-10,000 %-unit/mL OS QID Duration: 7 Days RX *trimethoprim-polymyxin B 10,000 unit/mL-0.1 % 2 drops(s) OS four times a day Disp #*1 Bottle Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___

{'Syncope': ['Syncope and collapse'], 'Fall': ['Syncope and collapse'], 'Weakness': ['Syncope and collapse', 'Chronic lymphoid leukemia', 'without mention of having achieved remission'], 'Constipation': ['Other and unspecified hyperlipidemia'], 'Systolic murmur': ['Peripheral vascular disease', 'unspecified'], 'Anemia': ['Anemia in neoplastic disease'], 'Thrombocytopenia': ['Other secondary thrombocytopenia'], 'Conjunctivitis': ['Conjunctivitis', 'unspecified'], 'Hypertension': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Gout': ['Gout', 'unspecified'], 'Esophageal reflux': ['Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. ___ is a ___ male with poorly differentiated penile squamous cell carcinoma s/p partial penectomy in ___ with rapid metastatic recurrence to soft tissue and RP nodes who presents for cycle 3 of TIP. He is feeling well. He notes occasional dizziness and mild numbness in his fingers. He denies fevers/chills, headache, vision changes, weakness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY: - ___: reported penile pain and bleeding to his PCP present for about 2 months. - ___: CT torso showing no clear metastatic disease. - ___: Distal partial penectomy, path showing poorly differentiated squamous cell carcinoma with sarcomatoid and acantholytic features, pT3. Dr. ___ inguinal ___ on ___ but patient had some difficult social circumstances as he was primary caretaker for his wife. - ___: At follow-up visit, he had a new 2x2 cm lesion in the left groin. - ___: CT pelvis showing extensive new retroperitoneal lymphadenopathy and new rim enhancing metastasis in the pre-pubic fat to the left of midline. - ___: Initial med onc evaluation, planned to complete restaging and begin palliative TIP, for which patient consented. - ___: C1D1 TIP - ___: C2D1 TIP PAST MEDICAL HISTORY: - Metastatic Penile SCC with sarcomatoid and acantholytic features, as above - Rheumatoid Arthritis previously treated with Plaquenil, MTX, sulfasalaine, leflunomide - Type 2 Diabetes Mellitus - Asthma - +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin - Osteoarthritis - Right Bundle Branch Block - Ventral Hernia - Hypertension - Hyperlipidemia Social History: ___ Family History: Mother deceased at ___. Father deceased at ___ from blood cancer. No family history of colon, lung, or prostate cancer. Physical Exam: ======================== Discharge Physical Exam: ======================== VITAL SIGNS: ___ 0807 Temp: 98.2 PO BP: 121/68 HR: 66 RR: 18 O2 sat: 100% O2 delivery: ra General: NAD HEENT: MMM CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+ SNT/ND LIMBS: No ___, WWP SKIN: No rashes on extremities NEURO: Speech fluent, strength grossly intact, ambulating in hallway well PSYCH: thought process logical, linear, future oriented ACCESS: chest port site intact w/o erythema, accessed and dressing C/D/I Pertinent Results: =============== Admission Labs: =============== ___ 02:03PM BLOOD WBC-9.2 RBC-3.14* Hgb-9.5* Hct-29.2* MCV-93 MCH-30.3 MCHC-32.5 RDW-18.0* RDWSD-60.0* Plt ___ ___ 02:03PM BLOOD Neuts-70.0 ___ Monos-6.8 Eos-1.5 Baso-0.8 Im ___ AbsNeut-6.45* AbsLymp-1.91 AbsMono-0.63 AbsEos-0.14 AbsBaso-0.07 ___ 02:03PM BLOOD ___ PTT-31.5 ___ ___ 02:03PM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-139 K-4.8 Cl-100 HCO3-28 AnGap-11 ___ 02:03PM BLOOD ALT-12 AST-18 AlkPhos-157* TotBili-<0.2 ___ 02:03PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7 ___ 03:38AM BLOOD WBC-11.3* RBC-2.97* Hgb-9.0* Hct-27.6* MCV-93 MCH-30.3 MCHC-32.6 RDW-19.1* RDWSD-64.3* Plt ___ ___ 03:38AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-142 K-4.6 Cl-110* HCO3-23 AnGap-9* ___ 03:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9 ___ 03:38AM BLOOD ALT-11 AST-___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy ___ now w/ rapid metastatic recurrence presenting for C3 TIP # Metastatic Penile Squamous Cell Carcinoma Unfortunately his high risk localized disease has rapidly progressed to at least soft tissue and RP nodes. He is being treated with TIP with palliative intent ___ JCO ___. He tolerated it well other than fatigue and decreased appetite. - required 2L NS boluses to maintain ___ ___ - clinic appointment scheduled for neulasta tomorrow - restaging imaging tomorrow # T2DM We hold home antihyperglycemics and required about 10U insulin despite dex. In concern for potential hypoglycemia at home, we downtitrated his home regimen - stopped glipizide as has poor po intake - decreased home metformin from 1000 bid to qd and only w/ food - he will keep a log of sugars and review w/ his outpatient oncologist # Asthma: quiescent, cont advair/flonase, albuterol prn # HTN: cont ACEI and ASA # DL: held statin while actively receiving chemo # RA: on prn oxy, a refill for 14 day supply given FEN: Regular diet DVT PROPH: Enoxaparin inpatient ACCESS: PORT CODE STATUS: Full code, presumed DISPO: Home today w/o services BILLING: >30 min spent coordinating care for discharge ________________ ___, D.O. Heme/Onc Hospitalist p: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 10 mg PO DAILY 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 7. Vitamin D 1000 UNIT PO DAILY 8. Atorvastatin 40 mg PO QPM 9. GlipiZIDE XL 5 mg PO DAILY 10. Dexamethasone 4 mg PO ASDIR 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 13. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion Discharge Medications: 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY take ONLY once a day if you are eating meals. do not take if not feeling well and not eating much 2. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Dexamethasone 4 mg PO ASDIR 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Lisinopril 10 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 2.5-5 mg by mouth q4hrs prn Disp #*28 Tablet Refills:*0 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Encounter for Chemotherapy - Metastatic Squamous Cell Carcinoma of the Penis - Secondary Neoplasm of Soft Tissue - Secondary Neoplasm of Lymph Nodes - DMII - Hypertension - Hyperlipidemia - Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You tolerated your chemotherapy well. Please follow up with your oncology team as instructed. You needed a small amount of insulin despite receiving steroids. You may not need a lot of diabetes medications as you have in the past. Keep a log of your sugars at home and review them with your oncologist in clinic. We decreased your metformin to once a day and stopped your glipizide. You should talk to your oncologist about whether you need to take atorvastatin. Followup Instructions: ___

{'dizziness': ['Metastatic Squamous Cell Carcinoma of the Penis'], 'mild numbness in fingers': ['Metastatic Squamous Cell Carcinoma of the Penis'], 'fevers/chills': [], 'headache': [], 'vision changes': [], 'weakness': [], 'shortness of breath': ['Asthma'], 'cough': [], 'hemoptysis': [], 'chest pain': [], 'palpitations': [], 'abdominal pain': [], 'nausea/vomiting': ['Ondansetron'], 'diarrhea': [], 'hematemesis': [], 'hematochezia/melena': [], 'dysuria': [], 'hematuria': [], 'new rashes': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Encounter for chemotherapy Major Surgical or Invasive Procedure: Port Placement ___ History of Present Illness: Mr. ___ is a pleasant ___ w/ HTN, DL, Asthma, T2DM, Rheumatoid arthritis, and poorly differentiated squamous cell carcinoma s/p partial penectomy in ___ (pT3, sarcomatoid and acantholytic features), now with rapid metastatic recurrence to at least soft tissue and RP nodes who is presenting for a PORT placement followed by chemo. He states he has been doing otherwise well w/o any F/C, no N/V, no CP/SOB. He had pain at the surgical incision in his penis but that has resolved. He has pain in his low back for which he takes oxycodone prn. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -___: CT torso showing no clear metastatic idsease -___: Distal partial penectomy, path showing poorly differentiated squamous cell carcinoma with sarcomatoid and acantholytic features, pT3. Dr. ___ inguinal ___ on ___ but patient had some difficult social circumstances as he was primary caretaker for his wife. -___: At follow-up visit, he had a new 2x2 cm lesion in the left groin. -___: CT pelvis showing extensive new retroperitoneal lymphadenopathy and new rim enhancing metastasis in the pre-pubic fat to the left of midline. -___: Initial med onc evaluation, planned to complete restaging and begin palliative TIP, for which patient consented. PAST MEDICAL HISTORY (per OMR): ASTHMA DIABETES TYPE II PPD POSITIVE RHEUMATOID ARTHRITIS previously treated with Plaquenil, MTX, sulfasalaine, leflunomide. +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin Osteoarthritis in left knee RIGHT BUNDLE BRANCH BLOCK VENTRAL HERNIA NORMOCYTIC ANEMIA HYPERTENSION HYPERLIPIDEMIA PENILE CANCER Social History: ___ Family History: Father had blood cancer, no history of colon, lung or prostate ca, no history of stroke or MI Physical Exam: VITALS: ___ 1154 Temp: 98.2 PO BP: 113/68 HR: 77 RR: 18 O2 sat: 99% O2 delivery: RA General: NAD, resting in bed comfortably HEENT: MMM, no OP lesions CV: RRR, +S1S2 no S3S4, no m/r/g PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs, no suprapubic tenderness, no CVAT LIMBS: WWP, no ___, no tremors SKIN: port site dressing C/D/I NEURO: CN III-XII intact, strength b/l ___ intact PSYCH: Thought process logical, linear, future oriented ACCESS: R chest port Pertinent Results: Admission Labs: ___ 08:15PM BLOOD WBC-8.1 RBC-3.73* Hgb-11.1* Hct-34.0* MCV-91 MCH-29.8 MCHC-32.6 RDW-13.9 RDWSD-46.3 Plt ___ ___ 08:15PM BLOOD Neuts-57.9 ___ Monos-5.3 Eos-4.0 Baso-0.9 Im ___ AbsNeut-4.68 AbsLymp-2.56 AbsMono-0.43 AbsEos-0.32 AbsBaso-0.07 ___ 08:15PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139 K-4.5 Cl-101 HCO3-27 AnGap-11 ___ 08:15PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.4 Mg-1.9 Labs at time of discharge: ___ 05:38AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.3 MCHC-32.5 RDW-14.4 RDWSD-47.1* Plt ___ ___ 05:38AM BLOOD Neuts-64.4 ___ Monos-2.3* Eos-0.6* Baso-0.2 Im ___ AbsNeut-4.26 AbsLymp-2.11 AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01 ___ 05:38AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-8* ___ 05:38AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8 Micro: Urine Cx (___): REFLEX URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 CFU/mL. Brief Hospital Course: ___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy ___ now w/ rapid metastatic recurrence presenting for PORT placement and chemo. Patient underwent port placement on ___ and started his first cycle of chemotherapy as an inpatient which was well tolerated. Patient was instructed to follow up in ___ clinic for continued monitoring. # Metastatic Penile Squamous Cell Carcinoma Met to at least soft tissue and RP nodes. Started TIP chemo as follows: - ___ - Taxol 175 mg/m2 over 3 hours on D1 - Ifosfamide 1200 mg/m2 on D ___ w/ mesna - Cisplatin 25 mg/m2 on D1-3 - received IVF 500cc boluses pre/post cisplatin - cont oxy prn w/ colace - plan for neulasta as outpatient on ___ - discharged with 4 days of dexamethasone 4mg BID given possibility of significant nausea with this regimen, will also send with PRN Zofran # Asympatomatic Bacturia - UCx with >100k GNR on routine screening UA - patient without symptoms at time of discharge and as such will not treat - advised with strict return precautions if patient develops symptoms of UTI # T2DM: held home antihyperglycemics, ISS, resume on discharge # Asthma: quiescent, cont advair/flonase, albuterol prn # HTN: held ACEI while on chemo, as well as ASA # DL: held statin while on chemo # RA: on prn oxy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 2. Atorvastatin 40 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. GlipiZIDE XL 5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 8. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate 9. Aspirin 81 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Dexamethasone 4 mg PO Q12H Duration: 4 Days take after chemo RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. GlipiZIDE XL 5 mg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Encounter for chemotherapy Penile Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was our pleasure to care for you at ___. You came to the hospital to start chemotherapy for your cancer. WHAT HAPPENED IN THE HOSPITAL? - you had a port placed in your chest to allow easy access for chemotherapy - you started your first cycle of chemotherapy which you tolerated well WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - follow up closely with oncology tomorrow ___ for an injection to support your blood counts We wish you all the best! Sincerely, Your care team at ___ Followup Instructions: ___

