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history of present illness: the patient is a 60 year old, right handed female who started experiencing nausea and vomiting one week ago. she felt dizzy and had diplopia. she fell the day prior to admission and was brought back to bed and could not get out of bed until the day of admission when ems was called. she was brought to hospital where a ct of her head showed left frontal hemorrhage and right occipital hemorrhage. also a mass was detected on her chest x-ray and confirmed by chest ct. patient was then transferred to . past medical history: lumbar diskectomy. hypertension. depression. allergies: none known. medications on admission: aspirin 81 mg p.o. q.day, univasc 30 mg q.day, thiamine 100 mg im, mvi one p.o. q.day, levaquin 500 mg iv q.24 hours, atenolol 75 mg p.o. q.a.m., norvasc 10 mg p.o. q.day, folate 1 mg p.o. q.day, tylenol and magnesium. physical examination: the patient's heart rate was 46, blood pressure 158/51, sao2 96 percent, respiratory rate 19. patient was awake, alert, slightly lethargic, oriented times two. lungs were clear, left lung slightly coarse breath sounds. abdomen soft, nontender. cardiac regular rate and rhythm. extremities had no edema. neurologic exam showed an awake, slightly lethargic, oriented times two, not to time, slightly reversed when following commands. right eye had slightly decreased adduction, slight decreased elevation of the right eye. also left lateral gaze nystagmus. face was symmetric. frontalis was intact. moderate dysarthria. no obvious drift. upper and lower extremities were full for muscle. reflexes were 1+ in the upper extremities and 1 in the lower extremities. no hoffmann, no clonus. sensation was intact to lower extremities bilaterally. laboratory data: white count 10.6, hematocrit 27.4, platelets 309. inr 1.3, ptt 33.2. sodium 139, potassium 3.4, chloride 106, co2 22. hospital course: the plan for this patient was admission to the icu, obtain an mri with gadolinium. she was made npo, iv fluids at 80 an hour. neuro checks were q.one hour. she was given mannitol 25 q.four hours and decadron 8 mg q.four hours. on the patient was noted to be arousable, oriented to person only, very dysarthric, more lethargic than the previous day. she had received ativan at the time of examination. she did have a slight right drift. she had an mri which showed a large right cerebellar t2 hypointense and t1 hyperintense mass which measured about 5 cm in maximal dimension. a dwi scan loss of signal in the right cerebellum and left frontal lobe. mr flow in both intracranial carotid arteries and in the anterior middle cerebral artery. there was flow in the vertebral arteries. the impression was cerebellar and cerebral hemorrhagic masses consistent with metastasis. the cerebellar mass is large and there is superior herniation into the cerebellum and compression of the fourth ventricle. given the patient's exam and mri findings, it was felt that the patient should have an emergent craniotomy for removal of this tumor and the hemorrhagic lesion. prior to surgery patient did have an interventional pulmonology consult. they saw her and felt she had a left upper lobe mass infiltrate with the diagnosis that included possible pneumonia versus lung mass versus combination. they did follow her throughout her stay here and did not recommend that she needed bronchoscopy at this time. they referred her to oncology. the patient was brought to the o.r. on where she underwent craniotomy and removal of the right cerebellar hemorrhagic lesion. patient did well intraoperatively and had no complications. on post-op day one patient was awake, oriented times name only, inattentive, unable to follow midline commands. she had abduction depression of the right eye. pupils were 5 to 3.5 in the right eye and left eye 4.5 to 2.5. she had a question of bilateral slight pronator drift, greater on the right than the left. recommendations were to keep her blood pressure less than 150, use minimal ativan only and to slowly advance her diet. her post-op hematocrit was 25.9. also on the 1st she had repeat mri which showed status post resection of right cerebellar hemorrhagic lesion without residual enhancement. left frontal hemorrhagic lesion with enhancement was suggestive of metastatic disease. the patient did require the use of nipride to keep her systolic blood pressure less than 140. she did have periods of agitation at times. on patient was awake, continued in the icu. her face was symmetric. no rebound, no drift. finger to nose showed slight right dysmetria. patient was advanced out of bed to a chair. her activity was also increased. patient was continued on iv decadron 4 mg q.six hours. in the late afternoon of the 2nd, patient was transferred out of the unit awake, alert and oriented times three, moving all extremities. vital signs were stable. she did see physical therapy when moved to the floor who recommended that she receive visitations every day by them to assist with her impaired mobility and help with her impaired mental status. on the patient was awake, alert, oriented, tolerating a diet, ambulating with help. her dysarthria was noted to be improved. she had a slight right drift noted. her dysmetria was also improved. her foley was removed. decadron was continued to be weaned. occupational therapy also saw her and assisted her with safety awareness and helped her with her upper extremities. on the 5th oncology saw patient who felt that she most likely will receive palliative chemotherapy with radiation rather than systemic chemo. patient's special stains for melanoma were found to be negative on . patient will need to go to a rehab facility for further assistance with her gait and rehabilitation needs. she is to follow up in the brain tumor clinic with dr. . she also needs to follow up with hematology/oncology here at . the patient was treated with levaquin for pneumonia that was diagnosed prior to admission. she received 10 days of levaquin therapy. discharge instructions: to keep the staples clean and dry, do not get them wet. she should have them removed on . she can come back to 5 to have those removed or she can have them removed at her rehab facility. right now her appointment for the brain tumor clinic is pending. also her appointment with oncology is pending at this time. discharge medications: 1. heparin 5000 units subcu. 2. regular insulin sliding scale. 3. nicotine patch 20 mg per 24 hours. 4. lopressor 50 mg tablet b.i.d. 5. protonix 40 mg q.day. 6. oxycodone with acetaminophen one to two tablets p.o. q.four to six hours. 7. decadron taper down to 2 mg p.o. b.i.d. , m.d. dictated by: medquist36 Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Personal history of tobacco use Intracerebral hemorrhage Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Loss of weight Unspecified disorder of adrenal glands

no known allergies. meds at home: atenolol, univasc, asa, norvasc. pt is alert and oriented but lethargic, thick speech, perla 3mm, mae, follows commands. c/o intermittent headache. mannitol and decadron started. sinus bradycardia from beta blockers. bp 150/48. bilateral angios. ivf @80cc/hr. hct 26.5 wbc 11.3. inr 1.2 sats 96% on ra. breath sounds clear. rr 15-20. pt remains npo. abd. soft. urine output brisk after mannitol. pt and family spoke with neurosurg team and are aware of findings and plan. they await further information. contact person is pt's daughter: . Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Personal history of tobacco use Intracerebral hemorrhage Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Loss of weight Unspecified disorder of adrenal glands

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: found down, s/p cardiac arrest major surgical or invasive procedure: endotracheal intubation history of present illness: 28 y/o male with unknown pmh who was found down in after 911 call. his identity was initially unknown on admission on and he was identified on . physician was driving by the scene with his wife and responded by initiating cpr approximately 15 minutes after man went down. ems arrived on the scene soon after call was made by unknown observer. patient was a well-dressed male thought to be in his 30s without any evidence of track marks or drug use. his pupils were dilated. he was intubated in the field. he was found in pea arrest. according to rhythm strips obtained from ems, his first rhythm was sinus bradycardia and he was given epinephrine and atropine. he then went into wct followed by mmvt. he was then shocked with 200 j and rhythm became pmvt and was shocked for the second time with 300 j. he then went into st and recovery of pulse. he received a total of 2 mg of epinephrine and 2 mg of atropine with 2 shocks (200 and 300j). he was then transported to ed. . in the ed, his pupils were fixed and dilated b/l. fast was negative. cxr revealed distended stomach. ct of head, chest, abdomen, pelvis, c-spine were all negative. the patient was transferred to the ccu hemodynamically stable on the ventilator. past medical history: phm (obtained from family after patient was identified): hep b+ hep c+ h/o ivda . psh: none known social history: sh: has a h/o drug abuse and has served time in jail. he currently lives with his grandparents in . family history: nc physical exam: pe: vitals: 97.4 153/87 105 14 100% on ac tv 600 rr 14 peep 5 fio2 100 general: sedated, on vent, myoclonic jerking heent: pupils 4 mm fixed and dilated. mmm. et tube in place. neck: no jvd. cv: st. normal s1, s2 without m/r/g. pulm: ctab, no wheezes or crackles. abd: soft, nt/nd with normoactive bs. ext: no c/c/e. 2+ dp b/l. neuro: intermittent myoclonic jerking. gcs 3. pertinent results: wbc-18.1* rbc-4.90 hgb-14.2 hct-40.3 mcv-82 mch-28.9 mchc-35.1* rdw-13.0 plt ct-271 . wbc-26.0* rbc-5.60 hgb-15.2 hct-43.5 mcv-78* mch-27.1 mchc-34.9 rdw-13.1 plt ct-226 . wbc-19.9* rbc-5.08 hgb-14.3 hct-40.1 mcv-79* mch-28.1 mchc-35.7* rdw-13.3 plt ct-222 . wbc-20.7* rbc-4.53* hgb-13.4* hct-36.3* mcv-80* mch-29.5 mchc-36.9* rdw-13.5 plt ct-223 . wbc-34.6*# rbc-5.41 hgb-14.8 hct-42.6 mcv-79* mch-27.4 mchc-34.8 rdw-13.6 plt ct-214 . wbc-29.2* rbc-5.33 hgb-15.0 hct-42.5 mcv-80* mch-28.1 mchc-35.2* rdw-14.0 plt ct-217 . wbc-29.9* rbc-4.26* hgb-12.0* hct-35.5* mcv-83 mch-28.1 mchc-33.7 rdw-14.0 plt ct-240 . wbc-30.4* rbc-4.15* hgb-11.5* hct-34.1* mcv-82 mch-27.7 mchc-33.7 rdw-13.8 plt ct-201 neuts-84.1* lymphs-10.4* monos-4.6 eos-0.7 baso-0.2 neuts-85.5* lymphs-10.2* monos-3.7 eos-0.4 baso-0.2 fibrino-174 urean-16 creat-1.5* . glucose-207* urean-16 creat-1.2 na-136 k-3.8 cl-102 hco3-20* angap-18 glucose-122* urean-13 creat-0.8 na-136 k-3.7 cl-104 hco3-18* angap-18 glucose-120* k-3.9 glucose-102 urean-11 creat-1.0 na-142 k-5.2* cl-111* hco3-24 angap-12 k-5.2* k-4.6 glucose-121* urean-11 creat-1.4* na-146* k-4.3 cl-116* hco3-25 angap-9 glucose-129* urean-12 creat-1.3* na-150* k-2.5* cl-113* hco3-22 angap-18 glucose-172* urean-15 creat-1.2 na-152* k-3.1* cl-117* hco3-21* angap-17 na-149* k-3.1* glucose-193* urean-18 creat-1.5* na-144 k-4.1 cl-112* hco3-15* angap-21* urean-23* creat-2.7*# na-142 k-4.9 cl-111* hco3-19* angap-17 glucose-186* urean-36* creat-5.2* na-139 k-5.7* cl-108 hco3-14* angap-23* glucose-159* urean-38* creat-5.5* na-138 k-4.8 cl-106 hco3-15* angap-22* alt-398* ast-224* ld(ldh)-339* alkphos-133* amylase-131* totbili-1.0 ck(cpk)-79 alt-423* ast-252* ck(cpk)-524* alkphos-130* totbili-1.9* alt-392* ast-251* ck(cpk)-298* alkphos-112 totbili-1.6* ck(cpk)-1768* alt-242* ast-656* alkphos-105 totbili-0.5 alt-377* ast-1447* ld(ldh)-4377* alkphos-119* totbili-1.1 alt-427* ast-1832* ld(ldh)-5187* alkphos-123* totbili-1.4 ck-mb-notdone ctropnt-<0.01 ck-mb-82* mb indx-15.6* ctropnt-1.45* ck-mb-55* mb indx-18.5* calcium-6.5* phos-9.0* mg-2.1 calcium-8.5 phos-1.6* mg-1.8 calcium-6.5* phos-9.0* mg-2.1 tsh-4.0 hbsab-positive hbcab-positive hav ab-negative hbsag-negative asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg carbamz-<0.5* phenyto-<0.6* valproa-<3* hcv ab-positive hcv ab-positive freeca-1.11* freeca-1.09* . imaging studies: 1. cxr the et tube tip is positioned approximately 2 cm from the carina. there has been interval placement of an og tube, extending beyond the ge junction, though the tip is not visualized on this study. the cardiac and the mediastinal contours are within normal limits. the lungs are clear. no pleural effusion or pneumothorax seen. the soft tissue and osseous structures are stable in appearance. impression: the og tube extends beyond the ge junction, though the tip is not visualized on this image. . 2. ct head, c-spine, chest, abdomen, pelvis w/contrast the study is limited secondary to motion. no definite hemorrhage is identified. no fracture or subluxation. no evidence of traumatic injury. . 3. echo the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is mildly depressed with mild global hypokinesis more prominent in the distal inferior, distal septal and apical segments. no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. ef 45% . 4. eeg this is a markedly abnormal electroencephalogram due to the presence of a suppressed background interrupted by rhythmic sharply contoured and evolving epileptiform activity. this eeg is consistent with brief periods of electrographic seizures on a suppressed background. the team was called and notified of this result. . 5. eeg this is an abnormal 24 hour bedside telemetry due to the presence of a low voltage, diffusely slow background activity. this suppressed activity may be seen with diffuse subcortical dysfunction, as occurs with cns depressant medications or diffuse cerebral ischemia. . culture results scx gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): moderate growth oropharyngeal flora. staph aureus coag +. moderate growth. ucx urine culture (final ): staphylococcus, coagulase negative. 10,000-100,000 organisms/ml. all bcx were negative brief hospital course: 28 y/o male with no known pmh at the time found down s/p cardiac arrest. pea then vt then vf. successful resuscitation with 2 shocks. the patient suffered anoxic brain injury s/p cardiac arrest. . 1. s/p cardiac arrest the patient was initially found down in . please see above hpi for further details. after arriving at ed, he was ruled out for any traumatic injury. he was then transferred to the ccu for further evaluation and management after his cardiac arrest. due to his recent vf arrest, the hypothermia protocol was initiated and the patient was cooled for 18 hours. gcs before protocol was initiated was 3. the patient met all inclusion criteria and he had none of the exclusion criteria. following the cooling protocol, he was re-warmed. upon initial arrival to the ccu, his ekg was analyzed for any evidence of arrhythmia or abnormality that would explain his cardiac arrest. echocardiogram was performed soon after the patient arrived in the ccu which was negative for any structural abnormality of the heart. see full echo report above for details. initial tox screen was positive for opiates and benzos. the leading diagnosis after cardiac causes were ruled out were possible substance abuse causing respiratory suppression then hypoxia which may have induced the cardiac arrest. since the patient was never awake from presentation, obtaining any hpi was impossible. after talking with his family, they mentioned that he had a history of substance abuse and was most likely using heroin and/or benzos prior to being found down. the exact etiology of what caused the patient's cardiac arrest remained uncertain. due to the patient's anoxic brain injury and after consulting neurology, the family decided to withdraw support on and the patient expired soon afterwards. . 2. anoxic brain injury after the patient was transferred to the ccu, neurology was consulted so they could perform an exam while patient was off sedation prior to initiating cooling protocol. upon arrival to the ccu, the patient was having myoclonic jerking which was more consistent with anoxic brain injury than seizure activity. neurology recommended eeg and then continued eeg monitoring. on initial exam, the patient did have a gag reflex and corneal reflexes. however, as his hospital course progressed, all of his reflexes were absent, even off sedation for 48 hours. he was monitored continuously with eeg which showed no signs of activity. he was maintained initially on dilantin to control any seizures secondary to anoxic brain injury and that was eventually discontinued. organ bank saw the patient and determined that he was not a suitable candidate for organ donation. during the last two days of the patient's hospitalization, he began to show evidence of multi-organ failure and required pressor support to maintain his bp. after several discussions with the family, ccu team, and neurology, it was communicated that the patient would never return to normal functioning. the family decided in complete agreement to withdraw support on and the patient passed away soon after the night of the 16th at 21:15. the family declined autopsy. medications on admission: unknown discharge medications: the patient expired on . discharge disposition: expired discharge diagnosis: the patient suffered a cardiac arrest and subsequent anoxic brain injury. the family decided to withdraw support on and the patient expired later that evening at 21:15. discharge condition: the patient expired. discharge instructions: the patient expired. followup instructions: the patient expired. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Other convulsions Hypopotassemia Cardiac arrest Anoxic brain damage Ventricular fibrillation Hyperosmolality and/or hypernatremia Opioid abuse, unspecified Other specified disease of white blood cells Disorders of magnesium metabolism Hepatitis C carrier