{'pain in low back': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Unspecified asthma', 'Rheumatoid arthritis'], 'pain at surgical incision site': ['Malignant neoplasm of penis', 'unspecified'], 'no fever, chills, or night sweats': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites'], 'no nausea or vomiting': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Unspecified asthma', 'Rheumatoid arthritis'], 'no chest pain or shortness of breath': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites'], 'no difficulty breathing': ['Unspecified asthma'], 'no swelling or edema': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no weakness or numbness': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no changes in vision': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no changes in bowel habits': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no urinary symptoms': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no other symptoms': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Hayfever / Adhesive Tape / Latex Attending: ___. Chief Complaint: Right humerus nonunion Major Surgical or Invasive Procedure: ___: ORIF Right humerus ___ History of Present Illness: Mr. ___ is a gentleman who had a fall and sustained a proximal humerus and humeral shaft fracture about 9 months ago. This was initially treated with closed management. However, he has gone on to develop a nonunion of his humeral shaft fracture. He has had a CT scan that shows a nonunion and has failed a bone stimulator. At this point, given the pain and deformity he is having, a decision was made to proceed with operative intervention Past Medical History: Right Distal Humeral Fracture in ___ Alcoholism Social History: ___ Family History: Non-contributory Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Pulm: Lungs CTA ___ Abdomen: Soft, NT, ND Extremities: + sensation/movement, + pulses, skin intact Pertinent Results: ___ 01:59PM WBC-7.0# RBC-2.99* HGB-10.4* HCT-31.2* MCV-104* MCH-34.8* MCHC-33.4 RDW-17.7* ___ 01:59PM PLT COUNT-84* Brief Hospital Course: Mr ___ admitted to ___ on ___ s/p ORIF R Humerus ___. On ___ pt was taken to the operating room and underwent an ORIF of his fracture. He tolerated the procedure and anesthesia well and was transferred to the recovery room, and then to the floor. Pt was given ancef x 24hours post-op. He was to remain ___ RUE . The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and pain well controlled. He is being discharged today in stable condition Medications on Admission: Pantoprazole 40mg QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD (). 4. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Constipation. Disp:*50 Tablet(s)* Refills:*1* 6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*20 Suppository(s)* Refills:*1* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses. Discharge Disposition: Home Discharge Diagnosis: Right humerus ___ Discharge Condition: Stable Discharge Instructions: Continue to be non-weight bearing on your right arm, wear your sling for comfort Please take all medication as prescribed If you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. 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. Followup Instructions: ___

{'pain': ['Nonunion of fracture'], 'deformity': ['Nonunion of fracture']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Hayfever / adhesive tape / Latex / Effexor XR Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: R hip TFN - ___ History of Present Illness: HPI: ___ male with history of hepatic steatosis presents s/p fall with R hip pain and deformity. States he was watching television this morning when he dozed off, rolled off the cough landing on his right side on a concrete floor with immediate onset of severe R hip pain. Also reports mild L anterior chest wall pain. Called EMS and was transported to ___ ED where he was noted to have shortening and external rotation of the R leg with intact neurovascular exam. No other complaints at this time. Imaging showed an intertrochanteric fracture of the R hip, for which we are consulted. Past Medical History: PMH/PSH: -Hepatic steatosis -Perforated duodenal ulcer, s/p repair -L shoulder labral repair -Bilateral meniscal repair -Ruptured appendix s/p appendectomy Social History: ___ Family History: N/C Physical Exam: Exam on Discharge 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 intertrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip TFN 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 rehab 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 WBAT in the right 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. Citalopram ___ mg PO DAILY 2. Gabapentin 600 mg PO TID 3. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis 4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 5. QUEtiapine Fumarate 50-100 mg PO QHS 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Citalopram ___ mg PO DAILY 2. Gabapentin 600 mg PO TID 3. Multivitamins 1 TAB PO DAILY 4. QUEtiapine Fumarate 50-100 mg PO QHS 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Calcium Carbonate 1250 mg PO TID 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks Start: Today - ___, First Dose: Next Routine Administration Time 9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain Do not drink alcohol, drive, or operate heavy machinery while taking. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 hours Disp #*50 Tablet Refills:*0 10. Senna 8.6 mg PO DAILY 11. Vitamin D 800 UNIT PO DAILY 12. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Instructions After Orthopedic 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: - Weight bearing as tolerated right lower extremity with upper extremity assist as needed 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 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. - 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 DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: ___ - WBAT RLE with upper extrmeity assist as needed Treatments Frequency: Dry sterile dressing changes daily, as needed PRN staining. Followup Instructions: ___

{'Right hip pain': ['Closed fracture of intertrochanteric section of neck of femur'], 'Mild L anterior chest wall pain': [], 'Hepatic steatosis': ['Other chronic nonalcoholic liver disease'], 'Fall': ['Accidental fall from other furniture'], 'History of drug use': ['Alcohol abuse'], 'Smoking history': ['Personal history of tobacco use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: ___ Attending: ___. Chief Complaint: Bleeding duodenal ulcer Major Surgical or Invasive Procedure: Laparotomy, oversewing of the duodenal ulcer, truncal vagotomy, liver biopsy and pyloroplasty. History of Present Illness: ___ year old male with a history of alcoholism and more recently, binge drinking, who was brought to the emergency room after experiencing abdominal pain x 1 week, followed by dark stools and lightheartedness. Patient reportedly had syncope at home today, landing on his left chest with subsequent pain. He was evaluated in the ED for the aforementioned symptoms and his dark stools progressed to bright red blood per rectum. An NGT was placed and approximately 350 ccs of bright red blood was removed. GI was consulted for concern of acute upper GI bleed and given the history of excessive alcohol intake along with a transaminatis and bilirubin of 2, he was started on Octreotide for concern for a variceal bleed. He was reportedly also started on a PPI drip. SBP intermittently dropped to ___ and thus over the course of his time in the ER, he was given 4 units of PRBCs and 5 liters of saline with transient improvement. Given chest pain s/p fall, a CXR was ordered which showed no fractures. EKG was also unremarkable and troponin x 1 was negative. Patient was then admitted to the MICU for further management of his GIB. Of note, patient has a history of excessive alcohol use for years, but more recently has been drinking heavily because of grief with his father's death. Past Medical History: Right Distal Humeral Fracture in ___ Alcoholism Social History: ___ Family History: Non-contributory Physical Exam: Vital signs stable, afebrile. No oropharyngeal erythema or exudate. No scleral icterus. Regular rate and rhythm; no murmurs, rubs or gallops. Lungs with minimal wheezes anteriorly. +BS. NTND. No ascites. No c/c/e. No peripheral stigmata of liver disease. Pertinent Results: ___ 07:12AM BLOOD WBC-6.0 RBC-3.03* Hgb-10.1* Hct-29.2* MCV-97 MCH-33.4* MCHC-34.6 RDW-20.2* Plt ___ ___ 09:48AM BLOOD ___ PTT-29.3 ___ ___ 04:50AM BLOOD Glucose-66* UreaN-8 Creat-0.7 Na-134 K-3.9 Cl-97 HCO3-28 AnGap-13 ___ 04:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.5* EGD (___): Large cratered bleeding ulcer in the duodenal bulb [apex]- this was treated with injection and cautery. Otherwise normal EGD to second part of the duodenum. Brief Hospital Course: ___: Admitted with GI bleed and GI consulted. ___: Scoped and to OR for procedure as described in Operative Note, transferred uneventfully to SICU, extubated successfully. ___: Transferred to floor. Placed on PCA for pain. ___: NGT and Foley removed. CVL removed. ___: Diet advanced to sips. ___: Diet advanced to full liquids. Hep locked and placed on po meds. ___: Diet advanced to regular diet. ___: Pt. discharged with instructions for followup as medically stable. Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*55 Tablet(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. 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* 4. Medications Please continue all other home medications as directed by your primary care provider. 5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Bleeding duodenal ulcer Discharge Condition: Stable. Discharge Instructions: Resume all home medications. Seek immediate medical attention for fever >101.5, chills, increased redness, swelling, bleeding or discharge from incision, chest pain, shortness of breath, difficulty breathing, severe headache, increasing neurological deficit, or anything else that is troubling you. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Call your surgeon to make follow up appointment. Followup Instructions: ___