allergies: cefazolin / penicillins attending: chief complaint: hypotension, hct drop major surgical or invasive procedure: egd blood transfusion history of present illness: 70-year-old man status post kidney transplant now on hd initially presented with dyspnea and epigastric pain. patient reports symptoms began suddenly yesterday while watching tv, with sudden sob and mild epigastric discomfort. pt reports that at some point today he had mild chest discomfort, similar to that he has regularly, and took a nitroglycerin. he denies nausea, vomiting, hematemesis, hematochezia or melena. he denies history of recent bleeding, dizziness, or light headedness. . in the ed, initial vital signs were:97.6 76 107/93 18 99%. cxr was clear. while he was in the ed he became hypotensive to the 80s and received several ivf totalling to 750cc. he had an episode of melena and coffee ground emesis. he was lavaged which resulted in bright blood (thought to be traumatic) that cleared quickly with few coffee grounds, no bile was drawn back. cta torso showed no pe or abdominal perforation. ekg also showed no st depressions in lateral leads, but troponin 0.06. renal was consulted and concerned about k of 6.1 and recommended urgent dialysis. during his ed stay he received 5mg iv morphine for epigastric pain, started on a protonix drip. pt was transfered to micu with 2pivs and stable vital signs. . in the micu, patient reports continued epigastric discomfort, but no further nausea, emesis, or melena. . ros: denies fevers, chills, change in weight, headache, dizziness, orthopnea/pnd or palpitations, urine production, lower extremity edema, new pains, rash. past medical history: : rx allergy: cephalosporins (cefazolin), s/p graft embolect - subdural hematoma: er - esrd s/p kidney transplant and rejection, now on hemodialysis - glomerulonephritis - cad: cardiac cath : completely occluded lcx (unchanged since ), 50% lesion lad (vs 30% prior) & completely stenotic rca - cath s/p 2 xience to rca after rotablation of heavily calcified artery - hyperparathyroidism - anemia - gout - hyperlipidemia - hypertension - eosinophilia (? 2o strongloides) - multiple lung nodules of unknown etiology - hypogonadism - obesity - bronchospasm - hx ppd positive but ruled out for pulmonary tb recently - chronic sdh s/p - left ij tunnelled catheter placement . past surgical history: - cardiac catherization on s/p 2 xience to rca after rotablation of heavily calcified artery. - - left brachial artery to cephalic vein primary av fistula. - - revision of av fistula with ligation of side branches - - creation of left upper arm arteriovenous graft, brachial to axillary. - - thrombectomy with revision of left arm arteriovenous (av) graft - cadaveric kidney transplant, right iliac fossa. (dr. - - right upper arm brachial - axillary graft (dr. - - rue avg fistulogram, angioplasty of intragraft partially occluding clot - - rue avg thrombectomy, fistulogram, arteriogram, 8-mm balloon angioplasty of outflow stenoses. - rue graft thrombectomy - tunneled hd catheter placement and av fistula ligation social history: -tobacco: smoked for a few years as a teenager -etoh: denies -illicits: denies -lives alone w cat; has three sons that are not very involved in his life; walks with a cane. has vna once a month and meals on wheels. -previously worked as a zoo keeper zoo family history: no history of kidney disease, + history for dm, htn physical exam: admission exam: general - well-appearing gentleman, sedated, in nad, no respiratory distress, warm to touch. heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, trace edema bilaterally., 2+ peripheral pulses (radials, dps) neuro - awake, a&ox3, cns ii-xii grossly intact discharge exam o: 98.0 136/88 75 18 100%ra general - obese latino male in nad heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. hematoma on back is unchanged. heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, trace edema bilaterally, 2+ peripheral pulses (radials, dps) neuro - awake, a&ox3, cns ii-xii grossly intact pertinent results: admission labs 02:45pm blood wbc-11.6* rbc-3.17*# hgb-8.5*# hct-29.4*# mcv-93 mch-26.9* mchc-29.0* rdw-19.5* plt ct-183 09:48pm blood wbc-13.6* rbc-2.59* hgb-7.1* hct-23.9* mcv-92 mch-27.3 mchc-29.6* rdw-19.4* plt ct-168 02:45pm blood glucose-144* urean-137* creat-8.7*# na-137 k-6.1* cl-97 hco3-20* angap-26* 02:45pm blood alt-25 ast-20 alkphos-107 totbili-0.2 02:45pm blood albumin-3.4* calcium-7.5* phos-3.1# mg-2.9* . cardiac labs 02:45pm blood ck-mb-4 ctropnt-0.06* probnp-4103* 09:48pm blood ctropnt-0.05* 02:26am blood ck-mb-3 ctropnt-0.10* 09:53am blood ck-mb-4 ctropnt-0.15* . discharge labs 06:30am blood wbc-8.5 rbc-2.96* hgb-8.5* hct-28.1* mcv-95 mch-28.8 mchc-30.3* rdw-19.0* plt ct-153 06:30am blood glucose-119* urean-49* creat-8.1*# na-135 k-4.4 cl-94* hco3-27 angap-18 06:30am blood calcium-7.8* phos-3.7 mg-2.3 . ekg : sinus rhythm. left atrial abnormality with a change in atrial morphology compared to the previous tracing of . there are new st-t wave changes recorded in leads i and avl as compared with prior tracing which may represent active lateral ischemic process. followup and clinical correlation are suggested. . ekg : sinus rhythm. compared to the previous tracing of there is further improvement inthe inferolateral st-t wave abnormalities. followup and clinical correlation are suggested. . cxr : no acute cardiopulmonary process. persistent increased interstitial markings in the lungs compatible with chronic interstitial disease. interval resolution of the right mid lung opacity since prior. . cta : 1. no evidence of acute pulmonary embolism or acute aortic dissection. 2. extensive atherosclerotic disease involving the aorta, major visceral arteries and coronary arteries. 3. no evidence of bowel perforation or other acute abdominal pathology. 4. scattered colonic diverticulosis without evidence of acute diverticulitis. . egd : esophagus: lumen: a medium size hiatal hernia was seen. mucosa: a salmon colored mucosa distributed in a segmental pattern, suggestive of long segment barrett's esophagus was found. stomach: mucosa: localized erythema and erosion of the mucosa with no bleeding were noted in the antrum. these findings are compatible with moderate gastritis. duodenum: mucosa: diffuse continuous friability, erythema and congestion of the mucosa with no bleeding were noted in the duodenal bulb compatible with moderate duodenitis. excavated lesions five ulcers ranging in size from 4 mm to 6 mm were found in the duodenal bulb. two of these had visible vessel in center. 6 cc epinephrine was injected in one and 4 cc in the other. 2 endoclips were placed on the the larger ulcer successfully. impression: medium hiatal hernia moderate gastritis moderate duodenitis ulcers in the duodenal bulb mucosa suggestive of barrett's esophagus otherwise normal egd to third part of the duodenum brief hospital course: 70 yom with history of esrd on hd, cad s/p in , p/w epigastric pain, hematemesis, melena, and dyspnea x 1 day, found to have duodenal ulcers, s/p clipping and epinephrine, with course complicated by demand ischemia. . # hematemesis/melena, gi bleeding, acute bood loss anemia: pt with hct drop to 23.9 from 29.4 on admission. he received 2 units of prbc transfused on . he was briefly intubated for egd performed on which showed multiple duodenal ulcers, two with visible vessels. both were injected with epinephrine, and 2 endoclips were placed on the the larger ulcer successfully. he was quickly extubated without complication. hct remained stable thereafter. his diet was advanced to clears, and he was maintained on ppi. low dose aspirin 81mg was restarted given his cad, and decision to restart plavix was made. his cardiologist was , and a note from : . "this patient has a drug-eluting stent placed in for recurrent in-stent restenosis inside a prior drug-eluting stent from . he should be on uninterrupted aspirin for life as well as lifelong clopidogrel (or equivalent anti-platelet) therapy given the anatomical substrate of a bilayer of drug-eluting stents that puts him at very high risk for late and very late stent thrombosis. late stent thrombosis carries significant mortality and morbidity risks. the only circumstance for which we would consider stopping dual anti-platelet therapy would be intracranial bleeding." . he was put back on aspirin 325mg daily and plavix 75mg daily. he was started on low dose bb, and as he tolerated this well his home metoprolol succinate 100mg daily was restarted. because he is high-risk to bleed, and remains on dual-anti-platelet therapy, he should have several hct checks in the near future. his home ppi was also increased. . additionally, an h pylori serology was checked, and came back equivocal. as this is a potentially reversible risk factor, it was decided to treat him with ppi, metronidazole x 10 days (he has pcn allergy), and clarithromycin x10 days. . # hypotension: in the setting of his gib. this resolved, and he remained normotensive. we continued to hold his home antihypertensives in the micu and these were restarted on the floor, where his pressures remained stable. # demand ischemia: pt with ekg on admission showing ischemic appearing t waves in i and avl, as well as st-t wave flattening in leads v5-v6 andii and avf. this was concerning for ischemia, but eventually resolved on subsequent ekg. thought to be demand related to the setting of hypotension and anemia. aspirin 325 and plavix 75 daily were restarted. he was continued on his home pravastatin 10mg daily, and his ldl was at goal <70. he was symptomc free on discharge. . # interstitial lung diseae: initially maintained on iv methylprednisolone in the setting of his npo status, and once diet was advanced he was restarted on home dose of prednisone 30mg, with bactrim ppx. given his upper gi bleed, his pulmonologist was , and felt that his prednisone could be lowered to 20mg daily. he will f/u w/ pulmonary on . # ckd on hd: mwf dialysis sessions. dialysis was deferred on friday given hypotension, but was restarted the following day. he was continued on sevelemer, calcinet, and nephrocaps, though sevelemer dose was decreased, and calcium acetate started, per renal recommendations. last dialysis sessions was monday . . # cad, s/ : as above, initially held asa, plavix, bb given that patient was bleeding and hypotensive. he was maintained on his pravastatin 10mg daily. eventually, all cad meds (see above) were restarted. his aspirin and plavix should never be stopped, except in setting of truly life-threatening bleed, given the way this pt is stented puts him at very high risk for in-stent thrombosis. per dr : "need to balance the risk and consequences of recurrent gi bleeding vs. the risks and consequences of stent thrombosis in his rca. patients with stent thrombosis carry a 20-40% mortality and a 30-40% chance of a large non-fatal mi" . # gout: continued allopurinol. . # code status: full (confirmed) =================================== transitional issues # needs to have hct checked frequently in near future to ensure no recurrent bleeding # repeat egd 4-6 weeks, per gi. medications on admission: allopurinol 100 mg qod b complex-vitamin c-folic acid 1 mg daily clopidogrel 75 mg daily metoprolol succinate 100 mg daily sevelamer carbonate 800 mg 5 tabs tid pravastatin 10 mg daily aspirin 325 mg daily cinacalcet 30 mg tablet sig: 0.5 tablet po daily (daily). oxycodone 5 mg tablet q6h prn pain fluticasone 50 mcg/actuation spray daily albuterol sulfate 90 mcg/actuation hfa aerosol inhaler prn docusate sodium 100 mg daily bactrim ds (unclear if taking) discharge medications: 1. allopurinol 100 mg tablet sig: one (1) tablet po every other day. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 4. sevelamer carbonate 800 mg tablet sig: three (3) tablet po tid w/meals (3 times a day with meals). 5. pravastatin 10 mg tablet sig: one (1) tablet po once a day. 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. cinacalcet 30 mg tablet sig: 0.5 tablet po daily (daily). 8. fluticasone 50 mcg/actuation spray, suspension sig: one (1) nasal once a day. 9. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation prn as needed for shortness of breath or wheezing. 10. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po m/w/f (). 11. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 12. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). disp:*90 capsule(s)* refills:*2* 13. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. 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* 15. clarithromycin 500 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 16. metronidazole 500 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 17. docusate sodium 100 mg capsule sig: one (1) capsule po once a day. 18. outpatient lab work : hematocrit - please fax results to dr. . phone: fax: discharge disposition: home discharge diagnosis: duodenal ulcers, gastrointestinal bleed discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr , it was a pleasure taking care of you at . you were admitted for a gastrointestinal bleed. this was found to be from ulcers in your stomach. for this, you had an endoscopy, and the bleeding was stopped. changes were made to your medications, which should also help prevent more bleeding. your duodenal ulcers may be related to a stomach infection from helicobacter pylori. this is a common infection that can pre-dispose you to ulcers. you will receive 10 days of antibiotics to treat this infection. please have your blood counts (hematocrit) checked at dialysis on wednesday. you will follow-up with the gi doctors and likely need another endoscopy in 4 - 6 weeks. the following changes were made to your medications: ** decrease sevalamer to 800mg tablets, take three (3) tablets three (3) times a day (you had previously been taking 5 tablets 3 times a day) ** decrease prednisone to 20mg once daily (you had been on 30mg once daily) ** start pantoprazole 40mg by mouth twice daily (you will take this instead of the 20 mg daily dose you were previously taking) ** start calcium acetate 667mg tablet, 1 tablet three times a day with meals ** start metronidazole 500mg by mouth twice a day for 10 days ** start clarithromycin 500mg by mouth twice a day for 10 days followup instructions: department: bidhc when: monday at 10:45 am with: , md building: 545a centre st. (, ma) none campus: off campus best parking: department: div. of gastroenterology when: wednesday at 2:30 pm with: , md building: ra (/ complex) campus: east best parking: main garage department: pft when: thursday at 1 pm department: pulmonary function lab when: thursday at 1 pm with: pulmonary function lab building: gz building (felbeerg/ complex) campus: east best parking: main garage department: medical specialties when: thursday at 2:00 pm with: dr. /dr. building: sc clinical ctr campus: east best parking: garage Procedure: Other endoscopy of small intestine Hemodialysis Endoscopic control of gastric or duodenal bleeding Diagnoses: Hyperpotassemia End stage renal disease Renal dialysis status Acute posthemorrhagic anemia Gout, unspecified Percutaneous transluminal coronary angioplasty status Diaphragmatic hernia without mention of obstruction or gangrene Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Hypotension, unspecified Postinflammatory pulmonary fibrosis Hyperparathyroidism, unspecified Duodenitis, without mention of hemorrhage Duodenal ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction Complications of transplanted kidney Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Barrett's esophagus

allergies: cefazolin / penicillins attending: chief complaint: dyspnea major surgical or invasive procedure: hemodialysis history of present illness: 69 year old male per omr h/o esrd, failed renal tx, s/p thrombectomy of av fistula, chf, cad s/p stents presenting with shortness of breath. onset was 2 hours prior when he returned from church and sat down on his couch. he reported it felt similar to past chf exacerbations in that it was sudden in onset, exacerbated by activity, no relieving factors. he denied fevers or chills, reported positive nonproductive cough, positive subjective lower extremity edema that is symmetric, positive unintentional weight gain of approximately 10 pounds over the past few weeks, no chest pain, no headache or change in vision, no abdominal pain, no dysuria or urinary frequency, no focal tingling or weakness. no change in medication. . in the ed, his initial 02sat was mid-80s on a nrb mask. he was started on bipap. his initial labs were notable for a k+ 8.2, cl 91, bun/cr 82/12.1, pro bnp 3760, trop 0.08. after insulin, dextrose, albuterol and calcium, his repeat k+ was down to 6.0. his ekg showed nsr at 60, 1 deg avb, lad, no hyper acute t waves. he was able to be taken off bipap and at the time of transfer, his 02sat was 98% on 4lpm via nc. . on arrival to the micu, his hr was 63, bp 155/67, sp02 98% on 2lpm via nc . past medical history: past medical history: - : rx allergy: cephalosporins (cefazolin), s/p graft embolect - subdural hematoma: er - esrd s/p kidney transplant and rejection, now on hemodialysis - glomerulonephritis - cad: cardiac cath : completely occluded lcx (unchanged since ), 50% lesion lad (vs 30% prior) & completely stenotic rca - cath s/p 2 xience des to rca after rotablation of heavily calcified artery - hyperparathyroidism - anemia - gout - hyperlipidemia - hypertension - eosinophilia (? 2o strongloides) - multiple lung nodules of unknown etiology - hypogonadism - obesity - bronchospasm - hx ppd positive but ruled out for pulmonary tb recently - chronic sdh s/p - left ij tunnelled catheter placement . past surgical history: - cardiac catherization on s/p 2 xience des to rca after rotablation of heavily calcified artery. - - left brachial artery to cephalic vein primary av fistula. - - revision of av fistula with ligation of side branches - - creation of left upper arm arteriovenous graft, brachial to axillary. - - thrombectomy with revision of left arm arteriovenous (av) graft - cadaveric kidney transplant, right iliac fossa. (dr. - - right upper arm brachial - axillary graft (dr. - - rue avg fistulogram, angioplasty of intragraft partially occluding clot - - rue avg thrombectomy, fistulogram, arteriogram, 8-mm balloon angioplasty of outflow stenoses. social history: -tobacco: smoked for a few years as a teenager -etoh: denies -illicits: denies -lives alone w cat; has three sons that are not very involved in his life; walks with a cane. has vna once a month and meals on wheels. -previously worked as a zoo keeper zoo family history: -no history of kidney disease, + history for dm, htn physical exam: vitals: t: bp: 155/67 p: 63 r: 18 o2: 97% on 2lpm via nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact pertinent results: 06:44am blood wbc-9.1 rbc-4.51* hgb-11.8* hct-38.9* mcv-86 mch-26.2* mchc-30.4* rdw-18.0* plt ct-218 08:34am blood wbc-9.1 rbc-4.29* hgb-11.3* hct-36.7* mcv-85 mch-26.2* mchc-30.7* rdw-18.0* plt ct-220 12:01am blood wbc-14.2*# rbc-4.74 hgb-12.8* hct-40.3 mcv-85 mch-27.0 mchc-31.7 rdw-18.1* plt ct-303 05:10pm blood wbc-8.5 rbc-4.53* hgb-12.1* hct-39.0* mcv-86 mch-26.8* mchc-31.1 rdw-17.9* plt ct-256 05:10pm blood neuts-79.9* lymphs-17.3* monos-1.3* eos-0.7 baso-0.9 06:44am blood plt ct-218 08:34am blood plt ct-220 08:34am blood pt-11.8 ptt-20.8* inr(pt)-1.0 06:44am blood glucose-94 urean-42* creat-7.3*# na-139 k-4.6 cl-93* hco3-27 angap-24* 08:34am blood glucose-90 urean-53* creat-9.0*# na-140 k-4.5 cl-92* hco3-29 angap-24* 12:01am blood glucose-125* urean-36* creat-5.8*# na-139 k-3.3 cl-92* hco3-27 angap-23* 05:10pm blood glucose-155* urean-82* creat-12.1* na-137 k-8.2* cl-91* hco3-24 angap-30* 08:34am blood ck-mb-2 ctropnt-0.10* 12:01am blood ck-mb-2 ctropnt-0.07* 05:10pm blood ck-mb-2 ctropnt-0.08* probnp-3760* 06:44am blood calcium-8.2* phos-8.7* mg-2.0 08:34am blood calcium-8.0* phos-8.8*# mg-1.9 echocardiography : conclusions the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , lv systolic function is now more vigorous. chest x-ray : impression: mild interstitial pulmonary edema, slightly improved from the prior study. 06:58am blood wbc-10.9 rbc-4.48* hgb-11.9* hct-37.9* mcv-85 mch-26.6* mchc-31.4 rdw-18.3* plt ct-243 07:00am blood wbc-10.5 rbc-4.39* hgb-12.3* hct-39.0* mcv-89 mch-28.0 mchc-31.5 rdw-18.4* plt ct-189 06:58am blood plt ct-243 07:00am blood plt ct-189 05:05pm blood glucose-123* urean-41* creat-7.2*# na-143 k-4.1 cl-93* hco3-29 angap-25* 07:00am blood glucose-91 urean-55* creat-9.1*# na-142 k-4.9 cl-92* hco3-30 angap-25* 09:10pm blood ck-mb-2 ctropnt-0.15* 07:00am blood ck-mb-2 ctropnt-0.15* 05:05pm blood ck-mb-2 ctropnt-0.16* 06:58am blood albumin-4.1 calcium-7.9* phos-11.2*# mg-2.3 05:05pm blood calcium-8.3* phos-6.7*# mg-2.1 07:00am blood calcium-8.2* phos-9.3*# mg-2.3 brief hospital course: # respiratory distress: pt reported to the ed with a sudden onset of shortness of breath. in the ed, he was initially desatting to the 80s on a nrb, was put on bipap, improved quite rapidly and was eventually able to be weaned down to a nc and was stable on 2l upon arrival in the micu. his 02 sat was continuously monitored. an echocardiography was done (ef>55%), the results of which are above. . #chest pain: pt developed left sided chest pain, accompanied by diaphoresis and mild dyspnea while moving around on . pain resolved after about half an hour with sublingual nitroglycerin and maalox and simethicone. ekg at the time showed new st depressions and t wave inversion in i, avl. troponins were cycled and were 0.16, 0.16, 0.15. in the morning, repeat ekg showed persistent t wave inversions, but resolution of st depression. the overall picture was consistent with an nstemi. the patient underwent a nuclear stress test which showed normal myocardial uptake and preserved ef of 59%. he did not undergo catheterization as his stress test was normal. . # hyperkalemia - emergent hemodialysis at the bedside was performed and the repeat k+ after dialysis was 3.3. . # esrd - received emergent hemodialysis at the bedside and resumed on his regular schedule. . # cad - he was continued on his asa, beta blocker, statin, and plavix. he had a repeat echo, the results of which are above. his cardiac enzymes were trended. . # gout - continued allopurinol . # hyperlipidemia - continued statin . # hypertension - continue beta blocker . . transitional care issues: has outstanding blood cultures that needs to be followed up on. medications on admission: - albuterol - allopurinol - cinacalcet (sensipar) - clopidogrel - fluticasone - metoprolol succinate - nitroglycerin - oxycodone-acetaminophen - pravastatin - sevelamer carbonate - asa discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 5. cinacalcet 30 mg tablet sig: one (1) tablet po daily (daily). 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 7. pravastatin 20 mg tablet sig: 0.5 tablet po hs (at bedtime). 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation inhalation twice a day as needed for shortness of breath or wheezing. 10. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 11. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 12. sevelamer carbonate 800 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 13. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual as required: as required for chest pain. 14. fluticasone 50 mcg/actuation spray, suspension sig: sprays nasal once a day: each nostril. 15. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. discharge disposition: home with service facility: homecare discharge diagnosis: primary: pulmonary edema, hyperkalemia secondary: end stage renal failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure to look after you at the . you were admitted with difficulty breathing. we found that your potassium level was high. you were admitted to the icu and given oxygen. we also treated you with hemodialysis to remove potassium and fluid. your breathing improved and you are back at your baseline at the time of discharge. the renal team will coordinate further dialysis at your outpatient facility. we made no changes to your home medications. please followup with your doctors, see below. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: advanced vasc. care cnt when: thursday at 10:00 am with: , md building: (, ma) campus: off campus best parking: free parking on site department: pulmonary function lab when: thursday at 2:10 pm with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: thursday at 2:30 pm with: dr. /dr. building: sc clinical ctr campus: east best parking: garage md, Procedure: Hemodialysis Diagnoses: Hyperpotassemia Anemia in chronic kidney disease End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Gout, unspecified Acute on chronic diastolic heart failure Personal history of malignant neoplasm of large intestine Other vitamin B12 deficiency anemia Hyperparathyroidism, unspecified Obesity, unspecified Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted kidney Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease

history of present illness: the patient is a 71-year-old male with a history of an inferior wall myocardial infarction approximately six years ago. an echocardiogram in showed an ejection fraction of 30%. chest pain with rest and on exertion was the chief complaint and the patient was admitted on to the emergency room for rule out myocardial infarction. an exercise tolerance test at that time showed an inferior wall defect and now anterior wall ischemia. a cardiac catheterization showed the left main coronary artery to be 30% occluded proximally and 60% occluded distally, the left anterior descending artery to have 70% mid-occlusion and 80% ostial occlusion, the right coronary artery to have 100% ostial occlusion and the left circumflex coronary artery to be occluded. past medical history: the past medical history included hypertension, hypercholesterolemia, gastroesophageal reflux disease, inferior wall myocardial infarction and bradycardia. medications on admission: aspirin 325 mg p.o. q.d. monopril 5 mg p.o. q.d. lipitor 10 mg p.o. q.d. nitroglycerin patch. hospital course: the patient was taken by dr. to the operating room for coronary artery bypass graft times four on with a left internal mammary artery graft to the left anterior descending artery, a reversed saphenous vein graft to the obtuse marginal artery and a right coronary artery grafts to the second obtuse marginal artery and the posterior descending artery. postoperatively, the patient did well. in the intensive care unit, the patient was extubated and weaned off all drips. the chest tube was discontinued without incident. the patient was ambulating at level 5 before discharge. upon discharge, the chest was clear to auscultation. the heart rate was regular and normal sinus rhythm. the incision was clean with no drainage and no pus. the sternum was stable. postoperatively, the patient's hematocrit was low and required several units of blood transfusion. upon discharge, however, the hematocrit was 25 and the patient was asymptomatic with no dizziness, no shortness of breath and no orthostatic hypotension. disposition: the patient will be discharged home with care. discharge medications: lopressor 12.5 mg p.o. b.i.d. lasix 20 mg p.o. b.i.d. potassium chloride 20 meq p.o. b.i.d. aspirin 81 mg p.o. q.d. lipitor 20 mg p.o. q.d. iron sulfate 325 mg p.o. t.i.d. percocet one to two tablets p.o. every four to six hours p.r.n. for pain. follow up: the patient was told to follow up with dr. in three to four weeks. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Arteriography of femoral and other lower extremity arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Personal history of tobacco use Old myocardial infarction

allergies: penicillins / percocet / morphine attending: chief complaint: abdominal pain, nausea, vomiting major surgical or invasive procedure: none history of present illness: ms is a 24 yo f with lupus since age 16, with esrd on hd, malignant htn, history of svc syndrome, and history of posterior reversible encephalopathy syndrome (pres) and intracerebral hemorrhage, who has had multiple recent admissions , , , , , mostly for hypertension, but most recently for diarrhea in addition to hypertension. . in the ed, vitals were 98 90 102/65 20 98% ra. she was complaining of abdominal pain x 3 hours, more severe than usual , no n/v/d. she received dilaudid 4 mg po x 3, zofran 8mg iv, hyperkalemia 6.2=>5.3 w/ kayexalate. initially, she was felt stable for floor; however, bp rose during ed course to sbp 270. she then received hydral 50 po x 1, home aliskeren, labetalol 1000 po x 1, 20 iv hydral x 2, labetalol 100 iv x 1, nicardipine 2.5 mg iv x 1 and started on nicardipine gtt. . upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. it feels different from her usual abd pain, although she is not able to characterize it more. she has been having some nausea and bilious emesis x 1 earlier today. she has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. she denies any chest pain, headache, vision changes. she was not able to take all of the medications due to her gi distress. . while in the micu she was weaned off a nicardipine drip and her diarrhea resolved. her bp remained wnl while on her home regimen and she was transferred to the floor in stable condition. last hd was . past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. malignant hypertension and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in and , not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on 17. history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in which has resolved social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother and brother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. physical exam: 100/63 81 18 100ra general: pleasant, thin young female sitting in the bed in nad watching tv. heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. s/p left eye enucleation. perrla/eomi. mmm. op clear. neck supple, no lad. cardiac: rrr. 4/6 systolic murmur heard best at the rusb. lungs: breathing comfortably, ctab, good air movement biaterally. abdomen: + bs, soft nd, tenderness to palpation in her luq. no rebound or guarding. extremities: no edema. right femoral hd line nontender, nonerythematous. skin: several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities psych: listens and responds to questions appropriately, pleasant pertinent results: 09:14pm lactate-0.9 09:13pm wbc-6.8 rbc-3.65* hgb-10.7* hct-33.7* mcv-93 mch-29.2 mchc-31.6 rdw-18.8* 09:13pm hypochrom-2+ anisocyt-2+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-occasional ovalocyt-1+ teardrop-occasional 09:13pm plt count-145* 08:55pm glucose-98 urea n-44* creat-7.7* sodium-137 potassium-6.3* chloride-102 total co2-20* anion gap-21* 08:55pm calcium-9.9 phosphate-5.8* magnesium-2.1 08:55pm asa-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:55pm wbc-7.0 rbc-3.69* hgb-11.1* hct-34.2* mcv-93 mch-30.2 mchc-32.5 rdw-19.2* 08:55pm plt count-126* 08:55pm pt-14.1* ptt-32.4 inr(pt)-1.2* 07:40am alt(sgpt)-18 ast(sgot)-55* alk phos-118* tot bili-0.4 07:40am lipase-58 brief hospital course: kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg . ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patient's bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. in weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely nutritional deficiency of vitamin k. coumadin will be restarted when inr at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code medications on admission: 1. aliskiren 150 mg po bid 2. citalopram 20 mg po daily 3. clonidine 0.2 mg/24 hr patch weekly qsat 4. hydromorphone 2 mg 1-2 tablets po q4h 5. fentanyl 25 mcg/hr patch 72 hr 6. gabapentin 300 mg po tid 7. hydralazine 100 mg po q8h 8. hydralazine 100 mg po bid prn fro sbp> 180. 9. prednisone 4 mg po daily 10. pantoprazole 40 mg po q24h 11. labetalol 1000 mg po tid 12. nifedipine 90 mg po qam 13. nifedipine 60 mg po qhs 14. warfarin 3 mg po once daily 15. lidocaine 5 %(700 mg/patch) topical once a day. 16. nifedipine 90 mg po once a day as needed for for sbp persistently above 200. discharge medications: 1. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). disp:*30 tablet sustained release(s)* refills:*2* 2. nifedipine 30 mg tablet sustained release sig: two (2) tablet sustained release po qhs (once a day (at bedtime)). disp:*30 tablet sustained release(s)* refills:*2* 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). disp:*30 adhesive patch, medicated(s)* refills:*2* 4. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 7. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 9. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 10. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 11. gabapentin 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 13. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 14. hydromorphone 2 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours) for 30 days. disp:*60 tablet, delayed release (e.c.)(s)* refills:*0* 16. levetiracetam 1,000 mg tablet sig: one (1) tablet po 3x/week (tu,th,sa). disp:*90 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: ugib- ulcer at ge junction hypertensive emergency anemia esrd on hd sbo discharge condition: the patient was afebrile and hemodynamically stable prior to discharge. discharge instructions: you were admitted to the hospital with abdominal pain. you had an injection of lidocaine to help the pain around your surgery sites. you then had some blood in your vomit. you were treated for a bleed in your stomach with a blood transfusion and medications. you stopped bleeding and felt better. you had a scope of your abdomen that showed an ulcer. you were treated with medications for this and need to have another scope of your abdomen in 6 weeks. you also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. once you were on your home medicines your blood pressure was better. medication changes: change: pantoprazole to 40mg twice daily please call your pcp or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. followup instructions: please follow up with dr. (gastroenterology) in weeks for an egd to re-look at your ulcer. please follow up with the ob/ clinic for a colposcopy on wednesday at 3:15pm in the building on the . their number is . please follow up with dr. at in the shapria building on the on at 2:00pm. Procedure: Hemodialysis Esophagogastroduodenoscopy [EGD] with closed biopsy Transfusion of packed cells Transfusion of other serum Injection of anesthetic into peripheral nerve for analgesia Proctostomy Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies Systemic lupus erythematosus Hyperpotassemia Thrombocytopenia, unspecified Anemia of other chronic disease End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Other chronic pain Renal dialysis status Acute posthemorrhagic anemia Diaphragmatic hernia without mention of obstruction or gangrene Unspecified disease of pericardium Hypotension, unspecified Disorders of phosphorus metabolism Long-term (current) use of anticoagulants Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Other specified peripheral vascular diseases Noncompliance with renal dialysis Personal history of noncompliance with medical treatment, presenting hazards to health Abdominal pain, left lower quadrant Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Unspecified intestinal obstruction Mononeuritis of unspecified site

allergies: penicillins / percocet attending: chief complaint: hypertensive urgency major surgical or invasive procedure: hemodialysis history of present illness: from admission note: the pt is a 24 y.o. f with esrd on hd, sle, malignant htn, history of svc syndrome admitted with htn and sob in the setting of missed hd. the patient reported missing hd yesterday because she thinks she is being overdiuresed. she reports persistent pain at site of rectus sheath hematoma. denies n/v/d. pt recently admitted from with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. at this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. pt. left ama after her transfusion despite the primary team's concerns to look for an active area of bleeding. in the ed, patient complain of mild dyspnea, sating well on ra. cxr mild volume overload. kub with no evidence of obstruction. she was started on a labetalol gtt. ecg - rad, lvh no change from prior. hct stable at 21. the renal team evaluated pt and recommended hd, however the patient refused. she was transferred to icu for bp control. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: gen: sleeping comfortably, easily awoken by verbal stimuli heent: l eye prosthetic non-reactive, r pupil reactive, mmm heart: s1s2 rrr, iii/vi sem throughout the precordium pulm: cta b/l abd: nabs, midline scar well-healed, soft, mild l ttp, no rebound/guarding ext: no edema, no clubbing, wwp. r femoral hd in place neuro: following commands, answers appropriately, motor strength, sensation is intact. pertinent results: 07:40am wbc-3.9* rbc-2.38* hgb-7.0* hct-21.3* mcv-90 mch-29.5 mchc-33.0 rdw-18.9* 07:40am neuts-74.9* lymphs-18.7 monos-3.1 eos-3.0 basos-0.2 07:40am plt count-101* 07:40am pt-16.3* ptt-36.6* inr(pt)-1.5* 07:40am ck-mb-6 07:40am ctropnt-0.09* 07:40am lipase-80* 07:40am alt(sgpt)-34 ast(sgot)-72* ck(cpk)-120 alk phos-124* tot bili-0.4 07:40am glucose-85 urea n-32* creat-7.0* sodium-142 potassium-4.3 chloride-110* total co2-19* anion gap-17 07:44am lactate-1.3 cxr: stable cardiomegaly with mild chf and a small left pleural effusion. left basilar air space disease which may represent pneumonia. clinical correlation and a follow up chest x-ray to clearance is recommended. kub: 1. nonspecific bowel gas pattern with no evidence of obstruction. 2. left basilar airspace disease which may represent pneumonia and a small left pleural effusion. please ensure follow-up to clearance. brief hospital course: 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patient's primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pt's bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg medications on admission: 1. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 2. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 4. labetalol 300 mg tablet sig: three (3) tablet po three times a day. 5. morphine 15 mg tablet sig: 0.5 tablet po q8h (every 8 hours) as needed for pain. 6. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 7. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 8. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 9. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 10. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 11. warfarin 4 mg tablet sig: one (1) tablet po once a day. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). :*30 tablet, delayed release (e.c.)(s)* refills:*2* 13. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a month. discharge medications: 1. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 2. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 3. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 4. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 7. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 8. labetalol 300 mg tablet sig: three (3) tablet po tid (3 times a day). 9. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 10. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 11. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 12. morphine 15 mg tablet sig: 0.5 tablet po every eight (8) hours as needed for pain. 13. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a month. discharge disposition: home discharge diagnosis: primary: malignant hypertension secondary: sle, end stage renal disease on hemodialysis, svc syndrome discharge condition: stable. sbp in 160s. discharge instructions: you were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. you were admitted and treated with your usual regimen of blood pressure meds and a short course of iv meds. with dialysis, your symptoms improved. you also had some abdominal pain, which was well controlled on your usual pain medications. we made no changes to your medications. please take everything as prescribed. please call your pcp or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. followup instructions: please schedule a follow up with dr in as scheduled. md Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Dysthymic disorder Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Noncompliance with renal dialysis Thrombotic microangiopathy Nontraumatic hematoma of soft tissue

allergies: penicillins / percocet attending: chief complaint: htn, abdominal pain major surgical or invasive procedure: none history of present illness: 24f with esrd on hd, sle, malignant htn, history of svc syndrome, pres, recently discharged on after admission for abdominal pain, mssa bacteremia, paroxysmal hypertension and esrd line, followed by readmission , now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this am, sob, and htn to 270s. pt was d/c'd from yesterday after hd session, went home, states she took her pm meds, took her 8 am medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). the abd pain comes and goes and is unchanged from her baseline. while she has nausea, she is asking for dinner. . in the ed, initial bp 272/148. cxr w/o evidence of volume overload. no ct scan performed. started on ntg gtt, given hydralazine 10 x 1, dilaudid 2 mg, labetaolo 20mg iv x 1. . upon arrival to the floor, her bp was 240/135. she continued to complain of abdominal pain but was eating crackers, breathing felt better. rr 17. past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of , currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-120's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. physical exam: 98.2 97 0% on 2 l nc gen: pleasant, comfortable heent: l eye enucleated. moon facies. right pupil reactive heart: hrrr, no m/r/g pulm: cta b/l abd: nabs, midline scar well-healed, soft, diffuse ttp, no rebound/guarding ext: no c/c/e neuro: aox4, cn 2-12 intact grossly. pertinent results: 07:17pm pt-22.4* ptt-43.64* inr(pt)-2.1* 04:45pm urine color-yellow appear-clear sp -1.010 04:45pm urine blood-neg nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 04:45pm urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi- 02:05pm glucose-76 urea n-21* creat-4.8*# sodium-139 potassium-4.5 chloride-105 total co2-26 anion gap-13 02:05pm alt(sgpt)-78* ast(sgot)-181* ck(cpk)-55 alk phos-192* tot bili-0.5 02:05pm ctropnt-0.12* 02:05pm ck-mb-5 02:05pm wbc-3.6* rbc-2.90* hgb-8.9* hct-26.6* mcv-92 mch-30.7 mchc-33.4 rdw-19.8* 02:05pm neuts-73.9* bands-0 lymphs-18.5 monos-3.8 eos-3.0 basos-0.8 02:05pm hypochrom-normal anisocyt-2+ poikilocy-2+ macrocyt-2+ microcyt-2+ polychrom-occasional spherocyt-occasional ovalocyt-1+ target-1+ schistocy-occasional teardrop-1+ elliptocy-occasional 02:05pm plt smr-low plt count-129* 12:00pm glucose-77 urea n-31* creat-6.0*# sodium-137 potassium-4.8 chloride-104 total co2-24 anion gap-14 12:00pm estgfr-using this 12:00pm calcium-8.4 phosphate-5.7* magnesium-1.9 12:00pm wbc-3.7* rbc-2.87* hgb-8.7* hct-26.1* mcv-91 mch-30.3 mchc-33.3 rdw-19.4* 12:00pm plt count-130* 12:00pm pt-28.8* ptt-58.6* inr(pt)-2.9* brief hospital course: the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on . this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday and again had markedly elevated blood pressures while at from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. . . medications on admission: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4pm. 5. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 6. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 7. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. aliskiren 150 mg tablet sig: one (1) tablet po bid 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for abdominal pain. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 12. citalopram 20 mg tablet sig: one (1) tablet po daily 13. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po three times a day as needed for nausea for 4 days. discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). :*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 3. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). :*120 tablet(s)* refills:*2* 4. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). :*405 tablet(s)* refills:*2* 5. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). :*180 tablet(s)* refills:*2* 6. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po hs (at bedtime). :*30 tablet sustained release(s)* refills:*2* 7. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). :*30 tablet sustained release(s)* refills:*2* 8. aliskiren 150 mg tablet sig: one (1) tablet po bid (). :*60 tablet(s)* refills:*2* 9. clonidine 0.2 mg/24 hr patch weekly sig: two (2) patches transdermal once a week: place two patches every week on fridays. :*8 patches* refills:*2* 10. dilaudid 2 mg tablet sig: 1-2 tablets po every 4-6 hours. :*180 tablet(s)* refills:*0* 11. clonidine 0.3 mg tablet sig: one (1) tablet po twice a day as needed for prn sbp>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . :*30 tablet(s)* refills:*0* 12. kayexalate powder sig: thirty (30) grams po once a day for 2 days: please take and for elevated potassium. :*240 grams* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: systemic lupus erythematosus end stage renal disease hypertension abdominal pain discharge condition: blood pressure stable and abdominal pain at baseline discharge instructions: you were admitted with high blood pressure. you were in the icu overnight for treatment. some of your medications were changed and you were increased to three times weekly . your abdominal pain is a difficult problem, as the reason for the pain is unclear. were continued on oral dilaudid. iv dilaudid is strongly discouraged and will continue to be in the future. you are now taking nifedipine sr 30mg at night in addition to 90mg in the morning. your other medications were the same. at home, if your blood pressure is above 200, then take 100mg hydralazine. if after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. if you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if bp still > 200. finally, your potassium has been high. please take kayexalate 30gm tomorrow and the next day. followup instructions: provider: ,schedule hemodialysis unit date/time: 7:30 provider: , . call to schedule appointment we will attempt to contact you on with appointment times for you. Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Hyperpotassemia Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Long-term (current) use of steroids Abdominal pain, generalized