{'abdominal pain': ['Acute duodenal ulcer with hemorrhage'], 'dark stools': ['Acute duodenal ulcer with hemorrhage'], 'lightheartedness': ['Acute duodenal ulcer with hemorrhage'], 'syncope': ['Acute duodenal ulcer with hemorrhage'], 'bright red blood per rectum': ['Acute duodenal ulcer with hemorrhage'], 'chest pain': ['Other shock without mention of trauma'], 'fall': ['Nonunion of fracture'], 'alcoholism': ['Other and unspecified alcohol dependence', 'continuous'], 'transaminatis': ['Other chronic nonalcoholic liver disease', 'Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: Hayfever / Adhesive Tape / Latex Attending: ___. Chief Complaint: "As ___ would say, the black dog is upon me. I've had an inordinate amount of unpleasantness." Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo married white man c a h/o accident ___ years ago resulting in nerve damage to right arm and associated chronic pain on opiates c/b alcohol abuse/dependence and depression who was brought to ___ ED by his wife at the insistence of Dr. ___ ___ for psychiatric evaluation. On ___ Mr. ___ impulsively ingested 20 to 23 pills of duloxetine 30 mg (he and his wife were not sure how many pills were left in the bottle--wife said she thought none and husband said around 30 were left). Patient took this ingestion while alone, but could not clarify whether he was intoxicated or not. Patient could not really give specifics re his thought process around taking the pills, but minimized the ingestion as not being suicidal in nature. Patient stated that he thought, ___ I'd go to sleep, that's all, a relaxing 4 hour nap." Patient reported that he has chronic sleep problems. He says that normally he has a good appetite, but he has not been eating since the overdose. He reported that his concentration and ability to enjoy things (e.g., his music collection, which he tells me is one of the largest in the country at 33,000 records) has not diminished, even in the context of his sense of being depressed. Despite his chief complaint re an "inordinate amount of unpleasantness," patient identified the main stressor as witnessing his mother's decline as she suffers from a progressive dementia. She is living in ___, though they talk on the phone regularly. He reported that he stopped working a few months ago, although he still strongly identifies c his profession as working ___. He said that this was a voluntary decision to stop working, although he acknowledged that the pain and limits in his functioning after the accident did have an impact on his worklife. Patient denied any h/o manic or psychotic episodes. Even though patient's alcohol level this morning before 11 am was nearly 200, patient denied having anything to drink this morning. Patient reported that he had 5 large glasses of straight vodka last night when pressed for an explanation as to how his alcohol level might be so high. Past Medical History: - h/o surgery for perforated duodenal ulcer (req 21 units of blood) at ___. - Steatosis with inflammation and stage III portal fibrosis. - Multiple orthopedic injuries: h/o bilateral knee surgeries, h/o left labrum shoulder repair, h/o a fall/slip on ice in ___ when he injured his right shoulder and right humerus shaft. - Ruptured appendix and subsequent perotinitis Past Psychiatric History: Patient has no previous h/o inpatient psychiatric hospitalizations or suicide attempts. Saw a psychiatrist as a teen for high school related angst. Took an antidepressant, possibly amitriptyline, many years ago, but had sexual side effects. More recently has been taking duloxetine for pain and depression prescribed by Dr. ___. Social History: From ___ area originally, older of two sons born to married parents. Reported that he was an excellent student, went on to college, first at ___, then transferred to ___ before ultimately graduating from ___ c a degree in ___. Worked initially for ___ then went on to work in ___ at ___ (___ at ___) for his professional career until retirement a few months ago. Patient lives c his wife of ___ years, no children, has cats. Not particularly religious. Denied weapons in the home. Substance Abuse History: In the ED, patient minimized his alcohol consumption, denied daily drinking, denied drinking to blackout, denied drinking & driving. On the inpatient unit, he reported drinking daily, sometimes vodka straight from the bottle. Admitted to drinking up to 5 large glasses of straight vodka the night prior to admission. Wife reported that she was not aware of the extent of his alcohol use, but she does know that he drinks alcohol. No h/o withdrawal seizures. Denied any other h/o drug use. Smokes ___ cigarettes a day. Family History: Per patient, his brother has a history of some kind of chronic psychotic illness (possibly schizophrenia) and is institutionalized (brother killed the family dog when brother was ___, which seems to have been the onset of his symptoms). Father died in ___ from complications of CHF, but he was also a heavy drinker. Mother is ___, lives in ___ and ___ Alzheimer's dementia. Physical Exam: ED Exam: 98.0, 94, 157/94, 16, 98% RA. Pain (RUE) ___. White male, sitting up in bed, wearing a t-shirt and a hospital ___. + palmar erythema. Mild diaphoresis by the time I met c patient at 1:15 pm (would have still had alcohol in his system). + jaw twitching. + tremors. Speech tremulous, normal use of language, expansive vocabulary. Mood is "better" c a slightly irritable affect at times. Thoughts organized, denied paranoia, denied abnormal perceptions. Minimized recent ingestion, despite potential lethality of ingestion. Denied suicidal intent c ingestion. Denied thoughts of harming others. Insight into problems c alcohol is quite limited, prominent denial. Judgment limited. Oriented in full detail. MOYF/B intact. Calculations intact. STM ___ reg, ___ recalled, ___ c category clue. Repetition intact. Presidents to ___. Proverbs appropriately abstract. HEENT: Normocephalic. PERRL, EOMI. ___ normal. Oropharynx clear. Neck: Supple, trachea midline. No adenopathy or thyromegaly. Back: No significant deformity, no focal tenderness Lungs: Clear to auscultation; no crackles or wheezes. CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal pulses Abdomen: Soft, nontender, nondistended; no masses or organomegaly. Extremities: Severe psoriasis on lower extremities, worse on left. No clubbing, cyanosis, or edema. Skin: Warm and dry. Neurological: *Cranial Nerves- I: Not tested II: Pupils equally round and reactive to light 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 except for all muscles on right arm which are ___. Patient's effort questionable on this part of the exam and reported pain on testing. No pronator drift. *Sensation- Intact globally *Reflexes- B T Pa *Coordination- Normal on finger-nose-finger, rapid alternating movements Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW Plts 7.8 4.67 16.7 48.9 105* 35.8* 34.2 14.8 163 Glucose BUN Creat Na K Cl HCO3 AnGap 89 19 0.8 141 4.2 96 25 24* Serum tox screen alcohol 185 at 10:53 am on ___, o/w neg Urine tox screen neg U/A SG 1.020, blood large, protein 75, ketones 50, WBC ___, bact few. Brief Hospital Course: Psychiatric: Since admission, Mr. ___ has actively engaged in medical treatment for the alcohol dependence and depression. He reflected on events leading to hospital admission, family/life stressors, alcohol dependence, and suicidal ideation. His wife visited every day and was an active part of his treatment and disposition planning. Mr. ___ initially required high doses of ativan for signs and symptoms of EtOH withdrawal, but he was eventually tapered off benzodiazepines uneventfully. During his hospital course, he was started on Celexa to address his depression. However, since he continued to have problems with sleep, he was changed from Celexa to Seroquel 50mg QHS. At time of discharge, pt states that he has many things to live for, including his main support, which is his wife. He is looking forward to spending time with his wife, his cats, and his friends, and he is hoping to spend some time "in the great outdoors" this weekend. He is currently denying any suicidal ideation and he feels that his overdose was an impulsive act that he will not repeat. He expressed ambivalence regarding following up at ___ for his alcohol dependence. However, he expressed a desire to stay sober and is willing to meet with an outpatient psychiatrist and therapist for support and continuity of care. Safety: He was maintained on 15 minute checks and had no behavioral triggers while on the unit. Groups/Milieu: He attended the Coping Skills group while an inpatient. Legal: ___ Medications on Admission: - Duloxetine 30 mg po daily - Oxycodone 15 mg po q 4 hours ATC - Pantoprazole 40 mg po bid - Gabapentin 300 mg po tid Discharge Medications: 1. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:*126 Tablet(s)* Refills:*0* 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 1 weeks. Disp:*21 Capsule(s)* Refills:*0* 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Major Depressive Episode, recurrent Alcohol Dependence Discharge Condition: MSE: pleasant, talkative Speech: goal directed Mood/Affect: 'better'/brighter T. Form: no LoA/TT/TB T. Content: no delusions/hallucinations/paranoid ideation Denies SI/HI Cognition: a and o x 3 Judgment/Insight: fair Discharge Instructions: You will be discharged home and follow up with your outpatient primary care doctor, ___ your outpatient psychiatrist. You will also be discharged with a prescription for Celexa. Followup Instructions: ___

{'inordinate amount of unpleasantness': ['Major depressive affective disorder', 'recurrent episode', 'severe', 'without mention of psychotic behavior'], 'impulsively ingested': ['Suicidal ideation'], 'chronic pain': ['Other chronic pain'], 'pain in joint': ['Pain in joint', 'shoulder region'], 'alcohol level': ['Acute alcoholic intoxication in alcoholism', 'continuous'], 'alcohol consumption': ['Opioid type dependence', 'continuous']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: chest pain, hematochezia Major Surgical or Invasive Procedure: none. History of Present Illness: ___ year old female with complex PMH including DM, CAD, s/p LURT ___, p/w angina and blood in stool. She reports ___ months of right chest pain associated with shortness of breath (her anginal equivalent), worse with exertion and relieved by rest and nitroglycerin. She feels that these symptoms are occurring more frequently than previous. She also reports chronic diarrhea with intermittent blood, occurring at increased frequency. There is also a new report of nocturnal bedwetting, occur only with deep sleep. In the ED, vital signs initially were T 98.3, BP 130/61, P 87, RR 18, Sat 98% RA. Labs significant for mildly elevated creatinine (1.4 from b/l circa 1.0). Cardiac enzymes negative x 1. EKG showed no acute ST changes, NSR. D-dimer not elevated at 250. INR therapeutic at 2.8. She received . Rectal tone was reported as normal and she was guaiac negative. The patient was admitted for work up of these complaints. Currently she is not c/o chest pain, SOB, has not had any diarrheal symptoms or incontinent episodes overnight. Past Medical History: # Living-unrelated kidney transplant on ___. # End-stage renal disease secondary to diabetes. # History of CREST syndrome and antiphospholipid antibody positivity with remote history of PE and on Coumadin since ___ # CAD status post MI and status post PTCA, EF 60% # type 1 diabetes w/ neuropathy, retinopathy and insulin pump # Gastroparesis # scleroderma # GERD # hiatal hernia # hypothyroidism # CHF EF 60% ___ # gout # s/p appendectomy # s/p cholecystectomy # hypothyroidism # herniated disk # gout # sleep apnea # Left ring finger trigger finger release ___ # Left cubital and carpal tunnel release ___ # PPD negative ___ # E coli UTI ___ ___ to cipro # Enterococcus UTI ___ amp ___ Social History: ___ Family History: Nephews x2: alopecia Sister: RA Daughter: ___ and celiac - adopted Nephew: addisons Sister and brother: sarcoid Physical ___: General: Caucasian female sitting up in bed in NARD. HEENT: NCAT, EOMI, no scleral icterus Neck: supple, no significant JVD, no hepatojugular reflux noted Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Pt has decreased sensation in b/l lower extremities from ankle down (baseline), 2+ biceps, 1+ knee reflexes bilaterally. Plantar response was flexor bilaterally. Pt able to ambulate with adequate locomotion, tandem arm swing, gait distance even. Pt able to walk on tip-toes and heels with no deficits. + rectal tone in ER. Pertinent Results: ___ 09:00AM BLOOD WBC-9.4 RBC-3.87* Hgb-11.7* Hct-35.7* MCV-92 MCH-30.4 MCHC-32.9 RDW-14.0 Plt ___ ___ 10:50PM BLOOD WBC-8.1 RBC-4.02* Hgb-12.2 Hct-37.9 MCV-94 MCH-30.3 MCHC-32.1 RDW-13.8 Plt ___ ___ 12:30AM BLOOD ___ PTT-32.4 ___ ___ 09:00AM BLOOD Glucose-78 UreaN-24* Creat-1.5* Na-142 K-4.4 Cl-106 HCO3-28 AnGap-12 ___ 10:50PM BLOOD Glucose-414* UreaN-24* Creat-1.4* Na-139 K-4.9 Cl-102 HCO3-26 AnGap-16 ___ 09:00AM BLOOD ALT-44* AST-27 AlkPhos-141* TotBili-0.3 ___ 10:50PM BLOOD CK(CPK)-54 ___ 10:50PM BLOOD CK-MB-NotDone cTropnT-<0.01 ___ 09:00AM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.5* Mg-1.7 ___ 10:50PM BLOOD %HbA1c-11.2* ___ 10:50PM BLOOD TSH-0.12* Brief Hospital Course: ___ y.o. Female with DMI, ESRD s/p renal transplant, CREST syndrome, CAD s/p MI w/ PTCA presented with chest pain, hematochezia with negative cardiac work up. ##. Atypical Chest pain: Patient admitted for atypical chest pain. During hospitalization pt's chest pain work up showed negative troponin, no acute EKG changes or arrhythmic events on telemetry; during hospitalization pt denied any further chest pain episodes. Based on her clinic symptoms and work-up it is unlikely that the chest pain was cardiac in nature. Pt has been undergoing a lot of stress and her chest pain frequency has increased with the increase in stressors. Pt was continued on her outpatient medications and set up for close follow up with Dr. ___. ## Diarrhea: Patient endorsed a one week history of a small amount of bloody diarrhea but was noted to be Guaiac negative in the ED. During hospitalization pt reported no further bloody bowel movements, her Hct remained stable and no leukocytosis or fevers were noted. Her symptoms of diarrhea also appear to have an onset similar to her recent stressors, it may also have been an episode of viral gastroenteritis as the episode resolved quickly. Pt will likely need a colonoscopy as an outpatient to follow up. ##. Nocturnal Urinary Incontinence: Pt has been having episodes of nocturnal urinary incontinence when she is deeply asleep, she is also taking two sleep medications. During hospitalization pt did not experience any nocturnal incontinence whilst on a reduced sleep medication regimen. With no signs or symptoms of cord compression episodes may be a combination of a progression of her diabetes causing decreased bladder sensation on top of her use of sleeping medications. ##. Renal transplant, Scleroderma: Pt was continued on her outpatient immunosuppressant regimen of Prograf, Cellcept, Prednisone. ##. DM 1: Pt's Hgb A1C noted to be elevated at 11.2%. Pt was continued on her insulin pump and neurontin for her neuropathy. ##. h/o PE/APA: Pt was continued on her Coumadin with a therapeutic INR. ##. PVD: Pt was continued on her outpatient cilostazol Medications on Admission: 1. Insulin as prescribed. 2. CellCept 500 mg tablets two per day. 3. Prograf 2 mg once daily. 4. Warfarin 2 mg once daily. 5. Trazodone 25 mg as needed. 6. Cilostazol 50 mg once daily. 7. Reglan 5 mg with meals. 8. Cymbalta 60 mg once daily. 9. Synthroid ___ mg once daily. 10. Desipramine 50 mg once daily. 11. Lipitor 80 mg once daily. 12. Neurontin 600 mg b.i.d. 13. Ambien 5 mg once daily. 14. Lasix 40 mg once daily. 15. Prednisone 7.5 mg once daily. 16. Bactrim 80/160 once daily. 17. Procardia-XL 30 mg once daily. 18. Ativan 1 mg p.r.n. 19. Betaxolol 30 mg once daily. 20. Nitroglycerin as needed. 21. Cipro 500 mg b.i.d. 22. Phenergan 25 mg once daily. 23. Vicodin 7.5/750 p.r.n. 24. Aspirin 81 mg daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day. 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. 10. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 11. Betaxolol 20 mg Tablet Sig: One (1) Tablet PO daily (). 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 14. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Cilostazol 50 mg Tablet Sig: 1.5 Tablets PO daily (). 17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every ___ hours). 18. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 19. Ascorbic Acid ___ mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home Discharge Diagnosis: Atypical Chest Pain Discharge Condition: Stable, Afebrile Discharge Instructions: You were admitted to the hospital for chest pain and bloody diarrhea. During your hospital stay your blood work and your EKG showed that it was unlikely this pain was due to a new heart attack. Your blood level also remained the same from previous studies. Please drink a lot of fluids. If you experience chest pain again please return to the ER. Weigh yourself every morning, call MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: ___

{'Chest pain': ['Other chest pain', 'Diastolic heart failure', 'Coronary atherosclerosis of native coronary artery', 'Congestive heart failure'], 'Blood in stool': ['Blood in stool'], 'Diarrhea': ['Gastroparesis'], 'Nocturnal bedwetting': ['Urinary incontinence']}

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 pain Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: Patient ___ yo F with hx of HTN who presented to the ED today c/o abd. pain. Pt. states that she has had this pain for approximately one month. The pain is epigastric, sharp in nature and present throughout the day at a low level, ___, worse in the morning with brief attacks ___ per ___, lasting a few minutes. It occasionally radiates to the back. The pain is worsened with eating solid food but not associated with positioning or time of day. The patient saw her PCP ___ ___, was started on Prilosec and an H.pylori was checked, which returned positive. She was begun on a Prevpac that she states she has taken 10 days of. She states that since starting the Prevpac, her pain has decreased somewhat with decreased AM pain and decreased frequency of attacks. However, her pain has not completely abated. Prior to starting the Prevpac, she also had a baseline level of constant nausea, intermittent non-bloody vomitting, and associated metallic taste in her mouth also for one month. She also noted constipation which has transitioned to diarrhea since starting the Prevpac. She has no associated fevers, blood in her stool, or black stools. Of note she has been taking 1000mg of Aleve approximately 3x/week to treat her migraine headaches. She states that she has been doing this for years. She also notes some minor dysphagia with pills and water yesterday, alleviated with drinking more water. Her LMP was ___ and she has had regular, normal periods prior. She has never had an endoscopy and has been reluctant to get one even at Dr. ___. . She has also been undergoing an extensive work up with Dr. ___ to evaluate her early onset HTN (dx ___, intermittent palpitations, flushing, chest pain, headaches, and now abdominal pain in the setting of her mother having had a pheochromocytoma. Her palpitatoins and chest discomfort have improved significantly since starting the atenolol. She has had a normal renal MRA, a normal MRI of the abd/pelvis, normal TFTs, normal LFTs, normal pancreatic enzymes, normal aldosterone level, normal chem 10, normal am cortisol, and a normal u/a. Abnormal labs include a borderline elevated urine normetanephrine from 24hr urine, a mildly elevated PTH, and a borderline elevated gastrin level on a PPI. In regards to her head ache, she states it occurs 3x/wk, bilateral and pounding in nature, with associated photophobia, phonophobia and occasional associated blood shot eyes. . ROS: Positive chills but no fevers. Moderate persistent headaches. No visual changes, dysphagia, odynophagia, chest pain, palpitations, tremor, shortness of breath, wheezing. Positive vomiting but no hematemasis, bilious emesis. No melena, blood per rectum, dysuria, hematuria, arthralgias. Past Medical History: Refractory Hypertension Low Grade Cervical Intraepithelial Neoplasia Migraines Depression Social History: ___ Family History: Mother with pheochromocytoma Physical Exam: Physical Exam: VS: T:98.7, BP:175/113, HR:79, RR:14, O2: 98% RA GEN: Well appearing, AOx3, NAD HEENT: PERRL, EOMI, sclera anicteric, non-injected NECK:supple, ? slight increased fullness in L anterior portion, does not move with swallowing CHEST: CTAB CV:RRR, no MRGs appreciated ABD:soft, NT/ND, +BS, no masses or HSM noted EXT: no edema, no cyanosis, no clubbing, no rashes NEURO: strength ___ in all extremities, sensation intact to gross. Pertinent Results: ___ 01:30PM BLOOD WBC-8.6 RBC-4.30 Hgb-12.8 Hct-37.3 MCV-87 MCH-29.7 MCHC-34.3 RDW-12.8 Plt ___ ___ 01:30PM BLOOD Neuts-71.5* ___ Monos-4.9 Eos-0.6 Baso-0.3 ___ 06:40AM BLOOD Glucose-83 UreaN-8 Creat-0.9 Na-138 K-3.8 Cl-105 HCO3-24 AnGap-13 ___ 01:30PM BLOOD ALT-32 AST-23 AlkPhos-65 TotBili-0.3 ___ 01:30PM BLOOD Lipase-18 ___ 06:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9 ___ 01:30PM BLOOD Prolact-9.6 ___ 01:30PM BLOOD HCG-<5 ___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG EGD: Normal Esophagus, stomach, antrum, and duodenum up to the ___ portion. Brief Hospital Course: Abdominal Pain: The patient was initially admitted for evaluation of her abdominal pain. There was a high initial suspicion for some form of peptic ulcer disease or gastritis given her history and NSAID use. She was continued on her Prevpac in hospital with some decrease in her episodes of acute pain attacks. However, an EGD showed a totally normal mucosa from the esophagus to the duodenum. Her Prevpac was changed to Levaquin, Flagyl and prilosec BID as it may be gentler on her stomach. She still had intermittent attacks of acute abdominal pain but they only lasted ___ minutes, with no time to intervene with pain medications. She was able to tolerate solid food prior to discharge without significant pain. In discussion with her PCP, further work up of her abdominal pain did not warrant inpatient evaluation. She will be worked up for alternate causes for her pain, including AIP and abdominal migraines, as an outpatient. HTN: The reason for the patient's hypertension remains unclear. It has previously been extensively worked up. The patient was evaluated by the endocrine service here who felt that she did not have a pheochromocytoma. They recommended a possible repeat MRA of the renal arteries in the future for re-evaluation. They also recommended outpatient 24hr urines for metanephrines, cortisol, DHEA, and free testosterone and a cortisol-stimulation test. She already has an outpatient endocrine appointment scheduled. She was changed to metoprolol for ease of uptitration and was discharged well controlled on 100mg of Toprol XL in addition to her lisinopril and HCTZ. Hyperparathyroidism: The endocrine service felt that her elevated PTH was consistent with secondary hyperparathyroidism given her normal calcium. Vitamin D levels were drawn and pending at the time of this writing. These will be followed up with her endocrinologist. Migraines: Well controlled with imitriptan. Medications on Admission: Amoxicill-Clarithro-Lansopraz [Prevpac] - 30 mg-500 mg-500 mg (day ___ Hydrochlorothiazide - 25 mg Lisinopril - 10 mg Atenolol 50mg Sumatriptan - 25 mg Tablet q2 PRN migrain Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lisinopril 10 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. Imitrex ___ mg Tablet Sig: One (1) Tablet PO q2H as needed for pain. 5. Toprol XL 100 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* 6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Tablet, Delayed Release (E.C.)(s) 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 9. Compazine 5 mg Tablet Sig: ___ Tablets PO three times a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Abdominal pain of unknown origin HTN Discharge Condition: All vital signs stable, tolerating POs, pain tolerable Discharge Instructions: You were admitted with abdominal pain. It is unclear what the source of your abdominal pain is but it does not require inpatient level of care. You had an endoscopy of your stomach which was entirely normal, showing no ulcers or signs of irritation or inflammation. You will need to follow up with the outpatient stomach doctors to ___ further causes. We have changed the antibiotics in your Prevpac to Levofloxacin and Flagyll that may be gentler on your stomach. You should also continue to take your Prilosec twice a day. You were also evaluated by the endocrine service here in regards to your high blood pressure. They suggested a number of further blood and urine tests. However, these should not be done in the stressful environment of the hospital that may alter the results. Please be sure to make your out patient endocrine appointment with Dr. ___. We have changed your Atenolol to Toprol XL, a similar drug, and increased it to better control your blood pressure. Please call your doctor or return to the emergency room if you are unable to keep down food or liquids, have any blood in the stool or vomit, have black and tarry stools, have fevers/chills, abdominal pain that does not stop after a few minutes, or any other symptoms that concern you. Please take all your medications as prescribed and attend all your recommended follow up appointments. Followup Instructions: ___