allergies: penicillins / percocet attending: chief complaint: headache major surgical or invasive procedure: hd history of present illness: ms. is a 24 year old woman with esrd on hd, sle, malignant htn admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. her last hd was yesterday. . upon arrival to the ed, her vitals were bp 240's systolic, hr 90's, 93% on ra. a head ct scan was done which showed no acute process. an abdominal ct was done given her femoral line pain, which also was normal. she was given nitropaste x2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her bp to 170/123 and improvement in her headache. . upon arrival to the micu, patient denies any current symptoms. she reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . pt was transferred to the floor when blood pressure was controlled. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vs: hr 96 bp 171/111 rr 12 o2 98% on ra physical exam: general in nad heent nc, at, eomi, perrla, mmm cvs rrr, 3/6 systolic murmur in all heart fields resp cta bl, no crackles or wheezes abd soft, hematoma raised on left anterior abdominal wall, +bs, mildly tender over hematoma ext left sided femoral hd line in place, no erythema, no edema neuro a+ox3, cn2-12 intact, pt has left sided artificial eye, motor and sensory intact pertinent results: ***labs on admission*** 07:03am wbc-5.2 rbc-2.79* hgb-8.5* hct-26.3* mcv-94 mch-30.3 mchc-32.2 rdw-19.2* 07:03am plt count-154 07:03am pt-29.5* ptt-49.2* inr(pt)-3.0* 07:03am glucose-94 urea n-53* creat-7.0* sodium-136 potassium-5.1 chloride-102 total co2-23 anion gap-16 07:03am calcium-8.8 phosphate-5.0* magnesium-1.9 12:00pm pt-43.8* ptt-56.1* inr(pt)-4.9* 12:00pm lipase-42 12:00pm alt(sgpt)-12 ast(sgot)-43* alk phos-96 tot bili-0.4 03:25pm urine blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 03:25pm urine rbc-* wbc-0-2 bacteria-occ yeast-none epi- 12:00pm blood pt-43.8* ptt-56.1* inr(pt)-4.9* 06:40am blood pt-18.6* ptt-38.7* inr(pt)-1.7* . ***labs on day of discharge*** 06:35am blood wbc-5.7 rbc-2.39* hgb-7.1* hct-22.1* mcv-93 mch-29.8 mchc-32.2 rdw-18.6* plt ct-136* 06:35am blood glucose-107* urean-34* creat-4.8* na-137 k-5.2* cl-101 hco3-27 angap-14 06:35am blood pt-22.8* ptt-42.3* inr(pt)-2.2* . imaging ekg sinus rhythm. possible left atrial abnormality. borderline voltage criteria for left ventricular hypertrophy. inferolateral st-t wave changes may be related to left ventricular hypertrophy. compared to the previous tracing of there is no significant diagnostic change. intervals axes rate pr qrs qt/qtc p qrs t 99 190 86 368/436 13 100 24 ct abd/pelv impression: 1. interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. infectious versus inflammatory process within the right lower lobe of the lung. small right simple pleural effusion. 3. cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. right lobe liver hemangioma, unchanged. ct head impression: 1. mildly limited study given administration of small amount of iv contrast material. however, no evidence of hemorrhage or mass effect. note added at attending review: this patient was administered contrast for the abdominal ct, and the head ct was performed after part of this dose. therefore, this is neither a noncontrast examination, nor a proper contrast ct. cxr conclusion: persistent cardiomegaly and mild pulmonary edema. brief hospital course: 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patient's bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg , labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pt's blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: (mother) medications on admission: clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday hydralazine 100mg po q8h labetalol 900mg po tid morphine 7.5mg q8h prn nicardipine 30mg po tid aliskiren 150 prednisone 4mg po qday clonazepam 0.5 mg celexa 20mg po qday gabapentin 300 mg acetaminophen 325 mg q6h prn ergocalciferol (vitamin d2) 50,000 unit po once a month coumadin 4 mg daily discharge medications: 1. morphine 15 mg tablet sig: 0.5 tablet po every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 3. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 4. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 8. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 9. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 10. warfarin 1 mg tablet sig: four (4) tablet po once a day. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 12. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). :*30 tablet sustained release(s)* refills:*1* 13. labetalol 300 mg tablet sig: three (3) tablet po three times a day. :*260 tablet(s)* refills:*1* 14. respiratory therapy please adjust settings of cpap machine to a lower volume as it is uncomfortable for the patient. discharge disposition: home discharge diagnosis: hypertensive urgency discharge condition: good, hemodynamically stable, afebrile, pain controlled discharge instructions: you were admitted for headaches and very high blood pressures. you were started on an iv medication for your blood pressure which controlled it. you were then started back on your home medications with improvement of your blood pressure. one new medication was added as your hypertension was difficult to control. you were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. you will need to continue your coumadin at 4mg daily and have your inr checked at dialysis next week. please take all medications as prescribed. it is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. please keep all scheduled appointments. medications changes include: 1. stop nicardipine 2. start nifedipine cr 90mg by mouth daily 3. increase labetalol to 900mg by mouth 3 times daily 4. continue at warfarin 4mg by mouth daily if you develop any of the following concerning symptoms, please call your pcp or go to the ed: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. followup instructions: please call your pcp, . at to set up a follow-up appointment in 1-2weeks. please continue your hd tuthsat. Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus Hyperpotassemia End stage renal disease Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of upper extremities, unspecified

allergies: penicillins / percocet attending: chief complaint: hypertensive urgency major surgical or invasive procedure: hemodialysis history of present illness: (from micu admit note) 24yof esrd-hd, sle, htn presents with 1 month abdominal pain and hypertension. pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). was admitted , for abdominal pain, then returned for sob with (-)cta, dc'ed . in ed, t98.5 hr95 bp 220/110 then 183/133 rr13 o2 100% on ra, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. renal was consulted, taken for hemodialysis. ct abd showed large ascites, no other pathology; ct head improved from prior with no acute ich; cxr(-). given iv dilaudid for abdominal pain. bp treated with 10mg iv labetalol. blood and urine cultures drawn, peritoneal fluid cx sent from catheter. admitted to micu for hypertension management. access: r-hd catheter, 1 piv in hand, 1 non-functioning peritoneal dialysis catheter. past medical history: pmh: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . psh: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: pe: t:99.4 bp:158/108 hr:95 rr:12 o2 100% ra gen: nad/ pt eyes closed due to pain/ pleasant despite pain heent: at, nc, perrla, eomi on r eye, l eye prosthesis, no conjuctival injection, anicteric, op clear, mmm neck: supple, no lad cv: s1 & s2, rrr ii/vi hsm at r/l usb, no rubs/gallops pulm: ctab, no w/r/r abd: soft, mildly tender at pd catheter, nd, + bs, midline incision with steri-stripes, pd catheter dressing c/i/d ext: warm, dry, +2 distal pulses bl, no edema neuro: alert & oriented, cn ii-xii grossly intact (except l eye), 5/5 strength throughout. no sensory deficits to light touch appreciated. no asterixis psych: appropriate affect pertinent results: admission labs: 07:00am blood wbc-3.7* rbc-3.35* hgb-9.7* hct-30.7* mcv-92 mch-28.9 mchc-31.5 rdw-17.7* plt ct-142* 07:00am blood pt-14.4* ptt-30.0 inr(pt)-1.3* 07:00am blood glucose-86 urean-22* creat-5.0* na-140 k-4.3 cl-105 hco3-25 angap-14 07:00am blood alt-8 ast-39 alkphos-92 totbili-0.3 07:00am blood lipase-76* 07:00am blood calcium-7.6* phos-4.7* mg-1.9 11:00pm ascites wbc-1265* rbc-1680* polys-43* lymphs-1* monos-2* mesothe-11* macroph-43* 10:05am urine color-yellow appear-clear sp -1.010 10:05am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 10:05am urine rbc-0 wbc-0 bacteri-occ yeast-none epi- discharge labs: 04:40am blood wbc-2.9* rbc-3.08* hgb-9.0* hct-28.3* mcv-92 mch-29.2 mchc-31.8 rdw-17.5* plt ct-182 04:40am blood pt-20.8* ptt-76.1* inr(pt)-2.0* 04:40am blood glucose-80 urean-21* creat-4.7* na-139 k-4.8 cl-106 hco3-24 angap-14 04:40am blood calcium-8.2* phos-4.5 mg-1.8 04:55am blood tsh-6.1* 04:40am blood free t4-1.2 blood cx (, ): 1/4 bottles with coag neg staph, ngtd urine cx (): mixed flora c/w contamination peritoneal fluid (): gram stain 2+ polys. culture no growth. imaging: cxr portable (): since , heart size enlargement is unchanged due to known pericardial effusion. lungs are otherwise clear. hilar contours are normal. incidentally, widening of both acromioclavicular joints is unchanged. ct a/p (): 1. no evidence of bowel obstruction or rim-enhancing fluid collection. 2. large ascites, slightly increased from , with peritoneal dialysis catheter in place. interval removal of surgical skin staples along the abdomen. 3. moderate pericardial effusion as before. 4. symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. appearance of the kidneys is unchanged from . ct head w/o contrast (): 1. no evidence of acute intracranial hemorrhage. 2. regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since . no new regions of hypoattenuation seen. brief hospital course: 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patient's inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with social work, and potential cbt. these can be arranged by her pcp. medications on admission: 1. aliskiren 150 mg 2. clonidine 0.3 mg/24 qwk 3. prochlorperazine maleate 10 mg prn 4. hydromorphone 2 mg tablet sig: q6 prn 5. bisacodyl 10mg 6. ergocalciferol (vitamin d2) 50,000 qmonth 7. hydralazine 75mg tid 8. hydralazine scale prn 9. labetalol 300 mg tid 10. nifedipine 90 mg qd 11. prednisone 4mg qd 12. warfarin 2 mg qd at 4pm discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 3. aliskiren 150 mg tablet sig: one (1) tablet po bid (). 4. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every ). 5. labetalol 200 mg tablet sig: two (2) tablet po three times a day. :*180 tablet(s)* refills:*2* 6. warfarin 4 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*0* 7. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po qmonth (). 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). :*180 tablet(s)* refills:*2* 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for 7 days. :*15 tablet(s)* refills:*0* 11. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. :*30 tablet(s)* refills:*0* 12. celexa 20 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 13. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 14. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 15. hydralazine 25 mg tablet sig: one (1) tablet po q30 min prn as needed for hypertension: for sbp > 180. discharge disposition: home discharge diagnosis: primary diagnosis: hypertensive urgency headache abdominal pain anxiety secondary diagnosis: htn sle esrd on hd svc and ij thrombosis, chronic anemia discharge condition: stable, bps improved. discharge instructions: you were admitted with elevated blood pressures, headache, and abdominal pain. you were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. your abdominal pain resolved and you continued to have intermittent headaches. your blood pressure medications were adjusted as below. you were also seen by psychiatry who recommended starting new medications for your anxiety. the following changes were made to your medication regimen: - we increased your hydralazine to 100 mg three times a day. - we also increased your labetalol to 400 mg three times a day. - we have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - we have increased your coumadin to 4 mg daily. - please continue taking all other medications as previously prescribed. call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. followup instructions: please follow-up with your pcp 1 week. please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. please discuss with your pcp the possibility of talking to a social worker at . you will need to continue to have your inr monitored at clinic. please have this level checked on , . Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus End stage renal disease Abdominal pain, unspecified site Anemia, unspecified Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism

allergies: penicillins / percocet attending: chief complaint: nausea, vomitting, abdominal pain, htn urgenc major surgical or invasive procedure: upper gi endoscopy exploratory laparotomy tunneled hemodialysis catheter in r femoral vein hemodialysis history of present illness: ms. is a 24 y/o f with h/o esrd, htn who started peritoneal dialysis during the week of and presented with a 1 day history of acute onset n/v, sharp abdominal pain on . (of note, the patient had presented to the ed on with hypotension, sbps in the 80s off after approximately 1.5l was taken off during dialysis in the setting of taking her po anti-htns. on she received 0.5l ivf, labs wnl, and was d/c'd home). on the day of admission on , the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish bms without melena or brbrp.she was admitted for further work- up of this abdminal pain. . in the ed here vitals were as follows: t: 97.0 hr: 101 bp: 240/180 rr: 17 o2sat: 100%ra. she received labetolol 20mg iv and was subsequently placed on a labetolol drip. she also received ceftriaxone 1gm iv, flagyl 500mg iv, dilaudid 0.5-1mg iv q1hr and zofran. her abdominal ct showed multifocal areas of small bowel wall thickening. her peritoneal cell count was negtaive for sbp. she had some signs of peritonitis and thus surgery was consulted. her lactate was normal. . upon arrival to the micu the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. she had no headache or visual changes. past medical history: - sle dx ( - 16 years old) when she had swollen fingers, arm rash and arthralgias. previous treatment with cytoxan, cellcept; currently on prednisone. complicated by uveitis () and esrd (). - ckd/esrd. diagosed . initiated dialysis . pd catheter placement . pt reluctant to start pd. - malignant hypertension. baseline bps 180's - 120's. history of hypertensive crisis with seizures. history of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - thrombocytopenia. ttp (got plasmapheresisis) versus malignant htn. - thrombotic events. svc thrombosis (); related to a catheter. negative lupus anticoagulant (, , 9/). - negative anticardiolipin antibodies igg and igm x4 (-). - negative beta-2 glycoprotein antibody (, 8/). - hocm: last noted on echo . - anemia. - history of left eye enucleation for fungal infection. - history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion. - history of coag negative staph bacteremia and hd line infection - and social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vitals: 98.4 hr 98 192/131 21 100%ra gen: mild distress, aox3 heent: peerla, eomi neck: supple, no lad, no bruit resp: ctab card: 2/6 systolic ejection murmur abd: soft, moderately tender with +/- guarding, bs+ extr: warm well perfused neuro: motor grossly intact rectal: yellow stool back: b cvat pertinent results: 08:50am blood wbc-3.5* rbc-2.55* hgb-7.8* hct-23.6* mcv-92 mch-30.6 mchc-33.2 rdw-16.8* plt ct-176 03:55pm blood pt-15.5* ptt-50.8* inr(pt)-1.4* 08:50am blood glucose-121* urean-33* creat-5.2*# na-140 k-4.2 cl-104 hco3-28 angap-12 06:15am blood alt-11 ast-49* alkphos-122* amylase-186* totbili-0.2 dirbili-0.1 indbili-0.1 06:15am blood lipase-30 08:50am blood albumin-2.5* calcium-7.8* phos-4.1 mg-1.9 06:55am blood hbsag-negative 10:48am blood hbsag-negative hbsab-positive hbcab-negative hav ab-negative igm hbc-negative igm hav-negative 11:56am urine color-yellow appear-clear sp -1.014 11:56am urine blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-tr 11:56am urine rbc-0-2 wbc- bacteri-few yeast-none epi-21-50 blood cultures: all negative ekg (): sinus rhythm. findings are within normal limits. compared to the previous tracing of there is no significant diagnostic change. cxr (): no acute cardiopulmonary abnormality. no free air under the diaphragms. ct chest/abdomen/pelvis (): there is a moderate-sized pericardial effusion, similar in appearance from . the great vessels are normal in caliber, without aneurysmal dilatation. evaluation of the great vessels is limited without iv contrast. interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. there is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from , and may reflect aspiration or pneumonia. scattered bilateral nodules are largely stable from as far back as . specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. a nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. there is a small right pleural effusion. axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without iv contrast. a catheter is visualized within the visualized right upper extremity, which may reflect a picc line that terminates within the right subclavian vein. the esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. there is a moderate- sized hiatal hernia. ct of the abdomen without iv contrast: there has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. these findings are all new from the prior ct on , but free air was present on chest radiograph performed . there is no obvious evidence of extravasation of oral contrast into the peritoneum. of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. the stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. evaluation for wall thickening is limited without iv contrast. limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. the liver is otherwise unremarkable. the gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. both kidneys are atrophic. evaluation of solid organs is limited by lack of iv contrast. there is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. there is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. ct of the pelvis without iv contrast: uterus and rectum are grossly unremarkable. however, assessment of the rectal wall is limited without iv contrast. osseous structures: bones are diffusely sclerotic, which may be related to renal osteodystrophy. there is bilateral sacroiliitis. impression: 1. interval development of a moderate amount of free intraperitoneal air, new from . a peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. however, as foci of air is seen in the region of the proximal stomach and ge junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. new dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. esophagus is contrast-filled possibly representing reflux. hiatal hernia. 3. anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. imaging cannot exclude sbp, which should be evaluated for clinically. 5. focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. gastric biopsies (): antrum: corpus-type mucosa, no diagnostic abnormalities recognized. jejunum: small intestinal mucosa, no diagnostic abnormalities recognized. ue venous u/s: no evidence of dvt of the left upper extremity, without thrombus identified within the left subclavian vein. brief hospital course: this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on , gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since . her lungs were also essentially unchanged from . however, her abdominal ct on showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on . there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions (, , and ) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured , where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. : nifedipine sr 90 mg daily aliskiren 150 mg labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patient's esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues//sat) as an outpatient. # anemia: during her admission, the patient's hct was monitored daily with hct to low-mid 20's. on , she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of between and . epo alfa sc was also given on . she remained hemodynamically stable. gi consulted and egd results were as stated above. the patient's hct remained stable (hovering between 25 - 27) from - . between - , the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on or as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on . the patient remained off heparin and coumadin from - given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on . this was mostly attributed to nutritional deficiency poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on , which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patient's bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from . during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. medications on admission: nifedipine 60 mg po daily labetalol 900 mg po tid hydralazine 50 mg po tid clonidine 0.3 mg/24hr patch qwed lactulose 30 ml tid aliskiren 150 mg prednisone 4 mg daily warfarin 2mg po daily calcitriol 1 mcg daily calcium carbonate 500mg qid dilaudid 2mg po q4-6hr prn pain discharge medications: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). :*30 patch weekly(s)* refills:*2* 2. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed. 3. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). :*120 tablet(s)* refills:*2* 4. labetalol 300 mg tablet sig: one (1) tablet po tid (3 times a day). :*90 tablet(s)* refills:*2* 5. warfarin 2 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 6. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. :*1500 ml(s)* refills:*0* 7. aliskiren 150 mg tablet sig: one (1) tablet po twice daily (). :*60 tablet(s)* refills:*2* 8. hydralazine 25 mg tablet sig: three (3) tablet po tid (3 times a day): in addition to 75 mg tid, if sbp>180, take 1 tab every 30 min until bp decreases to 150. if no improvement after 2 hours, call your doctor. :*300 tablet(s)* refills:*6* 9. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po daily (daily). :*1500 ml(s)* refills:*2* 10. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). :*30 tablet sustained release(s)* refills:*2* 11. oxycodone 5 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain for 5 days. :*30 tablet(s)* refills:*0* 12. colace 100 mg capsule sig: one (1) capsule po once a day. :*30 capsule(s)* refills:*2* 13. miralax 17 gram (100 %) powder in packet sig: one (1) po once a day. :*30 packets* refills:*2* discharge disposition: home discharge diagnosis: primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis secondary: sle anemia discharge condition: stable, pain well controlled, blood pressure at baseline discharge instructions: you were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. you have also been initiated on hemodialysis on tuesday/thursday/saturday schedule. please take all medications as prescribed in the list that you will be given at discharge. there have been some changes to your medications. please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. followup instructions: you will see dr. at hemodialysis on tuesday, , . you should have your coumadin level checked at this appointment. call dr. office at to schedule an appointment in weeks to have your staples removed. md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Non-invasive mechanical ventilation Exploratory laparotomy Esophagogastroduodenoscopy [EGD] with closed biopsy Transfusion of packed cells Transfusion of other serum Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Acidosis Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Abnormal coagulation profile Renal dialysis status Anemia, unspecified Esophageal reflux Hyposmolality and/or hyponatremia Other chronic pulmonary heart diseases Nausea with vomiting Constipation, unspecified Unspecified disease of pericardium Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Other diseases of lung, not elsewhere classified Other chest pain Fever, unspecified Rash and other nonspecific skin eruption Personal history of venous thrombosis and embolism Other ascites Abdominal pain, other specified site Hyperparathyroidism, unspecified Diarrhea Malignant essential hypertension Abdominal pain, epigastric