{'Abdominal pain': ['Abdominal pain', 'Unspecified essential hypertension', 'Secondary hyperparathyroidism', 'non-renal', 'Migraine', 'unspecified', 'without mention of intractable migraine without mention of status migrainosus'], 'epigastric': ['Abdominal pain', 'Unspecified essential hypertension', 'Secondary hyperparathyroidism', 'non-renal', 'Migraine', 'unspecified', 'without mention of intractable migraine without mention of status migrainosus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "not feeling well...I think I'm having a breakdown" Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ yo AA female, history of depressive symptoms brought to ___ ED by co-workers after telling her supervisor that she "wasn't feeling well" and "I am emotionally distraught." Per ED report, she feels that she cannot trust her friends, is unhappy, and fearful of losing her job as she was placed on warning last ___ when she approached her boss and said she was having difficulties due to depression. . In the ED, the patient reported that she tried to kill herself 2 nights prior to admission by overdosing on a handful of Benadryl and lisinopril. She could not recall the doses or the exact amount. She did not seek medical treatment after the ingestion but said "I got sick and threw up." Per the pt, one of her friends came over later in the evening, she then tried to cut her wrist with a kitchen knife but her friends stopped her and took all the knives out of her apartment. . The patient reported being depressed since this ___ when she briefly became homeless after her landlord sold the house she was living in. She said she stayed with friends until she found her own place. More recently she has been lending money to a woman who she thought was her friend, putting herself in debt. Per the patient, this friend has 2 children and recently became unemployed; she is also Ms. ___ first lesbian partner. The patient has for years considered herself bisexual but has not been able to reveal this to her family because they would find it unacceptable (they are very observant ___). She and this woman broke up a few months ago and patient said that during their relationship they were in love. In the ED she stated, "I'm tired of people hurting me for no reason people always do bad things to me. I just want to go away and make everything stop. I can never be happy. I'm just tired." The patient is very concerned that she will be considered "crazy." Past Medical History: PAST PSYCHIATRIC HISTORY[INCLUDE PRIOR HOSPITALIZATIONS, OUTPATENT TREATMENT/ECT HISTORY} * no current treaters * age ___ psychiatrically hospitalized after she overdoesd on on pills she found in the house precip. was family conflict PAST MEDICAL HISTORY[INCLUDE HISORY OF HEAD TRAUMA , SEIZURS OR NEUROLOGIC ILLNESS} * PCP ___ @ ___ * ___ NP @ ___ * HTN * Migraine headaches * weight loss * Low grade CIN Social History: ___ Family History: Pat uncle with ___ and hospitalizations Mat aunts and uncles with depression Mother with pheochromocytoma Physical Exam: 97.8 160/111 71 18 100%RA A/B: Appears stated age, dressed in street clothes, calm, cooperative with interviewer, appropriate eye contact. S: normal in volume, rate, normal prosody, goal-directed M: "better." A: brighter, mood-congruent, appropriate TP: linear, goal-oriented TC: denies SI/HI, no A/V hallucinations I: fair J: fair C: alert and oriented x3 Pertinent Results: 10.3> 14.4/41.1< 269 ___ 99 Serum Tox: negative Utox: Negative TSH-0.28 Urine: BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM Urine: RBC->182* WBC-56* BACTERIA-NONE YEAST-NONE EPI-1 Brief Hospital Course: This is a ___ female with h/o SA by overdose and subsequent hospitalization, and longstanding, untreated depression, currently admitted for SA 3 days PTA by overdose with benadryl and lisinopril, and preempted attempt to cut wrists with a kitchen knife. Given the patient's h/o SA by OD and psychiatric hospitalization with no follow-up care and pharmacotherapy, it is highly likely that the patient's current presentation is a reoccurrance of her pre-existing, untreated depression. Moreover, her presenting symptoms of anhedonia, weight loss, psychomotor decline, insomnia, and feeling of guilt, are consistent with depression with melancholic features. Axis I: Major depressive episode, severe, recurrent; r/o bipolar disorder Axis II: Deferred Axis III: hypertension, asthma, migraine headaches Axis IV: financial instability, social isolation, concerns about sexuality V: 40-50 #) Major depression with melancholic features: On admission, the patient endorsed multiple neurovegetative symptoms of depression (anhedonia, insomnia with early morning awakenings, decreased interest in life, decreased motivation, fatigued, decreased appetite, and decreased weight) in addition to depressed mood. She was often tearful. She and her mother denied any history of mania or hypomania. She was started on Buproprion SR that was tapered to 150 mg BID, which she tolerated well. For sleep, initially tried trazodone that was tapered up to 50 mg qhs. Pt continued to report poor sleep, and so Trazodone was discontinued and Seroquel 100 mg qhs was trialed with some improvement. On day of discharge patient stated she was, "better," noted to be future oriented with no SI/HI, but continued to have interrupted sleep. Follow-up as noted below. #). Medical: *Hypertension: The patient had not been taking her antihypertensives prior to admission. She was restarted on Lisinopril 20 mg daily and HCTZ 25 mg daily, but continued to be hypertensive with SBP= 140-170/90-100's. A medicine consultation was obtained, recommended increasing the lisinopril to 40 mg po qd in addition to the HCTZ 25 mg qd. Also recommended outpatient follow-up with PCP and renal for further evaluation of secondary causes of HTN. She will need a BMP in one week. - Follow-up appointment with PCP and ___ as noted below. - The patient was compliant attending group, milieu therapy. *Asthma: Stable. Patient was continued on home medication of fluticasone 110 mcg, 1 puff BID. #). Legal: ___ #). Safety: The patient was monitored on Q15 minute checks without incident. #). Psychosocial: The patient received group and individual therapy per the unit routine. Social work was in contact with her mother and supervisor at work. A family meeting with the mother occurred on the day of discharge, treatment plan was reviewed. Medications on Admission: FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1 puff(s) inhaled twice a day use twice daily for prevention of chest tightness LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth daily take with lisinopril-hctz ___ to total dose of 40-25. LISINOPRIL-HYDROCHLOROTHIAZIDE - 20 mg-25 mg Tablet - 1 Tablet(s) by mouth daily for blood pressure control (Patient was not taking any of these medications on admission) Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. Disp:*60 Tablet Extended Release(s)* Refills:*0* 4. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Axis I: Major depression, recurrent, severe, without psychotic features, r/o bipolar disorder Axis II: deferred Axis III: HTN, Asthma and Migraine headaches. Axis IV: Severe- financial instability, social isolation, concerns about sexuality V: 40 Discharge Condition: Patient ambulatory without assistance at time of discharge Condition: improved 97.9 140/74 91 18 99%RA A/B: Appears stated age, dressed in street clothes, calm, cooperative with interviewer, appropriate eye contact. S: normal in volume, rate, normal prosody, goal-directed M: 'better.' A: brighter, mood-congruent, appropriate TP: linear, goal and future oriented TC: denies SI/HI, no A/V hallucinations I: fair J: fair C: alert and oriented x3 Discharge Instructions: You were admitted to the hospital because you were severely depressed and had attempted suicide. You were started on an antidepressant called Wellbutrin. We have arranged for you to see a psychiatrist and a therapist. You should bring this paperwork with you to all of your appointments. Followup Instructions: ___

{'not feeling well': ['Major depressive affective disorder'], "I think I'm having a breakdown": ['Major depressive affective disorder'], 'cannot trust friends': ['Major depressive affective disorder'], 'unhappy': ['Major depressive affective disorder'], 'fearful of losing job': ['Major depressive affective disorder'], 'depressed since ___': ['Major depressive affective disorder'], 'briefly became homeless': ['Major depressive affective disorder'], 'lending money to a woman': ['Major depressive affective disorder'], 'in debt': ['Major depressive affective disorder'], 'lesbian partner': ['Major depressive affective disorder'], 'tired of people hurting me': ['Major depressive affective disorder'], 'want to go away and make everything stop': ['Major depressive affective disorder'], 'can never be happy': ['Major depressive affective disorder'], 'just tired': ['Major depressive affective disorder'], "concerned that she will be considered 'crazy'": ['Major depressive affective disorder'], 'overdosed on pills': ['Suicidal ideation'], 'tried to cut wrist': ['Suicidal ideation'], 'hypertension': ['Unspecified essential hypertension'], 'migraine headaches': ['Migraine', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Acute ___ in Pain Headache Major Surgical or Invasive Procedure: Conventional Angiography History of Present Illness: ___ with PMH HTN, left breast ca s/p mastectomy who presents with headache with hypertensive emergency and found to have ICH on imaging. Patient woke up this morning at 5AM with an ___ headache that she described as throbbing, bi-frontal, without radiation. She denies any dizziness, light-headedness, visual changes, photo-/phonophobia. Reports nausea but no vomiting. She checked her blood pressure which was in the 200s so she went to the emergency room. She took a regular strength tylenol, which she states helped alleviate the pain. She has never had a HA like this before, and rarely gets headaches. She states her SBPs are normally in 140, but that her PCP recently added HCTZ to her anti-hypertensive regimen. At OSH, SBP noted to be in 200s and patient was started on a nicardipine gtt. CT showed ICH and patient was transferred to ___ for further management. By the time I saw patient she was off nicardipine gtt and SBP's were 140s. Past Medical History: HTN Breast ca s/p mastectomy ___ (no chemo or radiation therapy) Social History: ___ Family History: mother with questionable brain disease, not fully clarified Physical Exam: PHYSICAL EXAM: Vitals: General: Awake, cooperative, NAD. HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. Cardiac: RRR. Well perfused. Pulmonary: Breathing comfortably on room air. Abdomen: Soft, NT/ND. Extremities: No cyanosis, clubbing, or edema bilaterally. 2+ radial, DP pulses. Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes. Had good knowledge of current events. There is no evidence of apraxia or neglect. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation and no extinction. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ 5 5 R ___ 5 5 -Sensory: No deficits to gross touch throughout. No extinction to DSS. Pertinent Results: ___ 08:30AM GLUCOSE-115* UREA N-26* CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 ___ 08:30AM CALCIUM-9.7 PHOSPHATE-2.3* MAGNESIUM-1.6 ___ 08:30AM WBC-8.7 RBC-4.51 HGB-13.5 HCT-41.8 MCV-93 MCH-29.9 MCHC-32.3 RDW-13.2 RDWSD-45.2 ___ 08:30AM NEUTS-65.4 ___ MONOS-8.0 EOS-1.1 BASOS-0.8 IM ___ AbsNeut-5.68 AbsLymp-2.12 AbsMono-0.70 AbsEos-0.10 AbsBaso-0.07 ___ 08:30AM PLT COUNT-236 ___ 08:30AM ___ PTT-29.2 ___ year old lady with history of PMH HTN, left breast ca s/p mastectomy ___, in remission) who presents with headache with hypertensive emergency found to have left parafalcine ICH. #ICH Her systolics were to 200 initially. Her neurologic exam was normal. CTH showed left cingulate gyrus small ICH. DSA was negative for aneurysm. MRI showed likely cavernoma with stable hemorrhage. Her headache improved with blood pressure control. Aspirin was held and losartan was increased to 150 mg daily (from 100 mg daily). She remained stable and was discharged on HD 2 with stable neurologic exam. She will need repeat MRI in ___ months to assess for vascular abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspir-81 (aspirin) 81 mg oral DAILY 2. Rosuvastatin Calcium 10 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Losartan Potassium 150 mg PO DAILY RX *losartan 100 mg 1.5 tablet(s) by mouth once a day Disp #*45 Tablet Refills:*0 2. Hydrochlorothiazide 25 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO QPM 4. HELD- Aspir-81 (aspirin) 81 mg oral DAILY This medication was held. Do not restart Aspir-81 until told to resume from a neurologist Discharge Disposition: Home Discharge Diagnosis: Intra-parenchymal Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ came to the hospital because of headache and high blood pressure. While ___ were here we found a small bleed on the left side of your brain which is likely due to a "cavernoma" or small cluster of blood vessels which ___ were probably born with. ___ had a special procedure which showed ___ did not have an aneurysm. We are changing your medications as follows: - We are increasing your losartan from 100 mg daily to 150 mg daily to better control your blood pressure. This is important to prevent further bleeding. - We also stopped your aspirin as it can increase your risk of bleeding. Now that ___ are leaving the hospital we recommend the following: - Please follow-up with your doctors as listed below - ___ will need to get a repeat MRI of your brain in ___ months We wish ___ the best, ___ Neurology Followup Instructions: ___