allergies: penicillins attending: chief complaint: seizures elevated blood pressures major surgical or invasive procedure: none history of present illness: the patient is a 20 year old female with h/o esrd secondary to sle. she is currently on hd through a l ij tunnelled catheter on mwf @ . she was dialysed on the day of admission and at the end of dialysis her her post hd bp was 230-240s and she also experienced a bitemporal headache with blurry vision. also, she described transient cp sensation for 1 minute at hd. . in ed she was noted to have sbp to 250s and was given phentolamine x2, clonopine po and patch, hydralazine with minimal effect. a ct head showed no evidence of bleed. a nipride gtt was started with some effect with sbp falling transiently to 190. . on arrival to micu, pt was switched to labetalol gtt out of concern for potential toxicity on nipride. labetalol was effective initially but pt did have sbp to 230. pt had witnessed, tonic clonic seizure for 30 seconds with + tongue biting and spontaneous resolution + post-ictal state. pt had repeat head ct negative and neuro eval who found pt neurologically intact and recommended holding on dilantin and getting mr head with gad in am to r/o posterior leukoencephalopathy . pt had second seizure lasting 2-3 minutes and was given 2mg iv ativan with good effect. dilantin iv 1gm load given. additional labs returned with phos at 1.1 so po and iv repletion started. * past medical history: esrd lupus on hd since through left tunneled cath sle htn- with hx hypertensive crisis hocm hx ttp pregnancy termination in ttp social history: lives with mom and 14 year old brother occasional etoh, no tobacco, heroin, cocaine family history: aunts with hypertension grandmother died of myeloma several men with prostate cancer physical exam: t 95.7 hr 93-110 bp 185-234/100-155 rr11-20 o2 sat 99-100% gen: sleeping in bed, nad, easily arousable neck: supple, normal rom, no thyromegaly, no bruit cv: rrr, nl s1 and s2, 2/6 sem lung: clear to auscultation bilaterally abd: +bs, soft, nontender ext: no edema neurologic examination: mental status: awake and alert, cooperative with exam. oriented to person, place, and date. she has mild attention problems, can say backwards-but takes several attempts and made one mistake on last try. speech is fluent with normal comprehension and repetition; naming intact. no dysarthria. registers , recalls at 5min. no evidence of apraxia or neglect fundus exam: no papilledema and no retinal hemorrhages bilaterally. cn ii-xii symmetrical and intact motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor tri wf we fe ff ip h q df pf te tf r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 sensation: intact to light touch, pinprick, vibration and proprioception throughout. reflexes: b t br pa ach right 2 2 2 2 2 left 2 2 2 2 2 grasp reflex absent toes were downgoing bilaterally coordination: normal on finger-nose-finger, heel to shin pertinent results: 08:44pm pt-14.8* ptt-40.3* inr(pt)-1.4 05:27pm pt-14.1* ptt-150 is hig inr(pt)-1.3 11:40am glucose-94 urea n-16 creat-3.9* sodium-141 potassium-3.9 chloride-95* total co2-32* anion gap-18 11:40am ck(cpk)-97 11:40am ck-mb-4 ctropnt-0.02* 11:40am hcg-<5 11:40am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 11:40am wbc-6.0 rbc-5.15 hgb-15.7 hct-47.8 mcv-93 mch-30.5 mchc-32.8 rdw-17.8* 11:40am neuts-75.7* lymphs-18.0 monos-5.1 eos-0.6 basos-0.6 11:40am hypochrom-1+ anisocyt-1+ macrocyt-1+ 11:40am plt count-141* * admission head ct: impression: no evidence of acute intracranial hemorrhage or mass effect. * admission chest x ray: no abnormalities * ecg: sinus tachycardia with slowing of the rate as compared to the previous tracing of . biatrial enlargement and new t wave inversion in lead avl with dissociated st-t wave flattening in lead i. * head mri: abnormal t2 and flair signal within both occipital and parietal lobes in a pattern suggestive of posterior reversible encephalopathy syndrome * knee x ray: normal l knee. brief hospital course: a/p 20 yo f with esrd on hd who p/w hypertensive crisis and has new onset seizure . 1) hypertensive emergency her blood pressure was controlled with a labetaolol drip and she was then transitioned to po labetalol. she was also continued on the clonidine patch. in light of her complaints of chest pain we were reassured by her ecg and by her flat cardiac enzymes. . 2) new onset seizure we thought that her new onset seizures were probably due to her severely elevated blood pressure but other diagnoses including lupus cerbritis were also considered. an mri with gadolinium was obtained. it demonstrated abnormal t2 and flair signal within both occipital and parietal lobes in a pattern suggestive of posterior reversible encephalopathy syndrome. we consulted the rheumatology service who thought that her presentation was more consistent with hypertensive encephalopathy rather lupus cerebritis. she was loaded with dilantin. with dilantin loading and control of her blood pressure she did not have a recurrence of her seizures. . 3) lupus: she was continued on her plaquenil and prednisone. . 4) esrd she continued to receive regulary scheduled hemodialysis. . 5) knee pain: on the day of discharge the patient complained of l knee pain. on physical exam she was afebrile, the knee was slightly warm and tender to the touch without obvious effusion. an x ray of the knee was read as normal. she had full range of motion but it was painful but she was able to bear weight on it. she was instructed to use tylenol prn for pain and to return o the clinic or emergency room should she develop worsening knee pain, fevers or chills. . communicaton: the patient and the patient's mother were extensively counselled about the patient's disease. she demonstrated an understanding of the importance of good medical compliance with therapy and keeping appointments. medications on admission: 1. clonidine tts 1 patch 1 ptch td qwed started in ed 2. folic acid 1 mg po daily 3. heparin 5000 unit sc tid 4. prednisone 10 mg po daily 5. hydroxychloroquine sulfate 200 mg po bid 6. labetalol hcl 200 mg po tid start: in am wean labetalol gtt as tolerated, hold for sbp<150 7. lisinopril 40 mg po daily start: in am order date: @ 1712 discharge medications: 1. hydroxychloroquine sulfate 200 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. lidocaine-aloe 0.5 % gel sig: appl topical every six (6) hours as needed for pain. disp:*1 vial* refills:*0* 4. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. clonidine hcl 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qthur (every thursday). disp:*10 patch weekly(s)* refills:*2* 6. levetiracetam 250 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. labetalol hcl 200 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 8. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 9. naproxen 500 mg tablet sig: one (1) tablet po three times a day as needed for pain. disp:*20 tablet(s)* refills:*0* 10. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary hypertensive encephalopathy and new onset seizures lupus nephritis end stage renal disease on hemodialysis secondary: h/o thrombotic thrombocytopenic purpura. discharge condition: good, without headaches or blurry vision, blood pressure well controlled and at her baseline. discharge instructions: please take all of your medications as prescribed. please attend all of your follow up appointments. as we discussed it is extremely important that you take all of your blood pressure medications as instructed. * please return to the emergency room of your pcp's office if you have severe headache, blurry or worsening vision or seizures. * it is crucial to your health that you attend all of your follow up appointments!!!! * please return to the emergency room or your pcp's office or office at if you experience worse knee pain, swelling, fevers or chills. followup instructions: provider: , md where: lm center phone: date/time: 11:20 provider: , md where: dermatology phone: date/time: 1:45 provider: , .d., ph.d.: medical specialties phone: date/time: 10:00 test for consideration post-discharge: beta-2 microglobulin. please call for a follow up appointmnt with neurology in months. please call dr. at for an appointment in 10 days. md Procedure: Hemodialysis Diagnoses: Systemic lupus erythematosus Anemia, unspecified Other convulsions Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hypertensive encephalopathy

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea, hypertension urgency major surgical or invasive procedure: hemodialysis history of present illness: 24f h/o sle, esrd on hd, h/o malignant htn, svc syndrome, pres, prior ich, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. she was recently admitted after presenting for hypertensive urgency and dyspnea for which she was started on nitroglycerin and labetalol drips, which were weaned off in the icu. she was also received 2u prbcs during hd. she was discahrged home without any changes to her medical regimen. . on the afternoon of she notes increased dyspnea, she therefore went to hd on wednesday, and again on thursday . after hd, her bp remained elevated, and she took an extra dose of labetalol 1000mg x 1. on her vna noted sbp 250s. she took extra doses of hydralazine, but otherwise felt well. she then woke up this morning with ha. she took all of her bp meds this morning, but remained with ha and sob, thus prompting her presentation to the ed. . no fevers, productive cough, taking all meds, had chronic diarrhea that is unchanged, some n/v at baseline, no coffee ground emesis, has some abdominal pain unchanged from baseline past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: denies tobacco, alcohol or illicit drug use. lives with mother and is on disability for multiple medical problems. family history: no known autoimmune disease. pertinent results: 08:00a alk,alt,ast,ck,cpis,lip,bili,tnt added 12:29pm 141 103 29 82 agap=13 3.4 28 6.5 &#8710; ck: 59 mb: notdone trop-t: 0.18 alt: 21 ap: 126 tbili: 0.4 alb: ast: 51 ldh: dbili: tprot: : lip: 56 pt: 15.0 ptt: 35.5 inr: 1.3 n:69.8 l:21.9 m:5.5 e:2.5 bas:0.3 hypochr: 1+ anisocy: 2+ macrocy: 1+ microcy: 1+ polychr: 1+ brief hospital course: # hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she stated that she did take her po meds. she was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. a sent of cardiac enzymes was sent and revealed a cpk of 59 and a troponin of 0.18. the patient also underwent dialysis in the icu. after dialysis the labetalol drip was weaned off. overnight, sbp's ranged 109 to 182 mmhg. the following day, her sbp's ranged 133 to 200. ultimately, she was discharged home on her normal medication regimen. # abdominal pain - the patient also presented complaining of adbominal pain. she had recently been treated for sbo; however, at the time of admit, she was without nausea or vomiting. she had a soft abdomen, was passing flatus, and was having daily bowel movements. she did have hypoactive bowel sounds. she was continued of her outpatient pain regimen of po dilaudid, fentanyl patch, and lidoacine patch. an ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. this ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. after the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent sbo. # esrd on hd - the patient gets hemodialysis on a tu/th/sa schedule. on admit, the patient was continued on her home does of sevalemer. renal was consulted, and the patient received dialysis on in the icu. # anemia/pancytopenia - the patient has a chronic anemia and baseline pancytopenia that are likely secondary to her ckd and sle. on admit she was actually above baseline. she was continued on her home does of epogen. # h/o gastric ulcer - the patient was continued on her ppi . # sle - the patient was continued on her home regimen of prednisone 4mg po daily. # h/o svc thrombosis - the patient has a goal inr of . however, naticoagulation was stopped after a recent admission secondary to a supratherapeutic inr. on admit, her inr was sub-therapeutic. therefore, her warfarin was restarted at 3 mg daily. # seizure disorder - the patient was continued on her home regimen of keppra 1000 mg po 3 times a week (tu/th/sa). # depression - the patient was continued on her home dose of celexa. medications on admission: 1.nifedipine 90 mg po daily (daily). 2.nifedipine 60 mg tablet sustained release po hs (at bedtime). 3.lidocaine 5 % patch q24hr. 4.aliskiren 150 mg tablet sig: one (1) tablet po bid 5.citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6.fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch q72h 7.prednisone 4 mg po daily (daily). 8.clonidine 0.1 mg/24 hr patch qsat (every saturday). 9.clonidine 0.3 mg/24 hr patch qsat (every saturday). 10.sevelamer hcl 1600 mg po tid w/meals (3 times a day with meals). 11.gabapentin 100 mg capsule sig: one (1) capsule po qhd 12.labetalol 1000 mg tablet tablet po tid 13.hydralazine 100 mg tablet po q8h 14.warfarin 3 mg tablet po once daily at 4 pm. 15.pantoprazole 40 mg po q12h (every 12 hours). 16.levetiracetam 1000 mg po 3x/week (tu,th,sa). discharge medications: 1. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 2. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical q24hr (). 4. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 7. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 9. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 10. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 11. gabapentin 100 mg capsule sig: one (1) capsule po qhd (each hemodialysis). 12. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). disp:*qs tablet(s)* refills:*2* 13. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 14. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 16. levetiracetam 500 mg tablet sig: two (2) tablet po qtuthsa (tu,th,sa). 17. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for abdominal pain. discharge disposition: home discharge diagnosis: hypertensive urgency lupus nephritis end stage renal disease on hemodialysis ascites discharge condition: hemodynamically stable with blood pressures 130-140/70-80s. discharge instructions: you were evaluated and treated for you hypertension. you were started on iv medications and transitioned to your home regimen and received a session of hemodialysis. you also had an ultrasound to evaluate the fluid in your belly. there was no evidence of blood clot contributing to the build up of the fluid. please continue to follow a low sodium diet at home and take all of your blood pressure medications in addition to going to dialysis. followup instructions: you have the following appointments scheduled: please also keep your tuesday/thursday/saturday dialysis schedule provider: , md phone: date/time: 2:00 provider: clinic phone: date/time: 3:15 Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease Anemia of other chronic disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Unspecified iridocyclitis Other ascites Other specified peripheral vascular diseases Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

allergies: penicillins / percocet attending: chief complaint: hypertensive urgency and ha major surgical or invasive procedure: none history of present illness: ms. is a 24 year old woman with esrd on hd, sle, malignant htn admitted with ha in the setting of hypertension. upon arrival to the ed, her vitals were 284/140, hr 67, rr 28, 100% on 4lnc. she was started on a nicardipine drip. she denied shortness of breath or chest pain. she is due for hd today. she has a left groin catheter which was recently placed and is causing her pain. she was also given dilaudid iv 1 mg x 2 with some relief. cxr was performed and showed no pulmonary edema. . upon arrival to the micu, patient denies ha, cp, sob, fevers, chills. patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral hd line. she reports that she was taking her medications as directed, including coumadin for svc thrombus. briefly, 24 yo f with esrd on hd, sle, malignant htn admitted for ha in the setting of htn to 284/140 in ed. initially, she was treated with a nicardipine gtt to control her bp. her cardiac enzymes were flat, no new ecg changes. she was started on a heparin gtt with transition to coumadin for a svc thrombosis. htn secondary to med noncompliance. she was restarted on her oral bp. she missed her pm meds yesterday, so nicardipine was restarted, and then turned off this am. she received all her am bp meds. her bps have been in the 160s/90s. she had no neurological deficits. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vs: 176/105, 87, 18, 100% ra general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic cardiovascular: 2/6 systolic murmur lusb respiratory / chest: (breath sounds: clear : ) abdominal: left ant wall abd hematoma, ttp extremities: right: trace, left: trace, left fem hd line without oozing or drainage skin: warm neurologic: aao x 3 pertinent results: 05:15am pt-13.7* ptt-33.6 inr(pt)-1.2* 05:15am hypochrom-2+ anisocyt-2+ poikilocy-2+ macrocyt-1+ microcyt-1+ polychrom-1+ spherocyt-occasional schistocy-occasional burr-1+ stippled-occasional teardrop-1+ bite-normal fragment-occasional elliptocy-occasional 05:15am ctropnt-0.08* 05:15am ck(cpk)-119 04:12pm ptt-120.8* 10:41pm ptt-144.8* 02:55pm ck-mb-notdone ctropnt-0.06* brief hospital course: 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr . pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patient's bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at , and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on . line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/c'ed as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. in the next 1-2 weeks. # anemia: pt's baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: (mother) # dispo: home with pcp and renal to re-check bp, inr level. follow-up with transplant surgery. medications on admission: clonidine 0.3mg / 24 hr patch weekly qwednesday hydralazine 100mg po q8h labetalol 800mg po tid hydromorphone 4mg po q4h prn nifedipine er 90mg po qday prednisone 4mg po qday lorazepam 0.5mg po qhs clonazepam 0.5 mg celexa 20mg po qday gabapentin 300 mg acetaminophen 325 mg q6h prn ergocalciferol (vitamin d2) 50,000 unit po once a month coumadin 4 mg daily aliskiren 150 discharge medications: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 3. labetalol 200 mg tablet sig: four (4) tablet po tid (3 times a day). 4. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 7. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 8. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. 9. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 10. nicardipine 30 mg capsule sig: one (1) capsule po q8h (every 8 hours). 11. morphine 15 mg tablet sig: 0.5 tablet po every eight (8) hours as needed for pain for 2 weeks. :*20 tablet(s)* refills:*0* 12. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours. 13. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). discharge disposition: home discharge diagnosis: primary diagnosis: hypertensive urgency end stage renal disease discharge condition: stable, blood pressure moderately controlled, afebrile, tolerating pos discharge instructions: you were admitted for headaches and very high blood pressures. you were started on an iv medication for your blood pressure which controlled it. you were then started back on your home medications with improvement of your blood pressure. some of medications were increased as your hypertension was difficult to control. you were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. you will need to take the coumadin as prescribed by your doctor, and have your inr checked frequently per your pcp's recommendations. please take all medications as prescribed. it is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. please keep all scheduled appointments. if you develop any of the following concerning symptoms, please call your pcp or go to the ed: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. followup instructions: provider: , md (renal) phone: date/time: 3:00 - will follow-up vitamin d level provider: , md () phone: date/time: 3:30 - will re-check your inr level provider: , md (transplant surgery) phone: date/time: 2:50p md Procedure: Hemodialysis Non-invasive mechanical ventilation Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Renal dialysis status Other opiates and related narcotics causing adverse effects in therapeutic use Dysthymic disorder Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Hypoxemia Abdominal pain, other specified site Other postprocedural status