{'headache': ['Hypertensive emergency', 'Other nontraumatic intracerebral hemorrhage'], 'hypertension': ['Hypertensive emergency', 'Essential (primary) hypertension'], 'ICH': ['Other nontraumatic intracerebral hemorrhage'], 'oriented': ['Coma scale', 'best verbal response'], 'obeys commands': ['Coma scale', 'best motor response'], 'history of nicotine dependence': ['Personal history of nicotine dependence'], 'history of breast cancer': ['Personal history of malignant neoplasm of breast']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Latex Attending: ___. Chief Complaint: Patient admitted for ___ reduction surgery. Major Surgical or Invasive Procedure: Status Post open gastric bypass and ___ liver resection History of Present Illness: ___ has class III extreme morbid obesity with ___ of 445.5 lbs as of ___ (her initial screen ___ on ___ was 451.3 lbs), height of 67.5 inches and BMI of 94.9. Her previous ___ loss efforts have included 2 months of hypnosis in ___ without any results, 3 months ___ Loss in ___ losing 5 lbs that she quickly regained, 6 months of Nutrisystem in ___ losing 70 lbs that she maintained for 6 months, 4 months of the ___ ___ Management Program liquid diet in ___ losing 40 lbs that she gained back after 3 months, 6 months of ___ Watchers in ___ losing 50 lbs and 2 months ___ ___ in ___ at age ___ losing 10 lbs. She has not taken prescription ___ loss medications or used over-the-counter ephedra-containing appetite suppressants/herbal supplements. Her ___ at age ___ was 360 lbs with her lowest adult ___ 340 lbs and her highest ___ being her initial screen ___ of 451 lbs. She weighed 380 lbs one year ago. She has been struggling with ___ as long as she can remember. Past Medical History: PCOS, Hypothyroidism, Hyperlipidemia, OSA CPAP, Recurrent urinary tract infections, HTN, Knee pain and foot pain, Occasional heartburn, History of gallbladder "gravel." Social History: ___ Family History: Family history is noted for father deceased had hyperlipidemia and obesity; mother living age ___ with obesity; grandfather deceased with heart disease; grandmother living age ___ with arthritis and other grandmother with lupus. Physical Exam: Her blood pressure was 138/70, pulse 95 and O2 saturation 97% on room air. On physical examination ___ was casually dressed, mildly anxious but in no distress. Her skin was warm, dry with mild facial erythema secondary to sun exposure, mild acne and mild hirsutism. Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi normal, mucous membranes were moist, tongue pink and the oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple without adenopathy, thyromegaly or carotid bruits. Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen was extremely obese with large pannus, soft, non-tender, non-distended with bowel sounds present, no masses or hernias, no incision scars. There were no spinal deformities or tenderness, no flank pain. Lower extremities were noted for trace edema, no venous insufficiency or clubbing. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and her gait was normal. Pertinent Results: ___ 01:58PM BLOOD Hct-33.2* ___ 05:35AM BLOOD WBC-12.5* RBC-4.08* Hgb-10.1* Hct-30.7* MCV-75* MCH-24.7* MCHC-32.8 RDW-13.3 Plt ___ ___ 05:35AM BLOOD WBC-14.2* RBC-4.13* Hgb-10.4* Hct-31.2* MCV-76* MCH-25.3* MCHC-33.4 RDW-13.7 Plt ___ ___ 05:35AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-138 K-4.2 Cl-104 HCO3-24 AnGap-14 ___ 05:35AM BLOOD ALT-69* AST-55* AlkPhos-127* Amylase-39 TotBili-0.8 ___ 05:35AM BLOOD ALT-59* AST-37 AlkPhos-118* TotBili-0.8 ___ 05:35AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 Brief Hospital Course: Patient underwent an open gastric bypass with a liver resection for a large adenoma. She tolerated the procedure very well. Postoperative course was relatively stable with problems with pain and low urine output. She was bolused with intravenous fluid several times. Her hematocrit was followed and she was progressed from a bariatric stage one diet to stage 3 without nausea or vomiting. Currently she is up ambulating, tolerating stage 3 diet and hydrating well. We will discharge today with follow up with Dr. ___ the ___ clinic. Medications on Admission: LEVOTHYROXINE 25 mcg Tablet qday; ORTHO TRI-CYCLEN 0.18 mg-35 mcg (7)/0.215 mg-35mcg (7)/0.25mg-35mcg (7) (28) Tablet - Tablet(s) by mouth, ACETAMINOPHEN 325 mg TabletPRN; CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Tablet once a day SUDAFED 30 mg Tablet PRN Assessment: Discharge Medications: 1. Oxycodone-Acetaminophen ___ mg/5 mL Solution Sig: ___ MLs PO Q4H (every 4 hours) as needed. Disp:*500 ML(s)* Refills:*0* 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): please crush. 3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as needed for constipation. Disp:*500 ml* Refills:*0* 4. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day: Please take for 6 months. You must open capsule and put in drink. Disp:*60 Capsule(s)* Refills:*5* 5. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: please take for one month. Disp:*600 ml* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Primary Diagnosis: Obesity Discharge Condition: Stable 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, 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 will be taking Zantac liquid ___ mg twice daily for one month. This medicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 6. 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'], 'gastric bypass': ['Morbid obesity'], 'liver resection': ['Benign neoplasm of liver and biliary passages'], 'adenoma': ['Benign neoplasm of liver and biliary passages'], 'pain': ['Morbid obesity', 'Calculus of gallbladder with other cholecystitis', 'Body Mass Index 40 and over'], 'urinary tract infections': ['Unspecified essential hypertension'], 'heartburn': ['Gastro-esophageal reflux disease'], 'knee pain': ['Morbid obesity'], 'foot pain': ['Morbid obesity'], 'hirsutism': ['Polycystic ovaries'], 'acne': ['Polycystic ovaries'], 'hypothyroidism': ['Unspecified acquired hypothyroidism'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'sleep apnea': ['Obstructive sleep apnea (adult)(pediatric)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Latex Attending: ___. Chief Complaint: Abd pain Major Surgical or Invasive Procedure: EGD History of Present Illness: Per admitting resident: ___ is a ___ y/o woman who had an open roux-en-y gastric bypass for extrmee morbid obesity (preop BMI 94.9) and partial liver resection in ___ with Dr. ___. She has been well since surgery. During her ___ follow-up visit, she was noted to have some increased nausea/heartburn noted but an EGD done on ___ was normal. She reports that she tolerated her regular dinner last night, but was woken from sleep at ~0200 with severe epigastric pain/burning, nausea, feeling the urge to vomit but no emesis, and she reported feeling dizzy and weak while climbing stairs at home. The epigastric burning lasted ~6 hours, at which point she called the ___ service and was advised to go to her local emergency room. At an OSH ED, she had a CT abd that was negative for free air, free fluid in the abdomen, CBC and chem-10 within normal limits and a negative troponin x1, and her symptoms resolved. At ~1500, she had some crackers and ginger ale, at which point her symptoms returned and she was transferred to ___ for further evaluation. Past Medical History: Past Medical History: 1. History of hepatic adenoma. 2. Polycystic ovary disease. 3. Hypothyroid for which she is on Synthroid. 4. Hyperlipidemia, resolved. 5. Obstructive sleep apnea, resolved. 6. Urinary tract infection. This is actually the incidence of these have decreased since her weight loss. 7. Hypertension, resolved. 8. Gastroesophageal reflux. This predated her weight loss operation, but has recurred recently to a mild extent. 9. Incisional hernia. Past Surgical History: 1. Wisdom teeth extraction in ___. 2. Tonsillectomy and adenoidectomy in ___. 3. Open Roux-en-Y gastric bypass, cholecystectomy and left hepatectomy for adenoma in ___. 4. Right liver resection in ___ at ___. Social History: ___ Family History: Family history is noted for father deceased had hyperlipidemia and obesity; mother living age ___ with obesity; grandfather deceased with heart disease; grandmother living age ___ with arthritis and other grandmother with lupus. Physical Exam: VSS Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1, S2 Resp: CTA B Abd: Soft, non-tender, non-distended, no rebound tenderness or guarding Wounds: Abd lap sites CDI Ext: No edema Pertinent Results: ___ 07:40PM BLOOD WBC-8.0 RBC-4.46 Hgb-12.1 Hct-37.0 MCV-83 MCH-27.1 MCHC-32.7 RDW-12.8 Plt ___ ___ 07:40PM BLOOD Neuts-58.5 ___ Monos-3.7 Eos-3.6 Baso-0.7 ___ 07:40PM BLOOD Glucose-90 UreaN-7 Creat-0.5 Na-139 K-3.9 Cl-104 HCO3-26 AnGap-13 ___ 07:40PM BLOOD ALT-25 AST-26 AlkPhos-66 TotBili-0.5 ___ 07:40PM BLOOD Lipase-36 ___ 07:40PM BLOOD Albumin-4.0 ___ 09:50PM BLOOD Lactate-1.5 EGD: Normal mucosa in the esophagus Evidence of a previous Roux-en-y Gastric bypass surgery was seen. The GE junction was at 40 cm and the GJ at 45 cm. The mucosa of the stomach pouch appeared normal. There was slight narrowing at the GJ junction to 13 mm but the scope could easily traverse. There was some nodularity at the GJ junction. No ulcer noted. The blind limb appeared normal. (biopsy) Normal mucosa in the duodenum Otherwise normal EGD to jejunum and blind limb Brief Hospital Course: Ms. ___ is a ___ year-old female with a history of roux-en-Y gastric bypass with history of a marginal ulcer admitted to the hospital on ___ due to new onset epigastric pain in setting of known smoking. Upon arrival, she was placed on bowel rest with intravenous fluids and antiacids. Po's were trialed on HD2 due to resolution of pain, however, the patient's pain returned. She subsequently underwent an EGD on HD3, which did not show a marginal ulcer, therefore, her pain was attributed to a possible ulcer in the remnant stomach. Post-procedure, as she remained hemodynamically stable with improved pain and tolerance to a stage 3 diet, she was discharged to home on omeprazole. She will follow-up with Dr. ___ in clinic within the next few weeks. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Multivitamins W/minerals 1 TAB PO BID 3. Omeprazole 40 mg PO BID 4. Calcium Carbonate 500 mg PO DAILY 5. Citalopram 10 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. biotin 2,500 mcg oral daily 8. Cyanocobalamin 500 mcg PO 1X/WEEK (___) 9. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. biotin 2,500 mcg oral daily 3. Calcium Carbonate 500 mg PO DAILY 4. Citalopram 10 mg PO DAILY 5. Cyanocobalamin 500 mcg PO 1X/WEEK (___) 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins W/minerals 1 TAB PO BID 8. Omeprazole 40 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 10 ML by mouth four times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: presumed remnant stomach ulcer Secondary diagnosis: history of morbid obesity, post Roux-en-Y gastric bypass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen at the ___ due to stomach pain caused by a presumed ulcer, which has occured as the result of smoking. We monitored your blood counts and labs while you were admitted and have determined that your symptoms are unlikely due to a bleeding ulcer. We are sending you home at this time. Please continue to take your antiacid, twice daily. Followup Instructions: ___

{'Abd pain': ['Morbid obesity', 'Esophageal reflux'], 'nausea/heartburn': ['Morbid obesity', 'Esophageal reflux'], 'epigastric pain/burning': ['Morbid obesity', 'Esophageal reflux'], 'feeling the urge to vomit': ['Morbid obesity', 'Esophageal reflux'], 'dizzy and weak': ['Morbid obesity', 'Esophageal reflux'], 'incisional hernia': ['Morbid obesity', 'Ventral hernia without mention of obstruction or gangrene'], 'hypertension': ['Morbid obesity', 'Hypertension, resolved'], 'gastroesophageal reflux': ['Morbid obesity', 'Esophageal reflux'], 'open roux-en-y gastric bypass': ['Morbid obesity', 'Bariatric surgery status'], 'partial liver resection': ['Morbid obesity', 'Bariatric surgery status'], 'history of hepatic adenoma': ['Morbid obesity', 'Personal history of peptic ulcer disease'], 'polycystic ovary disease': ['Morbid obesity'], 'hypothyroid for which she is on Synthroid': ['Unspecified acquired hypothyroidism'], 'hyperlipidemia, resolved': ['Morbid obesity'], 'obstructive sleep apnea, resolved': ['Morbid obesity'], 'urinary tract infection': ['Morbid obesity'], 'right liver resection': ['Morbid obesity', 'Bariatric surgery status']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Headaches Major Surgical or Invasive Procedure: 1. Revision L4-5 and L5-S1 laminectomy with medial facetectomy and foraminotomy at L4-5 and L5-S1. 2. Attempt at dural repair although a dural leak was not identified. History of Present Illness: This is a gentleman with positional headaches which persisted. He underwent lumbar microdiscectomy on ___ ___ ___. He was admitted to the hospital for the severity of these headaches. Lying flat, he had no headaches. A MRI was obtained which showed fluid both behind S1-S2 and in the canal as well as tracking to the subcutaneous tissue. Given his recent history of surgery as well as postural headaches, mild photophobia and nausea and vomiting Past Medical History: Hypertension Social History: ___ Family History: non contributory Physical Exam: On physical exam, he is approximately 6 feet 2 inches, weighing 257 pounds with a blood pressure of 134/89 and pulse of 70. He is a well-nourished male whose affect is appropriate and judgment appears to be intact. He has a mildly antalgic gait favoring the left. He is able to toe walk without difficulty; however, heel walking on the left is difficult, he is unable to keep his foot dorsiflexed. Alignment of his spine without any obvious scoliotic or kyphotic curvatures. Skin is intact without any lesions, ecchymosis, or erythema. He is nontender along his lumbar spine. Lower extremity strength is ___ throughout with the exception of the left anterior tibialis which is approximately ___ in his left ___ which is approximately ___. He is sensory intact to light touch throughout. Distal pulses are intact. He has a mildly positive straight leg raising exam on the left in the supine position. Negative clonus. Reflexes were symmetrical bilaterally. Calves are soft and nontender. Pertinent Results: ___ 10:00AM BLOOD WBC-6.7 RBC-4.37* Hgb-13.4* Hct-36.3* MCV-83 MCH-30.8 MCHC-37.0* RDW-13.1 Plt ___ ___ 07:40AM BLOOD WBC-7.3 RBC-4.57* Hgb-14.0 Hct-38.8* MCV-85 MCH-30.6 MCHC-36.1* RDW-13.1 Plt ___ ___ 06:35AM BLOOD WBC-10.9 RBC-4.29* Hgb-13.2* Hct-36.2* MCV-84 MCH-30.7 MCHC-36.4* RDW-12.7 Plt ___ MRI L spine ___ IMPRESSION: Status post laminectomy at L5-S1 level on the left side with linear fluid collection extending from laminectomy site and from the right side of the thecal sac posteriorly to the subcutaneous fat where a small fluid collection is seen with ___ as described above. This could represent a CSF leak or postoperative seroma. Additionally, partially visualized in the sacral canal is a CSF-intensity collection which appears to be not contiguous with the thecal sac on the visualized images and could represent a CSF leak within the spinal canal. However, to exclude intraspinal arachnoid cyst or unusual extension of the thecal sac, correlation with patient's preoperative MRI would be helpful. Mild degenerative changes. Brief Hospital Course: Mr. ___ was admitted to ___ for severe headaches, nausea & vomiting consistant with a dural leak. He reciently underwent L4-5 microdiscectomy for a herniated disc on ___. He tolerated that procedure well. After MRI of his lumbar spine that showed fluid in the sacral region, the risks and benifits of exploratory surgery for a dural leak were discussed. Mr. ___ was concented and brought to the OR for his repair. He tolerated the procedure well. He was then brought to the PACU and then the general floor. Mr. ___ was kept on bedrest for three days time. The head of his bed was elevated slowly over the duration of a day. He experienced no residual headaches, nausea or vomiting. He was discharge to home. Medications on Admission: None Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Cerebrospinal fluid (CSF) leak, L5-S1. 2. Status post L5 hemilaminectomy and diskectomy. Discharge Condition: stable to home Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at ___. Please resume all home mediciation as prescribed by your primary care physician. You have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on ___ 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Followup Instructions: ___

{'headaches': ['Other nervous system complications'], 'nausea': ['Other nervous system complications'], 'vomiting': ['Other nervous system complications'], 'photophobia': ['Other nervous system complications'], 'mild antalgic gait': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'difficulty heel walking': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'unable to keep foot dorsiflexed': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'mildly positive straight leg raising exam': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'CSF leak': [' or later complication', 'without mention of misadventure at time of operation'], 'fluid collection': [' or later complication', 'without mention of misadventure at time of operation'], 'herniated disc': [' or later complication', 'without mention of misadventure at time of operation'], 'hypertension': ['Unspecified essential hypertension'], 'esophageal reflux': ['Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Metastatic adenocarcinoma of the colon to the liver. Major Surgical or Invasive Procedure: ___ left lateral segmentectomy and port placement History of Present Illness: Per Dr. ___ report, Mr. ___ is a ___ male who underwent a laparoscopic extended right hemicolectomy on ___ for stage II transverse colon cancer. He developed a rising CEA, and a CT scan in ___ demonstrated a low-density lesion in the left lobe of the liver suspicious for metastatic disease. His most recent CEA was 19. A follow-up CT scan on ___ demonstrated a 2.0 x 2.0 cm lesion in the left lateral segment. He is, therefore, brought to the operating room for left lateral segmentectomy after informed consent was obtained. I should note that chest CT was negative for metastatic disease. Brief Hospital Course: On ___ he underwent left lateral segmentectomy with intraoperative ultrasound and left double-lumen port placement for metastatic adenocarcinoma of the colon to the liver. Surgeon was Dr. ___. Please refer to operative report for complete details. Operative findings per Dr. ___ were: a solitary lesion in the left lateral segment was found. No other lesions were found grossly or by intraoperative ultrasound. No extrahepatic disease was noted. Postop, he did well. LFTs initially increased slightly, but then started trending down. Diet was advanced and tolerated. The abdominal incision was clean, dry and intact. Vital signs remained stable and he was transitioned to po pain medication once the epidural was removed on ___. He was ambulatory. Pathology results were pending at time of discharge. Medications on Admission: Lisinopril 10', Verapamil SR 240' Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 3. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: metastatic colon CA to liver Discharge Condition: good Discharge Instructions: Please call Dr. ___ ___ if fever, chills, nausea, vomiting, worsening abdominal pain, incision redness/bleeding/drainage or any concerns may shower No driving while taking pain medication No heavy lifting Followup Instructions: ___