allergies: penicillins / percocet / morphine attending: chief complaint: acute onset dyspnea major surgical or invasive procedure: dialysis history of present illness: please see micu note for full details. in brief this is a 24 y.o. woman with sle, esrd on hd, hx malignant htn, h/o svc syndrome, h/o posterior reversible encephalopathy syndrome (pres) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite dr. attempting to arrange transport for her (? refused to come). she was admitted therefore on to micu with vs: t 100.4 hr 108 bp 240/180 rr 28 pox100 ra. she was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. in the micu she was dialyzed with 1.7l fluid removal (though + 300cc given tranfusion). her sob is improved. her hct was also noted to be low (18->from 22 ) so transfused 2 units prbc's, recent egd with gastric ulcer , guaiac negative in ed, no bm in unit, hemolysis w/u negative. bp in icu 140/106 currently but of note was hypotensive on hd to 86/62. she notes sob improved rapidly on arrival. ros: currently she has no complaints. she notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to . she has been getting hd via right femoral catheter which is not painful, no discharge from the sight. she denies ha, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: denies tobacco, alcohol or illicit drug use. lives with mother and is on disability for multiple medical problems. family history: no known autoimmune disease. physical exam: vitals - t: 97.7, bp: 140/99 p: 88 r: 19 o2: 98% on ra general: sleeping comfortably but awakens easily, alert, oriented x3 heent: nc/at; perrla on right, enucleated eye on left; op clear, nonerythematous, mmm, moon facies neck: supple, jvp flat, no lad, full rom, left ej in place lungs: coarse bs throughout, no w/r/r, no decreased bs at bases cv: s1, s2 nl, no m/r/g appreciated abdomen: firm, non-tender to palpation, no masses or organomegally ext: warm, well perfused, 1+ dp/pt, no clubbing, cyanosis or edema neuro: a&o x3, motor ue/le bilaterally pertinent results: 05:28pm hct-26.0*# 11:38am hypochrom-2+ anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-occasional polychrom-normal ovalocyt-1+ schistocy-occasional teardrop-occasional 05:04am glucose-85 urea n-72* creat-10.4* sodium-139 potassium-5.5* chloride-109* total co2-14* anion gap-22* 05:04am ld(ldh)-264* tot bili-0.2 05:04am calcium-6.6* phosphate-6.5* magnesium-1.6 05:04am haptoglob-142 05:04am wbc-3.4* rbc-1.93* hgb-5.8* hct-17.0* mcv-88 mch-30.0 mchc-34.2 rdw-18.4* 05:04am plt count-97* 01:34am glucose-84 urea n-70* creat-10.5*# sodium-136 potassium-5.6* chloride-108 total co2-14* anion gap-20 01:34am estgfr-using this 01:34am alt(sgpt)-10 ast(sgot)-39 alk phos-108 tot bili-0.2 01:34am lipase-115* 01:34am albumin-3.2* calcium-6.6* phosphate-6.8* magnesium-1.7 01:34am wbc-4.5 rbc-2.08* hgb-6.0* hct-18.3* mcv-88 mch-28.6 mchc-32.5 rdw-18.6* 01:34am neuts-78.5* lymphs-16.5* monos-3.0 eos-1.4 basos-0.6 01:34am plt count-104* 01:34am pt-15.0* ptt-33.6 inr(pt)-1.3* brief hospital course: # dyspnea: pt's dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pt's baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen . # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. medications on admission: 1. nifedipine 90 mg tablet sustained release po qam 2. nifedipine 60 mg tablet sustained release po qhs 3. lidocaine 5 % transdermal one daily 4. aliskiren 150 mg po bid 5. citalopram 20 mg po daily (daily). 6. fentanyl 25 mcg/hr patch q72h (every 72 hours). 7. prednisone 4mg po daily (daily). 8. clonidine 0.1 mg/24 hr patch weekly transdermal qsat 9. clonidine 0.3 mg/24 hr patch weekly transdermal qsat 10. sevelamer hcl 400 mg four (4) tablet po tid w/meals 11. gabapentin 100 mg capsule sig: one (1) capsule po bid 12. labetalol 200 mg tablet sig: five (5) tablet po tid 13. hydralazine 100 mg po q8h 14. hydromorphone 2 mg 1-2 tablets po q6h as needed for pain. 15. pantoprazole 40 mg po q12h 16. levetiracetam 1,000 mg po 3x/week (tu,th,sa). discharge medications: 1. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 2. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po hs (at bedtime). 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical q24 h (). 4. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 5. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 7. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 9. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 10. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 11. gabapentin 100 mg capsule sig: one (1) capsule po qhd (each hemodialysis). 12. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 13. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 14. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 16. levetiracetam 500 mg tablet sig: two (2) tablet po 3x/week (tu,th,sa). discharge disposition: home with service facility: vna discharge diagnosis: primary: malignant htn, esrd on hd, shortness of breath secondary: lupus discharge condition: stable, afebrile discharge instructions: you were admitted to the hospital after you noticed some shortness of breath. whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. we think your blood level was low because you were not receiving your epo shots, we think the fluid is from not receiving dialysis. before you were discharged from the hospital your breathing was better. we recommend that you continue going to dialysis. we made no changes to your medications. if you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ed. followup instructions: provider: clinic phone: date/time: 3:15 provider: , md phone: date/time: 2:00 md Procedure: Venous catheterization, not elsewhere classified Hemodialysis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies Systemic lupus erythematosus Hyperpotassemia Anemia of other chronic disease End stage renal disease Other chronic pain Depressive disorder, not elsewhere classified Unspecified disease of pericardium Hypotension, unspecified Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Abdominal pain, other specified site Noncompliance with renal dialysis

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea, malignant hypertension major surgical or invasive procedure: none history of present illness: briefly, 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented with abdominal pain and shortness of breath. on she refused ultrafiltration at hd because she was at her dry weight. awoke at 3 am feeling more short of breath. she also had worsening abdominal pain and vomiting without hematemasis. she took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. she developed a slight frontal headache but no blurry vision or neurologic symptoms. ros largely negative. . in the emergency room her initial vitals were t: 99.1 bp: 280/140 hr: 79 rr: 16 o2: 100% on ra. she had two large bore peripheral ivs placed. she received 100 mg po hydralazine, 200 mg po labetolol, zofran 4 mg iv, vancomycin 1 gram iv, levofloxacin 750 mg iv x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. she had a cxr which was concerning for volume overload. she was admitted the micu for further evaluation. . in the micu she was stablized and transitioned to her home meds. nephrology gave her hd with 2l uf and subjective improvement in sob. . past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of , currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-120's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. physical exam: on admission per micu team: vitals: t: 96.5 bp: 162/120 hr: 79 rr: 13 o2: 100% on 4l general: pleasant, comfortable, no distress heent: l eye enucleated. moon facies. right pupil reactive heart: regular rate and rhythm, s1 + s2, soft systolic murmur at rlsb, no rubs or gallops respiratory: crackles at bases bilaterally, no wheezes, rales, ronchi gi: soft, non-tender, non-distended, +bs gu: no foley ext: warm and well perfused, no clubbing, cyanosis or edema . pertinent results: 08:35am wbc-3.8* rbc-2.53* hgb-7.6* hct-23.4* mcv-93 mch-29.9 mchc-32.3 rdw-19.9* 08:35am plt count-93* . 08:35am glucose-88 urea n-36* creat-6.0* sodium-135 potassium-5.7* chloride-101 total co2-25 anion gap-15 08:35am calcium-9.4 phosphate-5.3* magnesium-2.0 . 08:40am pt-28.3* ptt-45.3* inr(pt)-2.9* . cxr pa and lat: impression: 1. persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. minimal costophrenic angle blunting may suggest small effusions. 2. no definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. repeat imaging following diuresis could be considered. . inr trend: 09:30am blood pt-30.4* inr(pt)-3.1* 08:40am blood pt-28.3* ptt-45.3* inr(pt)-2.9* 04:07am blood pt-29.9* ptt-48.9* inr(pt)-3.1* 05:55am blood pt-33.3* ptt-54.1* inr(pt)-3.5* brief hospital course: 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patient's blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at yesterday. she has received and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. refused to go to a "home" and declined to talk to social work at this time. of note, she has missed sessions and often requests durations and flow rates for her that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on . ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on to be faxed to coumadin clinic in . - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . medications on admission: hydromorphone 2 mg tablet sig: 1-2 tablets po q4h prednisone 1 mg tablet citalopram 20 mg tablet pantoprazole 40 mg tablet, warfarin 3 mg daily gabapentin 300 mg tid nifedipine 90 mg tablet sr daily nifedipine 60 mg tablet sr daily hydralazine 100 mg tablet q8h labetalol 1000 mg tablet tid aliskiren 150 mg tablet po bid clonidine 0.2 mg/24 hr patch weekly docusate sodium 100 mg capsule po bid senna 8.6 mg tablet fentanyl 25 mcg/hr patch 72 hr lidocaine 5 %(700 mg/patch) daily hydralazine 100 mg po:prn for sbp > 200 discharge medications: 1. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. prednisone 1 mg tablet sig: one (1) tablet po daily (daily). 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. warfarin 3 mg tablet sig: one (1) tablet po once a day: do not take dose on . then restart per your pcp. 6. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 7. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 8. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po qhs (once a day (at bedtime)). 9. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 10. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 11. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 12. clonidine 0.2 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 13. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 15. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 16. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 17. hydralazine 50 mg tablet sig: two (2) tablet po bid (2 times a day) as needed: for systolic blood pressure > 200. discharge disposition: home with service facility: vna discharge diagnosis: malignant hypertension systemic lupus erythematosus end stage renal disease abdominal pain discharge condition: good, vss, on room air, pain controlled. discharge instructions: you came to the hospital for shortness of breath and hypertension. you were given antihypertensive drips and during 2 liters were taken off with good improvement in your shortness of breath. you will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . medication changes: - please do not take your coumadin tonight because your inr is too high. you will need to have it checked by vna services and adjusted. - please take all of your medications as prescribed. . please call your doctor or return to the ed if you have intractable headaches, shortness of breath, intractable pain or other concerns. followup instructions: provider: , md phone: date/time: 3:30 provider: , md phone: date/time: 9:30 Procedure: Hemodialysis Venous catheterization for renal dialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia of other chronic disease End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Renal dialysis status Peripheral vascular disease, unspecified Unspecified disease of pericardium Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Unspecified iridocyclitis Noncompliance with renal dialysis Personal history of noncompliance with medical treatment, presenting hazards to health Surgical or other procedure not carried out because of patient's decision Abdominal pain, left lower quadrant Acquired absence of organ, eye Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus

allergies: penicillins / percocet attending: chief complaint: right leg pain. major surgical or invasive procedure: none. history of present illness: ms. is a 24 y.o. f with lupus, chronic kidney disease v (not currently on hd or pd), and multiple admissions for hypertensive urgency/emergency, who presented to the ed for continued r leg pain that starts in her r buttocks and refers down her r leg. she describes it as feeling like the pain is deep within her bone. the pain was in the am, and she felt like she couldn't get out of bed. denies any swelling of her rle. when getting vs in , pt noted to be very hypertensive at 263/176. the patient reportedly has baseline sbps in 130-170s. she took her hydralazine, aliskirien, and labetalol at 5 am on day of admission. she denies any recent recrational drug use including cocaine and amphetamines. she denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, brbpr, dysuria. during md interview, the patient was nauseous and had small amount of emesis of a recent coolata. pt states that flushing her pd cath causes a large amount of stomach pain. . of note, the patient was recently admitted from 08.26-29.08. the patient initially presented to the ed after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. she was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. the patient did receive 2 u of prbc's during this hospitalization for baseline anemia. the patient did have a work-up for her right leg pain complaints with plain films of the right hip and mri of the l-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. the patient received dilaudid for pain control and was ambulating without pain prior to discharge. in addition, the patient completed a course of ciprofloxacin for a positive ua with negative cultures. the patient was unable to tolerate peritoneal dialysis for unclear reasons. peritoneal dialysate culture was negative for infection. . in the ed: vs t 98.2 hr 101 bp 263/176 rr 20 o2 sat 100% ra. bps in ed ranged from -175 with hr in 96-108. initially given labetalol 10 mg iv x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. leni of r leg was negative. cxr performed. given morphine 4 mg iv x 1 for leg pain. per ed, cannot do v/q scan due to volume overload after talking with radiology. renal c/s initiated. a-line placed. past medical history: - systemic lupus erythematosus. diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias. previous treatment with cytoxan, cellcept; currently on prednisone. complicated by uveitis () and esrd (). - ckd/esrd. diagosed . initiated dialysis . pd catheter placement . pt reluctant to start pd. - malignant hypertension. baseline bps 180's - 120's. history of hypertensive crisis with seizures. history of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - thrombocytopenia. ttp (got plasmapheresisis) versus malignant htn. - thrombotic events. svc thrombosis (); related to a catheter. negative lupus anticoagulant (, , 9/). negative anticardiolipin antibodies igg and igm x4 (-). negative beta-2 glycoprotein antibody (, 8/). - hocm: last noted on echo . - anemia. - history of left eye enucleation for fungal infection. - history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion. - history of coag negative staph bacteremia and hd line infection - and . past surgical history: - placement of multiple catheters including dialysis. - tonsillectomy. - left eye enucleation in . - pd catheter placement in . social history: single. recently moved into her own apartment. on disability. denies etoh, tobacco or recreational drug use. family history: negative for autoimmune diseases, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vs: t 98.9 99$% ra gen: nad, pleasant female sitting in bed with moon facies heent: eomi of r eye, l eye prosthesis, no exudate, no erythema, mmm, no lad chest: ctab except at r base with decreased breath sounds; no w/r/r cv: tachy, normal s1s2, ii/vi systolic murmur accentuated with valsalva abd: ndnt, soft, nabs, pd cathether placed in llq, dressing c/d/i ext: no c/c/e, strength of les and symmetric bilaterally. negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. some pain on flexion at the hip. neuro: ii - xii intact to direct testing. no deficit in light tough sensation. gait normal. derm: no rashes noted pertinent results: labs at admission: 11:43am glucose-86 urea n-49* creat-8.1* sodium-139 potassium-5.0 chloride-110* total co2-16* anion gap-18 11:43am calcium-6.2* phosphate-5.8* magnesium-1.6 11:43am pt-18.4* ptt-42.8* inr(pt)-1.7* 07:00am wbc-5.5 rbc-2.88* hgb-8.1* hct-24.7* mcv-86 mch-28.1 mchc-32.8 rdw-18.0* 07:00am neuts-74.7* lymphs-17.5* monos-4.2 eos-3.3 basos-0.2 07:00am plt count-101* ua: moderate leuk, small blood, negative nitrite, protein 100, 21-50 wbc . microbiology: urine culture (): mixed flora . studies: cardiology report ecg study date of 6:55:16 am sinus tachycardia. the tracing is marred by baseline artifact. there is left atrial enlargement. compared to the previous tracing of the rate has increased. the axis is more rightward. otherwise, no diagnostic interim change. . unilat lower ext veins right study date of 8:54 am -scale and doppler son of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. appropriate color flow and compression is noted within the calf veins. no intraluminal thrombus is present. impression: no evidence of right lower extremity dvt. . tte (): the left atrium is normal in size. there is severe symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. the gradient increased with the valsalva manuever. the findings are consistent with hypertrophic obstructive cardiomyopathy (hocm). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. . r hip xr : no acute fracture or dislocation. . mri l-spine : diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. there is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. lab results at discharge: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:15am 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* renal & glucose glucose urean creat na k cl hco3 angap 06:15am 100 44* 8.1* 137 4.8 109* 17* 16 chemistry totprot albumin globuln calcium phos mg uricacd iron 06:15am 6.8* 5.4* 1.6 calcium freeca 11:30am 0.94* brief hospital course: icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . history: . 1. hypertensive urgency: during the patient's stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patient's hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in , and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patient's home prednisone regimen was continued. medications on admission: - prednisone 5 mg daily - coumadin 2 mg at bedtime - nifedipine 60 mg sustained release daily - hydralazine 50 mg every 8 hours - clonidine 0.3 mg/24 hr patch weekly every wednesday - ergocalciferol (vitamin d2) 50,000 unit weekly - aliskiren 150 mg twice daily - docusate sodium 100 mg 2 times a day - labetalol 900 mg three times a day - lactulose 15-30 ml once a day: goal is soft bowel movements per day discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 4. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 5. calcitriol 0.5 mcg capsule sig: two (2) capsule po daily (daily). disp:*60 capsule(s)* refills:*0* 6. hydromorphone 2 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 7. labetalol 300 mg tablet sig: three (3) tablet po tid (3 times a day). 8. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 10. hydralazine 50 mg tablet sig: one (1) tablet po q8h (every 8 hours). 11. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: - hypertensive urgency - right lower extremity pain - urinary tract infection secondary diagnosis: - systemic lupus erythematosus. diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias. previous treatment with cytoxan, cellcept; currently on prednisone. complicated by uveitis () and esrd () - ckd/esrd. diagosed . initiated dialysis . pd catheter placement . pt reluctant to start pd - malignant hypertension. baseline bps 180's - 120's. history of hypertensive crisis with seizures. history of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - thrombocytopenia. ttp (got plasmapheresisis) versus malignant htn - thrombotic events. svc thrombosis (); related to a catheter. negative lupus anticoagulant (, , 9/). negative anticardiolipin antibodies igg and igm x4 (-). negative beta-2 glycoprotein antibody (, ) - hocm: last noted on echo - anemia - history of left eye enucleation for fungal infection - history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion. - history of coag negative staph bacteremia and hd line infection - and discharge condition: stable systolic blood pressure over past 24 hours. discharge instructions: you were admitted to the hospital for uncontrolled high blood pressure. you spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. you were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. you were also treated for urinary tract infection with antibiotics. your right leg pain improved during admission, and we are unsure of the cause of this pain. you should discuss the need for an mri of the hip if the pain returns when you meet with your primary care doctor. please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. please take your medications as prescribed. - calcitriol was added to your medications. - you should hold coumadin for two days and restart saturday, . you should have your inr checked at your visit in kidney clinic . - you can take dilaudid 2-4 mg every eight hours as needed for pain. you should be vigilant about taking lactulose if you need to take dilaudid. - you should continue lactulose as per dr. instructions. - no other changes were made. please keep follow up appointments as described below. followup instructions: please call the office of your kidney doctor, dr. , at ( to schedule an appointment for , as discussed. follow up with your lung doctor: provider: , md phone: date/time: 1:00 follow up with your new primary care doctor: provider: , md phone: date/time: 10:00 Procedure: Arterial catheterization Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Chronic kidney disease, Stage V Other primary cardiomyopathies Systemic lupus erythematosus Hyperpotassemia Sciatica Thrombocytopenia, unspecified Anemia of other chronic disease Abnormal coagulation profile Urinary tract infection, site not specified Personal history of venous thrombosis and embolism Hyperparathyroidism, unspecified

allergies: penicillins / percocet attending: chief complaint: malignant hypertension major surgical or invasive procedure: none history of present illness: 24 year old female with esrd on hd, sle, malignant htn presents with headache and abdominal pain beginning this morning. patient had her hemodialysis day before yesterday. she has had multiple admissions to with hypertensive urgency with symptoms of headache and abdominal pain. has had extensive work-up for abdominal pain including ex-lap on which was negative. patient states that her headache and abdominal pain are similar in characteristics to her previous admission. patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. in the ed, initial vitals were t97, bp253/170, hr100, rr24 100%ra. was initially given 10mg iv labetalol once and then started on drip at 2mg/hour. she also received hydralazine iv 10 mg once and 2 inch nitropaste. she morphine 4mg once for pain and 4mg zofran for nausea. her bp elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. on arrival to the micu her vitals were t 96.4 hr 99 bp 175/120 rr 15 100%ra. patient was comfortable. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vitals: 97.5 122/80 88 18 100%ra. gen: sleeping, easily arousable, appears comfortable. heent: at/nc, l eye prosthetic non-reactive, r pupil reactive, mmm. heart: s1s2 rrr, iii/vi sem heard best at apex, + s3 pulm: cta b/l, no w/r/r. abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior pd site with dry dressing, patient with tenderness to palpation over prior pd cath site, no guarding/rebound ext: no edema, no clubbing, wwp. r femoral hd catheter in place. neuro: following commands, answers appropriately, motor strength, sensation is intact. pertinent results: admission: 02:00am blood wbc-5.8 rbc-3.30* hgb-10.1* hct-30.3* mcv-92 mch-30.7 mchc-33.5 rdw-20.7* plt ct-199 02:00am blood pt-14.2* ptt-32.1 inr(pt)-1.2* 02:00am blood urean-35* creat-5.0* na-138 k-5.5* cl-103 hco3-21* angap-20 02:00am blood alt-16 ast-69* ck(cpk)-89 alkphos-109 totbili-0.4 02:00am blood lipase-73* 02:00am blood ck-mb-notdone ctropnt-0.07* 06:45am blood calcium-8.1* phos-5.1* mg-1.8 03:52pm blood dsdna-negative 03:52pm blood crp-11.5* 03:52pm blood c3-68* c4-19 12:09pm blood type-art po2-158* pco2-42 ph-7.36 caltco2-25 base xs--1 02:08am blood po2-52* pco2-38 ph-7.39 caltco2-24 base xs--1 comment-green top 12:09pm blood lactate-0.9 02:08am blood glucose-68* lactate-1.3 na-140 k-4.8 cl-103 03:00pm blood wbc-4.7 rbc-2.35* hgb-7.1* hct-22.3* mcv-95 mch-30.3 mchc-31.9 rdw-20.6* plt ct-131* 12:55am blood pt-14.7* ptt-66.2* inr(pt)-1.3* 03:52pm blood esr-21* 03:00pm blood glucose-97 urean-42* creat-6.6* na-138 k-4.3 cl-106 hco3-23 angap-13 02:00am blood alt-16 ast-69* ck(cpk)-89 alkphos-109 totbili-0.4 03:00pm blood calcium-8.6 phos-4.5 mg-1.8 04:23pm urine color-straw appear-hazy sp -1.008 04:23pm urine blood-neg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.5 leuks-neg 04:23pm urine rbc-<1 wbc-<1 bacteri-few yeast-none epi-12 transe-<1 micro: blood cx- : no growth urine cx- : no growth tte the left atrium and right atrium are normal in cavity size. a possible secundum type atrial septal defect is seen by color doppler (clip ) there is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. there is no significant resting lvot gradient, but a mild gradient (30mmhg peak) is seen with valsalva manuever. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is a small circumferential pericardial effusion without echocardiographic signs of tamponade. impression: marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible lvot gradient. mild aortic regurgitation. mild pulmonary artery systolic hypertension. possible secundum type atrial septal defect. compared with the prior study (images reviewed) of , a possible secundum type atrial septal defect is now suggested. if clinically indicated, a follow-up study with saline contrast and/or a tee would be better able to characterize the possible atrial septal defect. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. cxr impression: 1. cardiomegaly with findings suggestive of mild pulmonary edema. 2. bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. no evidence of free intraperitoneal air. mrv impression: no appreciable change since the mrv chest exam dated . svc is patent. again seen is occlusion of the right internal jugular and left brachiocephalic veins. right external jugular vein is provides the major venous drainage from the neck. brief hospital course: 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dc'd on and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on . patient's aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patient's pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patient's nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on . the morning of , the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on and signed out ama. 2. angioedema: on the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patient's airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on . she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on . the patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on . the patient also had her pd catheter removed on secondary to chronic abdominal pain. the patient was scheduled to have dialysis on . 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patient's hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. medications on admission: aliskiren 150 mg clonidine 0.3mg / 24 hr patch weekly qwednesday hydralazine 100mg po q8h labetalol 800mg po tid hydromorphone 4mg po q4h prn nifedipine er 90mg po qday prednisone 4mg po qday lorazepam 0.5mg po qhs clonazepam 0.5 mg celexa 20mg po qday gabapentin 300 mg acetaminophen 325 mg q6h prn ergocalciferol (vitamin d2) 50,000 unit po once a month warfarin held on discharge due to supratherap inr discharge medications: as patient signed out ama, no medications were issued. she was told to resume her admission medications, however no instructions were taken by the patient. discharge disposition: home discharge diagnosis: 1) hypertensive urgency 2) abdominal pain 3) end stage renal disease on hemodialysis 4) venous thromboembolism discharge condition: signed out ama discharge instructions: pt signed out ama return to the hospital with any concerning symptoms. be sure to call your doctor's office on to arrange hemodialysis and review your medications and discuss follow-up plan. followup instructions: follow-up with your dr. next week, and call to arrange your hemodialysis. Procedure: Hemodialysis Venous catheterization for renal dialysis Non-invasive mechanical ventilation Removal of peritoneal drainage device Incision of peritoneum Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Long-term (current) use of steroids Dysthymic disorder Unspecified disease of pericardium Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Other antihypertensive agents causing adverse effects in therapeutic use Abdominal pain, other specified site Mechanical complication due to peritoneal dialysis catheter Angioneurotic edema, not elsewhere classified Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation

allergies: penicillins / percocet / morphine attending: chief complaint: headache, hypertensive urgency major surgical or invasive procedure: hemodialysis x 2 history of present illness: 24 year old female with sle, esrd on hd, hx malignant htn, h/o svc syndrome, h/o posterior reversible encephalopathy syndrome (pres) and prior intracerebral hemorrhage, recently admitted with diarrhea, hypertensive urgency. treated at that time with nicardipine drip for a short period and then to her home regimen. yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. diarrhea mild as prior. no fever, chills, no hematemesis or hematochezia. no melena. today reports onset of headache therefore to the ed. in the ed, initial vs were 280/160, 99.4, 105, rr 18. she was given dilaudid 2 mg po x 2. hydral 20 mg x 3 for bp. calcium gluconate 1 gram. insulin 10 units, d 50 amp, sodium bicarbonate, kayexalate for k 6.7 (dialysis dependent tues/thurs/sat) but with report of peaked t waves. renal dialysis fellow was not contact. hct 33.4, wbc 4.6, trop 0.10. admitted for hypertensive urgency to icu. no gtt was started. of note usualy bp 160/100. review of sytems: patient tearful complaining of frontal headache and nausea past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-120's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather physical exam: vitals: bp 240/146, 101, 98.6, general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachycardic, 3/6 sem rusb abdomen: soft, diffusely tender, no rebound or gaurding. ext: cachectic, warm, 2+ dp pulse no clubbing, cyanosis or edema pertinent results: 05:45am glucose-83 urea n-54* creat-7.6* sodium-138 potassium-6.7* chloride-103 total co2-23 anion gap-19 05:45am ck(cpk)-96 05:45am ctropnt-0.10* 05:45am ck-mb-notdone 05:45am wbc-4.6 rbc-3.66* hgb-10.8* hct-33.4* mcv-91 mch-29.6 mchc-32.4 rdw-17.9* 05:45am neuts-65.4 lymphs-25.1 monos-4.8 eos-4.1* basos-0.7 05:45am plt count-128* 05:45am pt-14.2* ptt-36.4* inr(pt)-1.2* 07:14am k+-6.0* 12:17pm k+-5.3 images: cxr: persistent severe cardiomegaly. head ct: normal brain ct. brief hospital course: 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. medications on admission: medications: as per last discharge summary -aliskiren 150 mg tablet -clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday) -clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). -labetalol 200 mg tablet sig 5 tab tid -nifedipine 60 mg tablet sustained release qpm -nifedipine 90 mg tablet sustained release qam -citalopram 20 mg tablet sig daily -hydromorphone 2 mg tablet sig q4 prn -fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). -hydralazine 50 mg tablet sig: two (2) tablet po q8h -hydralazine 50 mg tablet sig: two (2) tablet po bid prn -prednisone 4 mg daily -coumadin 4 mg daily at 4 pm discharge medications: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 5. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 6. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po qpm (once a day (in the evening)). 7. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 8. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 9. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 10. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 11. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 12. hydralazine 100 mg tablet sig: one (1) tablet po twice a day as needed for hypertension. 13. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. discharge disposition: home with service facility: vna discharge diagnosis: primary - hypertensive urgency end-stage renal disease on dialysis secondary - systemic lupus erythematous history of thombosis and superior vena cava syndrome obstructive sleep apnea discharge condition: stable discharge instructions: you were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. it is very important that you take your blood pressure medications reguarly. your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. you underwent two sessions of dialysis during your hospitalization. it is extremely important that you attend dialysis three times weekly as an outpatient. medication changes: you should be taking 3 mg of coumadin daily. you will need to have your inr checked at dialysis. otherwise continue your outpatient medications as prescribed. call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. followup instructions: it is very important that you keep your previously scheduled appointments: you have an appointment with gynecology to evaluate an abnormality recently seen on pap smear. provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 2:00 md Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies Systemic lupus erythematosus Hyperpotassemia Thrombocytopenia, unspecified Anemia of other chronic disease End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Other chronic pain Renal dialysis status Nausea with vomiting Unspecified disease of pericardium Disorders of phosphorus metabolism Long-term (current) use of anticoagulants Other specified peripheral vascular diseases Noncompliance with renal dialysis Personal history of noncompliance with medical treatment, presenting hazards to health Abdominal pain, left lower quadrant Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Diarrhea

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea and hypertensive emergency major surgical or invasive procedure: hemodialysis history of present illness: ms. is a 25 year old female with a history of sle, end stage renal disease on , malignant hypertension, svc syndrome, pres, prior ich and frequent admissions for hypertensive emergency now presenting with dyspnea and cough productive of white sputum x 1-2 days with initial sbp 280s in ed. denies f/c, cp, ha, numbness, weakness, visual changes, n/v, confusion. reports compliance with meds but has noticed that clonidine patches have fallen off last 24-48 hours. her usual crampy abdominal pain at baseline. last bm yesterday normal. pt last dialyzed saturday (day prior to admission). most recently admitted with groin pain hd site, with line infection, hypertension, last admitted to micu for hypertensive emergency and discharged . . in ed, initial vs sbp 280/140s t100.3 hr 110 rr 28 sao2 100%. she recieved hydralazine 40mg iv, was maxed out on nitro drip and sbp 240s. also reportedly had fever to 101, cxr with retrocardiac opacity and received vancomycin 1g iv and levofloxacin 500mg. has 18g piv. past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: home: lives with mother occupation: on disability, previously employed with various temp jobs etoh: denies drugs: denies tobacco: denies family history: no history of autoimmune disease physical exam: general: a&ox3. nad, oriented x3. heent: nc/at; perrla on right, enucleated eye on left; op clear, nonerythematous, mmm. neck: supple, no lad, full rom. lungs: ctab, with decreased bs right base, scant crackles. no egophony, slight dullness to percussion bases. cv: regular, tachy, prominent heart sounds, s1, s2 +s3, no rubs appreciated. abdomen: soft, minimally distended, diffuse mild tenderness to deep palpation, no rebound, guarding. ext: wwp, 2+ dp/pt pluses, no clubbing, cyanosis or edema. neuro: aaox3. cn 2-12 intact. 5./5 pertinent results: 02:15am blood wbc-6.1# rbc-2.66* hgb-7.4* hct-23.8* mcv-90 mch-27.9 mchc-31.1 rdw-19.1* plt ct-169# 07:52am blood wbc-4.9 rbc-2.45* hgb-7.0* hct-22.0* mcv-90 mch-28.7 mchc-32.0 rdw-20.1* plt ct-150 11:44am blood wbc-3.8* rbc-2.40* hgb-6.9* hct-21.7* mcv-90 mch-28.8 mchc-32.0 rdw-20.0* plt ct-154 02:15am blood neuts-82.4* bands-0 lymphs-12.6* monos-3.2 eos-1.6 baso-0.3 07:52am blood neuts-80.6* lymphs-13.6* monos-3.9 eos-1.7 baso-0.3 11:44am blood neuts-81.3* lymphs-11.5* monos-4.4 eos-2.4 baso-0.4 02:15am blood pt-14.1* ptt-34.0 inr(pt)-1.2* 07:52am blood pt-14.2* ptt-36.1* inr(pt)-1.2* 11:44am blood pt-13.7* ptt-34.7 inr(pt)-1.2* 02:15am blood glucose-80 urean-35* creat-5.8* na-137 k-4.8 cl-100 hco3-23 angap-19 07:52am blood glucose-87 urean-37* creat-6.2* na-137 k-4.0 cl-100 hco3-24 angap-17 11:44am blood glucose-131* urean-46* creat-7.1* na-136 k-5.5* cl-102 hco3-21* angap-19 07:52am blood calcium-8.5 phos-5.6* mg-1.7 11:44am blood calcium-8.0* phos-6.7* mg-1.7 07:52am blood vanco-4.9* 11:44am blood vanco-5.1* brief hospital course: 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome was admitted to the micu with dyspnea and hypertensive emergency with sbp 280s. she has frequent admissions for hypertensive emergency. see below for specific hospital course on each problem. . # htn urgency/emergency: patient was admitted directly to the icu with shortness of breath and hypertension. one of her clonidine patches had fallen off and it was likely that this could have caused some of the elevation in bp. she was started on a nitro gtt in the ed, but in the micu she was placed on a labetolol drip. lactate on admission was 0.9 and there was no evidence of new end organ damage. she was restarted on all of her home meds (except her qhs nifedipine) and transferred to the floor the next day with sbp in the 160s. during her admission renal was follwing and recommended that she be given a home blood pressure cuff. for sbp > 200, she will have hydralazine 100mg po. she will re-check in 30 mins with instructions to repeat up to three times before seeking medical attention in the emergency room. she was also given dilaudid prn for her pain, which is a continuation of her outpatient pain regimen. she did not require hydralazine iv prn on the floor. prior to discharge her evening dose of nifedipine was restarted and she recieved hemodialysis. she remained normotensive during the rest of her admission and was discharged with stable vital signs. # dyspnea: patient was admitted with dyspnea, which improved with resolution of her hypertension. she required supplementary oxygen intermitantly during the admission but was saturation >92 % on ra at discharge. there was concern for infection in the ed and was given as above, likely secondary to pulmonary edema +/- infection given fever, cough and infiltrate. she was started on vancomycin in the ed, but that was discontinued and she was not put on additional antibiotics. she remaine afebrile throughout the rest of her stay. blood cultures were negative at time of discharge. . # fever: concerning for pna given complaints of dyspnea and cough and infiltrate on cxr. other possible etiologies onclude line infection given indwelling femoral hd line, however, the femoral line had been exchanged during previous admission. see above course in dyspnea section. . # chronic abdominal pain - abdominal pain was well controlled throughout the admission with po dilaudid. she was moving her bowels throughout the stay. lidocaine patch was also continued.ontinue neurontin per hd. . # esrd on hd - hd satuth. sevelamer was continued during the hospitalization. she recieved hemodialysis on thursday, prior to discharge. . # anemia - pt has chronic anemia, baseline pancytopenia, likely ckd and sle, currently at/slightly below baseline, though has h/o gib. hct 23 here, most recently 22 on discharge . we continued epo per renal and was administered 2 units prbc's prior to hemodialysis. . # h/o gastric ulcer - continue ppi. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - now off anticoagulation secondary to noncompliance with coumadin . # seizure disorder - continue keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continue celexa. . # fen: - low salt diet. . # prophylaxis: heparin sc, ppi. # access: pivx2. # code: full # communication: patient medications on admission: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 3. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 4. aliskiren 150 mg tablet sig: one (1) tablet po bid 5. citalopram 20 mg tablet sig: one (1) tablet po daily 6. prednisone 1 mg tablet sig: four (4) tablet po daily 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 9. sevelamer hcl 400 mg tablet sig: one tablet po tid 10. gabapentin 100 mg capsule sig: one (1) capsule po qhd 11. labetalol 200 mg tablet sig: five (5) tablet po tid 12. hydralazine 50 mg tablet sig: two (2) tablet po q8h 13. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 14. levetiracetam 500 mg tablet sig: two (2) tablet po days (tu,th,sa). 15. senna 8.6 mg tablet sig: one (1) tablet po bid 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid 17. alprazolam 0.25 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 18. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever. 19. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po hs (at bedtime). discharge medications: 1. blood pressure machine for home blood pressure monitoring three times daily 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 3. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 4. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). 5. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po qhs (once a day (at bedtime)). 6. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 7. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 8. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for pain. 10. sevelamer hcl 400 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 11. gabapentin 100 mg capsule sig: one (1) capsule po qhd (each hemodialysis). 12. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 13. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 14. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 15. levetiracetam 500 mg tablet sig: two (2) tablet po qt, th sat (). 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 17. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 18. alprazolam 0.25 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 19. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain. 20. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 21. hydralazine 100 mg tablet sig: one (1) tablet po once as needed for systolic blood pressure > 200: take one tablet if systolic blood pressure > 200. re-check blood pressure in 30 mins. repeat up to 3 times. . disp:*30 tablet(s)* refills:*3* discharge disposition: home discharge diagnosis: primary diagnosis: 1. hypertensive emergency 2. dyspnea 3. end-stage renal disease (renal failure) secondary diagnosis: - systemic lupus erythematosus - end stage renal disease on - malignant hypertension - thrombocytopenia - thrombotic events with negative hypercoagulability work-up - hocm - anemia - history of left eye enucleation for fungal infection - history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion - history of coag negative staph bacteremia and hd line infection - and - thrombotic microangiopathy - obstructive sleep apnea on cpap - left abdominal wall hematoma - mssa bacteremia associated with hd line -. discharge condition: stable, vitals stable, asymptommatic discharge instructions: you were admitted to the hospital because of high blood pressure. you were admitted to the intensive care unit for iv medications to stabilize your blood pressure while your home medications were restarted. you the were transferred to the floor for continued management. you recieved hemodialysis while in the hospital. changes to medication/management: you have been given a blood pressure cuff to take your blood presure at home. if your blood pressure is greater than 200, take hydralazine 100 mg by mouth. recheck blood pressure in 30 minutes. repeat up to 3 times. followup instructions: provider: ,schedule hemodialysis unit date/time: 12:00 provider: , md phone: date/time: 8:30 provider: , md phone: date/time: 2:45 Procedure: Hemodialysis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease Anemia of other chronic disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Esophageal reflux Depressive disorder, not elsewhere classified Compression of vein Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Other ascites Other specified peripheral vascular diseases Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Noncompliance with renal dialysis Other acute pain Other disorders of bone and cartilage Mild dysplasia of cervix