{'Metastatic adenocarcinoma of the colon to the liver': ['Malignant neoplasm of liver', 'secondary'], 'Rising CEA': ['Malignant neoplasm of liver', 'secondary'], 'Low-density lesion in the left lobe of the liver suspicious for metastatic disease': ['Malignant neoplasm of liver', 'secondary'], 'Solitary lesion in the left lateral segment': ['Malignant neoplasm of liver', 'secondary'], 'No other lesions were found grossly or by intraoperative ultrasound': [], 'No extrahepatic disease was noted': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Direct laryngoscopy at bedside by ENT History of Present Illness: his patient is a ___ year old male, hx of metastatic colon cancer, who was sent to ED from ___ clinic today. Pt was seen in f/u for ongoing clinical trial, is C1D28 of protocol ___. He was reporting increased dyspnea and wheezing. It began 2 weeks ago and has progressively gotten worse over the past few days. His family has noticed increasing wheezing at rest and increasing cough productive of white phlegm, no hemoptysis. He also had ongoing weight loss, total 10lb since starting investigational regimen He denies chest pain and palpitations. He has persistent right upper quadrant pain that has not changed since beginning treatment, has declined pain meds for this. Denies any cough or hemoptysis. Denies fever/chills. No HA or neck pain, no bleeding. CXR in clinic today showed increased pulm nodules as well as enlargement of a lesion in the arytenoid cartilage, leading to extrathoracic tracheal narrowing. He was referred to ED where CT neck showed mass inferior to right vocal cord with significant airway narrowing. ENT was consulted for emergent tracheostomy. Scope performed by ENT at bedside. Received decadron x 1. Pt has declined tracheostomy. Palliative/case management was consulted and plan is to enroll pt in hospice, however he was not stable for discharge from ED until arrangements can be made. Past Medical History: ONCOLOGIC HISTORY: He had an extended right hemicolectomy in ___, for a T3, N0 adenocarcinoma, a rise in CEA in late ___, prompted a left lateral segmentectomy in ___, by Dr. ___ ___ isolated liver metastasis. Postoperatively, CEA normalized and he received six courses of FOLFOX ending in ___. Treatment was complicated by mild peripheral neuropathy, which cleared only incompletely and a progressively enlarging spleen, which on laparoscopic splenectomy was only remarkable for small focus of necrosis. Midepigastric pain in the ___, which did not improve with a course of anti H. pylori treatment prompted a CT scan, which demonstrated a new pulmonary nodule and a paraaortic lymph node. In the intervening time, he underwent resection of a pyogenic granuloma from the anterior right inferior turbinate by Dr. ___ on ___. An attempted CT scan guided biopsy of the periaortic soft tissue mass in ___, was nondiagnostic. His CEA remained flat and periodic CTs demonstrated progressively, but slowly enlarging masses in the retroperitoneum and lung. A repeat biopsy in early ___, finely demonstrated metastatic adenocarcinoma. He began salvage chemotherapy with FOLFOX and Avastin in mid ___. . Other Past Medical History: Hypertension Social History: ___ Family History: Essentially negative for any cancer except for a father who died at age ___ of lung cancer after heavy smoking all his life. His mother died in her ___ of old age. He has one brother who is alive and well. Physical Exam: Physical Exam General: NAD, cachectic VITAL SIGNS: T 97.7 BP 131/82 HR 83 RR 20 94%RA HEENT: MMM, no OP lesions Neck: supple, no JVD, firm 5cm mass L distal trachea, inspiratory and exp stridor CV: RR, NL S1S2 no S3S4 or MRG PULM: referred high pitched upper airway sounds, nonlabored ABD: BS+, soft, mild ttp RUQ EXT: warm well perfused, no edema SKIN: No rashes or skin breakdown NEURO: alert and oriented x 4, ___, EOMI, face symmetric, moves all ext, no clonus Pertinent Results: ___ 12:30PM BLOOD WBC-6.2 RBC-3.90* Hgb-12.0* Hct-40.0 MCV-103* MCH-30.9 MCHC-30.0* RDW-13.9 Plt ___ ___ 12:30PM BLOOD Neuts-73.9* Lymphs-17.6* Monos-6.2 Eos-1.5 Baso-0.7 ___ 12:30PM BLOOD ___ PTT-35.1 ___ ___ 12:30PM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-138 K-4.3 Cl-97 HCO3-28 AnGap-17 Brief Hospital Course: Mr ___ is a ___ yr old male with hx metastatic colon Ca involving liver, peritoneum and lung who is admitted with arytenoid cartilage mass with compromise of upper airway. Given his poor prognosis and progression despite all available treatments, he elected to transition to hospice this admission. Active Issues # Likely Metastatic Colon Cancer: patient had increased dyspnea and wheezing for 2 weeks ago and has progressively gotten worse over the past few days. Increasing wheezing at rest and increasing cough productive of white phlegm, no hemoptysis. CXR in clinic showed increased pulm nodules as well as enlargement of a lesion in the arytenoid cartilage, leading to extrathoracic tracheal narrowing. He was referred to ED where CT neck showed mass inferior to right vocal cord with significant airway narrowing. ENT was consulted for emergent tracheostomy. Scope performed by ENT at bedside. Received decadron x 1. Pt has declined tracheostomy despite a repeated invitation. Palliative/case management was consulted and patient was enrolled in hospice prior to discharge. Transitional Issues: -Please follow up with oncology appointment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 3. Verapamil SR 240 mg PO Q24H 4. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, fever 5. LOPERamide 4 mg PO QID:PRN diarrhea Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, fever 2. LOPERamide 4 mg PO QID:PRN diarrhea 3. Ondansetron 8 mg PO Q8H:PRN nausea 4. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 5. Verapamil SR 240 mg PO Q24H 6. Dexamethasone 4 mg PO DAILY RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 7. Racepinephrine 0.5 mL IH Q4H:PRN stridor, dyspnea RX *racepinephrine 2.25 % 0.5 (One half) mL INH q4h:prn Disp #*4 Vial Refills:*0 8. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN pain/shortness of breath RX *morphine concentrate 20 mg/mL 0.25 ml by mouth q4h:prn Disp ___ Milliliter Refills:*0 9. Lorazepam 1 mg PO Q6H:PRN anxiety RX *lorazepam 1 mg 1 tablet(s) by mouth q6h:prn Disp #*45 Tablet Refills:*0 10. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours RX *scopolamine base [Transderm-Scop] 1.5 mg/72 hour 1 ptch TD q72h Disp #*4 Patch Refills:*0 11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of breath RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml inh q4h:prn Disp #*15 Vial Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: 1. Metastatic Colon Cancer Discharge Condition: Condition: stable Mental status: alert and oriented. calm and cooperative Ambulatory status: ambulates without assistance Discharge Instructions: Dear Mr. ___, You were admitted for difficulty breathing and wheezing. You were admitted for observation and symptom management. You received steroids which greatly improved your symptoms. Palliative care was consulted and hospice was setup on discharge. Thank you for letting us participate in your care. Your ___ Team Followup Instructions: ___

{'dyspnea': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'wheezing': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'weight loss': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'right upper quadrant pain': ['Malignant neoplasm of liver', 'Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'mass inferior to right vocal cord': ['Unspecified disease of pharynx'], 'extrathoracic tracheal narrowing': ['Unspecified disease of pharynx'], 'increasing pulm nodules': ['Secondary malignant neoplasm of lung'], 'enlargement of a lesion in the arytenoid cartilage': ['Unspecified disease of pharynx'], '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: Leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o male with history of hypertension, metastatic colonic adenocarcinoma with mets to lung/RP LAD presenting with LLE swelling. Patient on C2D3 of FOLFOX+Avastin. Started noting yesterday progressive LLE swelling and pain with exention up leg. Came into ED for evaluation. In ED, LENIs showng extensive LLE clot burden. No complaints of palpitations, chest pain, or shortness of breath. No recent prolonged immobility. Patient started on heparin and admitted to OMED for further manegment. Past Medical History: ONCOLOGIC HISTORY: He had an extended right hemicolectomy in ___, for a T3, N0 adenocarcinoma, a rise in CEA in late ___, prompted a left lateral segmentectomy in ___, by Dr. ___ ___ isolated liver metastasis. Postoperatively, CEA normalized and he received six courses of FOLFOX ending in ___. Treatment was complicated by mild peripheral neuropathy, which cleared only incompletely and a progressively enlarging spleen, which on laparoscopic splenectomy was only remarkable for small focus of necrosis. Midepigastric pain in the ___, which did not improve with a course of anti H. pylori treatment prompted a CT scan, which demonstrated a new pulmonary nodule and a paraaortic lymph node. In the intervening time, he underwent resection of a pyogenic granuloma from the anterior right inferior turbinate by Dr. ___ on ___. An attempted CT scan guided biopsy of the periaortic soft tissue mass in ___, was nondiagnostic. His CEA remained flat and periodic CTs demonstrated progressively, but slowly enlarging masses in the retroperitoneum and lung. A repeat biopsy in early ___, finely demonstrated metastatic adenocarcinoma. He began salvage chemotherapy with FOLFOX and Avastin in mid ___. . Other Past Medical History: Hypertension Social History: ___ Family History: Essentially negative for any cancer except for a father who died at age ___ of lung cancer after heavy smoking all his life. His mother died in her ___ of old age. He has one brother who is alive and well. Physical Exam: VS: 97.0 125/82 60 18 GENERAL: Well appearing middle aged man in NAD. HEENT: PERLL, EOMI, OP clear without lesion. NECK: Supple, no LAD HEART: RRR, No MRG LUNG: Nonlabored, CTAB GI: Soft, NT/ND. Normoactive BS. EXT: Notable swollen left leg from thigh to ankle with blue/purple discoloration. Not particularly warm or tender. No pitting noted. NEURO: CNII-XII intact. No gross sensory or motor deficits. AAOx3. Pertinent Results: ___ 06:00PM BLOOD WBC-1.8*# RBC-4.04* Hgb-13.0* Hct-37.4* MCV-93 MCH-32.3* MCHC-34.8 RDW-14.7 Plt ___ ___ 06:37AM BLOOD WBC-2.9*# RBC-4.02* Hgb-12.8* Hct-37.3* MCV-93 MCH-31.8 MCHC-34.3 RDW-14.8 Plt ___ ___ 06:00PM BLOOD ___ PTT-23.0 ___ ___ 06:37AM BLOOD ___ PTT-150* ___ ___ 06:00PM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-139 K-4.4 Cl-102 HCO3-24 AnGap-17 ___ 06:37AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-138 K-4.6 Cl-103 HCO3-25 AnGap-15 ___ 06:37AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.5 ___ 06:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06:00PM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 ___ 06:00PM URINE CastHy-3* IMAGING ___ US ___: 1. Extensive DVT within the left lower extremity. 2. No DVT in the right leg. CT Head ___: No CT evidence for intracranial metastases; MR is more sensitive for detecting small masses. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION ___ year old with metastatic colon cancer undergoing salvage chemotherapy presents with lower extremity swelling, found to have DVT and no signs or symptoms of PE. ACTIVE ISSUES # DVT: Patient was started on heparin drip night of admission. Patient was switched to lovenox 60 sc bid morning after admission. He was discharged with instructions to continue therapeutic lovenox indefinitely, or until told otherwise by his outpatient oncologist. # Metastatic colon cancer: On admission, patient was C2D2 of modified FOLFOX with bevacizumab and was still receiving ___ infusion. After consulting with attending, Patient was still on ___ pump when presented to floor. Pump was due to come off day after admission (___) and it was ended on arrival to floor after discussion with attending, infusion was discontinued. Patient is to follow up as previously planned with his outpatient oncologist. CHRONIC ISSUES #HTN: Well controlled. Continued home lisinopril and verapamil. OUTSTANDING STUDIES - None TRANSITIONAL ISSUES - Continue lovenox for at least ___ months, or perhaps indefininitely based on risk/benefit evaluation. Medications on Admission: APREPITANT [EMEND] - 80 mg Capsule - One Capsule(s) by mouth once daily for two days after each course of chemotherapy; start 24 hours after chemotherapy is given DEXAMETHASONE - 4 mg Tablet - One Tablet(s) by mouth twice daily for 48 hours after each course of chemotherapy LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - Tablet(s) by mouth daily ONDANSETRON - 8 mg Tablet, Rapid Dissolve - one Tablet(s) by mouth every 8 hours as needed for as needed for nausea or vomiting PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every ___ as needed for nausea VERAPAMIL - (Prescribed by Other Provider) - 240 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*60 syringes* Refills:*2* 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 4. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primay: Deep vein thrombosis Secondary: Metastatic colon cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you noticed swelling in your leg. We did an ultrasound which showed a blood clot in the veins of that leg. We started you on blood thinning medication. You will need to take this medicine (2 shots a day) every day until your doctor tells you to stop (several months at the least). Please note the following changes to your medications: START: Enoxaparin (Lovenox) injections 60mg twice daily Also, please wear a compression stocking to your left leg to help with the swelling. It has been a pleasure taking care of you. Followup Instructions: ___

{'Leg swelling': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'Pain with extension up leg': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'No complaints of palpitations, chest pain, or shortness of breath': [], 'No recent prolonged immobility': [], 'Extensive LLE clot burden': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'Metastatic colonic adenocarcinoma': ['Secondary malignant neoplasm of lung', 'Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'Hypertension': ['Unspecified essential hypertension'], 'Enlarging spleen': [], 'Midepigastric pain': [], 'Pyogenic granuloma': [], 'Peripheral neuropathy': [], 'Spleen necrosis': [], 'Pulmonary nodule': ['Secondary malignant neoplasm of lung'], 'Paraaortic lymph node': ['Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'CEA remained flat': [], 'Progressively enlarging masses in retroperitoneum and lung': ['Secondary malignant neoplasm of retroperitoneum and peritoneum', 'Secondary malignant neoplasm of lung']}