allergies: penicillins / percocet attending: chief complaint: abdominal pain, shortness of breath, chest discomfort major surgical or invasive procedure: hd and history of present illness: the pt is a 24 y.o. f with esrd on hd, sle, malignant htn, history of svc syndrome, pres, recently discharged on after admission for abdominal pain, mssa bacteremia, paroxysmal hypertension and esrd line, presents with central crampy abdominal pain, chest discomfort, sob, htn to 230s. pt states that at around 11pm last night developed shortness of breath that felt as though someone was sitting on her chest. she states that she feels as though she cannot catch her breath. pt also describes chest discomfort which she states that she has not had before. she also has her chronic abdominal pain. she states that it comes and goes and is unchanged from her baseline. . in the ed, initial vitals: 98.9 4 100%ra. sbp as high as 241 recorded. she received labetalol 20 iv x 2 without improvement. she was given hydral 20 iv without improvement, so she was placed on a labetalol gtt @ 4 mg/min with improvement of sbp 220. she was given iv zofran, iv dilaudid, hydralazine 50mg po, labetolol 200mg po, labetolol 100mg iv x 3, levofloxacin 750mg iv, ceftriaxone 1g iv, vancomycin 1g iv, weregiven for question of infiltrate on cxr prior to ct. nitroprusside gtt added and .5 mg/kg, pressure initially improved to 180s. tried to wean off the nitroprusside and pressure went back up to 208. chest pain has resolved, still sob with abdominal pain. pan-scan w/o contrast showed interval worsening of chronic pulmonary edema. pleural and pericardial effusions stable. ativan seemed to help symptoms. one blood culture was sent in the ed. per report, ekg showed lvh, st depression in v6. trop a little more elevated than normal but cks flat. was discussed with renal and it was not felt that htn is a volume issue so no need for emergent . . upon arrival to the floor, her sbp was 203. she continued to complain of abdominal pain and shortness of breath though her chest discomfort was improved. respiratory rate up to 30. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, , getting vanc with hd. . pshx: 1. placement of multiple catheters including . 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. physical exam: pe: 98.6 128/98 82 20 100% on 2l nc vitals gen- nad heent- mmm cv- regular, nl s1, s2, + s3. lungs- cta bilat abd- + bs, soft, nd. tender only to deep palpation ext- 2+ dp bilat. trace pedal edema neuro- aa+ox3. pertinent results: admission labs: 02:20am wbc-5.0 rbc-2.61* hgb-7.7* hct-23.5* mcv-90 mch-29.4 mchc-32.6 rdw-19.3* 02:20am neuts-76.1* bands-0 lymphs-17.9* monos-4.5 eos-1.1 basos-0.5 02:20am plt smr-normal plt count-168 02:20am pt-21.8* ptt-34.7 inr(pt)-2.1* 02:20am ctropnt-0.12* 02:20am alt(sgpt)-46* ast(sgot)-94* ck(cpk)-76 alk phos-173* tot bili-0.4 02:20am glucose-74 urea n-47* creat-7.3* sodium-140 potassium-5.8* chloride-109* total co2-19* anion gap-18 04:00am urine blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 08:00am urine blood-sm nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 12:58pm ck-mb-notdone ctropnt-0.12* . ct c/a/p - - 1. interval worsening of pulmonary edema, now moderate to severe. unchanged moderate pericardial effusion. periportal edema persists. 2. small right pleural effusion, unchanged. 3. small amount of ascites. 4. no evidence of bowel obstruction. contrast material reaches the rectum. 5. redemonstration of extensive mediastinal and hilar lymphadenopathy. the study and the report were reviewed by the staff radiologist. discharge labs: 12:00pm blood wbc-3.7* rbc-2.87* hgb-8.7* hct-26.1* mcv-91 mch-30.3 mchc-33.3 rdw-19.4* plt ct-130* 12:00pm blood plt ct-130* 12:00pm blood pt-28.8* ptt-58.6* inr(pt)-2.9* 12:00pm blood glucose-77 urean-31* creat-6.0*# na-137 k-4.8 cl-104 hco3-24 angap-14 12:00pm blood calcium-8.4 phos-5.7* mg-1.9 brief hospital course: this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. . # hypertension: the patient had very high blood pressures on presentation (200's/100's) that nevertheless are within levels she's certainly reached during previous admissions. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure, she was started on a labetalol and nitroprusside drip and admitted to the icu. this was then changed to a nicardipine drip. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine and hydralazine on and transferred to the medicine floor. the next day, her bp remained within goal of 120's/80's. she was dialyzed and sent home. . tachypnea/shortness of breath - on admission, likely due to pulmonary edema, however, cannot rule out cardiac etiology in setting of small enzyme leak. has osa. ce's were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on . # abdominal pain: consistent with patient's baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from . on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs . # esrd: renal followed. hd given and . # coagulopathy: patient on lifetime anticoagulation for hx of multiple thrombotic events. continued coumadin . # hocm: evidence of myocardial hypertrophy on echo. currently not symptomatic. continued labetalol. medications on admission: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4pm. 5. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 6. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 7. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. aliskiren 150 mg tablet sig: one (1) tablet po bid 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for abdominal pain. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 12. citalopram 20 mg tablet sig: one (1) tablet po daily 13. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po three times a day as needed for nausea for 4 days. 14. vancomycin at hd discharge medications: 1. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 6. aliskiren 150 mg tablet sig: one (1) tablet po bid () as needed for severe htn. 7. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed. 10. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). 11. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). discharge disposition: home discharge diagnosis: sle esrd on hd malignant hypertension chronic abdominal pain discharge condition: good. tolerating pos. bp 110's/80's discharge instructions: you were admitted with hypertension and abdominal pain. while you were here, we treated your hypertension with medications and dialyzed you. your hypertension is resolved at the time of discharge. your belly pain partially resolved and at time of discharge is comparable to your chronic belly pain. . please follow up as below. . please continue your medications as prescribed. . please call your doctor or return to the ed if you have any headaches, lightheadedness, changes in vision, vomitting, blood in your stool, loss of consciousness or any other concerning symptoms. followup instructions: please follow up with your primary care doctor within 1 week. you need to schedule an appointment with either your pcp or ob/gyn for a pap smear as soon as possible. you should also get a repeat urinalysis and urine culture if you have any uti symptoms. . please continue sessions as directed by the nephrology team- your next session should be on tuesday. Procedure: Hemodialysis Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Acidosis Systemic lupus erythematosus Hyperpotassemia Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Urinary tract infection, site not specified Unspecified disease of pericardium Bacteremia Compression of vein Long-term (current) use of anticoagulants Other chest pain Personal history of venous thrombosis and embolism Noncompliance with renal dialysis Infection and inflammatory reaction due to other vascular device, implant, and graft Primary hypercoagulable state Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site

allergies: penicillins / percocet / morphine attending: chief complaint: altered mental status, solmolence, and relative hypotension major surgical or invasive procedure: none, hd per schedule on the day of discharge, transfused 1u prbc history of present illness: ms. is a 24 year old woman with esrd on hd, sle, hx of malignant htn admitted with change in mental status. patient missed hd on and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. ems was called, 1 mg of narcan was administered with slight improvement in mental status. on arrival to the ed her vitals were 112/64 62 16 99ra she was noted to be hyperkalemic in the absence of ekg changes and was given calcium, d5, 10u regular insulin, 30 mg po kayxalate and repeat k was 5.4. abg: 7.29/38/199. repeat glucose was 41 and 1amp d50 was given. she was sent to the icu for monitoring. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 pshx: 1. placement of multiple catheters including . 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: hr: 80 (79 - 80) bpm bp: 127/59(76) {127/59(76) - 139/64(82)} mmhg rr: 34 (21 - 34) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) physical examination gen: sleeping comfortably, easily awoken by verbal stimuli heent: l eye prosthetic non-reactive, r pupil reactive, mmm heart: s1s2 rrr, iii/vi sem throughout the precordium pulm: cta b/l abd: nabs, midline scar well-healed, soft, mild l ttp, no rebound/guarding ext: no edema, no clubbing, wwp. r femoral hd in place neuro: following commands, answers appropriately, motor strength, sensation is intact pertinent results: 01:50pm pt-14.9* ptt-36.8* inr(pt)-1.3* 01:50pm hypochrom-2+ anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-occasional ovalocyt-1+ schistocy-occasional stippled-occasional teardrop-occasional 01:50pm wbc-5.0 rbc-2.21* hgb-6.4* hct-20.7* mcv-94 mch-29.1 mchc-31.1 rdw-19.6* 10:30pm glucose-87 urea n-66* creat-8.4* sodium-142 potassium-5.9* chloride-110* total co2-16* anion gap-22* history: altered mental status. evaluate underlying for pneumonia. upright portable chest: comparison is made to and , exams. study is slightly limited by patient motion. in the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. there is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left cp angle, likely related to small effusion. exam is otherwise unchanged from prior with persistent cardiomegaly. a catheter is seen projecting over the abdomen, partially imaged. impression: slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. brief hospital course: 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patient's narcotics were held, pressors returned to and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. medications on admission: prednisone 4mg qd citalopram 20 mg daily gabapentin 300 mg warfarin 4mg daily pantoprazole 40 mg qd clonidine 0.1 mg/24 qwed clonidine 0.3 mg/24 hr qwed labetalol 900 mg tid nifedipine 90 mg qd aliskiren 150 mg hydralazine 100 mg q8h morphine 7.5 mg q8h prn pain discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 3. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. labetalol 100 mg tablet sig: three (3) tablet po tid (3 times a day). 6. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 7. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 8. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 9. sevelamer hcl 400 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). discharge disposition: home discharge diagnosis: primary: narcotic overdose relative hypotension anemia secondary: esrd on hd sle malignant hypertension discharge condition: stable - received hd prior to discharge discharge instructions: you were admitted for altered mental status after missing hemodialysis. it was likely from the dilaudid you took as well as missing your scheduled . you were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. narcotic medications were held and hypotension and altered mental status resolved. please use narcotic medications with caution. you are recommended to use morphine for pain control rather than dilaudid. no medication changes were made. please return to the ed if you have any altered mental status or miss or have symptoms such as vision changes or headache from your history of malignant hypertension. followup instructions: provider: , md phone: date/time: 3:00 hd as previously scheduled Procedure: Hemodialysis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Acidosis Systemic lupus erythematosus Hyperpotassemia Other iatrogenic hypotension Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Accidental poisoning by other opiates and related narcotics Dysthymic disorder Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Noncompliance with renal dialysis Poisoning by other opiates and related narcotics Thrombotic microangiopathy Altered mental status Nontraumatic hematoma of soft tissue

allergies: penicillins / percocet attending: chief complaint: headache, abdominal pain major surgical or invasive procedure: hemodialysis history of present illness: 24yo f w/pmhx of esrd on hd, sle, malignant htn presents with headache and abdominal pain beginning this morning, awakening her from sleep. had been previously discharged from yesterday after being admitted for hypertension and abdominal pain. has had extensive work-up for abdominal pain including ex-lap on which was negative. upon discharge yesterday she states her abdominal pain had subsided. she had hd yesterday without complications. she awoke at 6am with a headache and crampy, stabbing abdominal pain. took 2mg po dilaudid without relief and came to ed. no nausea/vomiting, no changes in vision, no fevers, chills, night sweats. no chest pain, sob, diarrhea. in the ed, initial vitals were t98.7, bp260/130, hr70, rr16. was initially given 10mg iv labetalol x 2, 4mg zofran for nausea. no improvement in bp and started on labetolol gtt. got 1mg iv dilaudid for pain. currently, patient continues to complain of headache and abdominal pain, both . no vision changes, chest pain or shortness of breath. has been feeling increased anxiety recently and saw psychiatrist, was put on celexa. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: t98.2, bp176/135, hr94, rr 22, 100% ra gen: well-appearing african-american woman, lying comfortably heent: anicteric, l eye prosthetic non-reactive, r pupil reactive, mmm, neck supple with submanibular lad cv: rrr, ii/vi sem best heard at apex pulm: cta b/l abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. pd catheter in llq without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. ext: no edema, no clubbing, 2+ peripheral pulses dp and radial. r femoral hd in place without erythema, purulance neuro: a&o x 3, cn intact ii-xii, motor strength in upper and lower extremities pertinent results: admission labs: cbc: 05:21am blood wbc-3.5* rbc-3.07* hgb-9.3* hct-27.5* mcv-90 mch-30.1 mchc-33.6 rdw-17.6* plt ct-180 chem 10: 01:16pm blood glucose-87 urean-17 creat-4.0* na-136 k-5.2* cl-106 hco3-23 angap-12 09:20pm blood calcium-7.6* phos-3.8 mg-1.8 coags: 01:16pm blood pt-23.9* ptt-40.2* inr(pt)-2.3* studies: 1)peritoneal fluid (): negative for malignant cells. reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)bilat up ext veins us (): no evidence of deep vein thrombosis of the right or left upper extremity. 3) mri/mra (): findings: examination is somewhat limited by patient motion. t2/flair sequences are unremarkable with interval resolve of previously noted posterior abnormalities. the major vessels appear patent proximally. there are stable areas of low signal in the left frontal and right occipetal/temporal lobes. impression: 1. interval resolution of previously noted posterior white matter abnormalities. 2. stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. very limited mra as above. brief hospital course: 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. course: the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her course: 1. hypertensive urgency: pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. she may not have been taking her medications secondary to pain. negative serum tox. on the floor, we continued hemodialysis tu, th, sat. she was initially continued on po labetolol 400mg tid, hydralazine 100mg po q8h, nifedipine 90mg po qday and clonidine; she received hydralazine 10mg iv for goal bp < 180/100. renal team followed patient during this hospitalization. per renal team recs, labetalol was increased to 800mg tid due to poor blood pressure control. pt discharged on clonidine 0.3mg patch, hydralazine 100mg three times a day, aliskiren 150mg twice a day, nifedipine 90mg daily and lobatalol 800mg tid. this regimen worked well. 2. abdominal pain: extensive prior workup unrevealing. pt had recent ct scan during prior admission which did not show source of abdominal pain. on admission, lfts were normal except for slightly low albumin, lipase was slightly elevated and kub was negative for free air or evidence of sbo. peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. negative gram stain or peritoneal fluid cultures, excluding sbp as a cause of the abdominal pain. pd catheter was not removed. pt was continued on po dilaudid 1-2mg q6h and pain resolved. she denied n/v/diarrhea or constipation. 3. esrd: pt on hemodialysis, on t/th/sat schedule. renal following patient closely throughout this hospitalization. lytes were checked frequently and kayexalate given prn. 4. hx of svc/brachiocephalic dvt: pt was initially subtherapeutic on coumadin. unclear if she had not been taking coumadin although patient reported that she has been taking all home meds. we started heparin gtt to bridge to coumadin. once therapeutic, continued coumadin 5mg po qday. 5. anxiety: likely contributing to medical problems and could have very well been the etiology of this admission. although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po qday, ativan 1mg po q8hours prn and psychiatry was re-consulted. per psych recs, started standing clonazepam. pt refused psych vna. outpatient pcp followup recommended. 6. headache nos: pt complained of r-sided ha for several weeks, radiating to r jaw where patient had previous tooth extraction. right upper extremity ultrasound was negative for dvt. she did not have any focal neuro findings, no visual deficits. she was initially treated with tylenol prn q6h; pt requested iv dilaudid for ha, but use of this medication by iv route was limited by team. it was felt by the pain service that her ha did not fit migraine, tension type ha or rebound ha. they recommended increasing dilaudid to 4-6mg q6h prn, continuing tylenol and starting neurontin 300mg qhs which was slowly titrated to 300mg for better control. per pain recs, a neurology consult was also obtained during this admission. mri/mra showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited mra as above. per pain recs, dilaudid was further increased to 4mg q4h for better control of her ha. neurology recommended outpt f/u and pt scheduled with clinic with dr. on . 7. anemia: likely related to esrd. no evidence of acute bleeding. hct remained stable during this hospitalization. 8. sle: no acute issues. continued prednisone 4mg po qday 9. fen: tolerated regular diet, repleted lytes prn 9. prophylaxis: heparin gtt, then coumadin, bowel regigmen medications on admission: (from prior discharge summary) bisacodyl 10mg po qday prn prednisone 4mg po qday aliskiren 150mg po bid clonidine 0.3mg / 24 hr patch weekly qmonday labetalol 400mg po tid warfarin 4mg po qday nifedipine 90mg po qday hydralazine 100mg po q8h hydromorphone 2-4mg po q4h prn lorazepam 1mg po q8h celexa 20mg po qday prochlorperazine 10mg po q6h colace 100mg po bid hydralazine 25mg po q30min prn for htn discharge medications: 1. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every ). 3. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po qmonth (). 4. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 5. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. warfarin 2 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). :*100 tablet(s)* refills:*2* 8. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). :*90 capsule(s)* refills:*2* 9. hydromorphone 4 mg tablet sig: one (1) tablet po every four (4) hours as needed for headache. :*84 tablet(s)* refills:*0* 10. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). :*60 tablet(s)* refills:*0* 11. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). :*60 capsule(s)* refills:*2* 13. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. :*60 tablet(s)* refills:*0* 14. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 15. labetalol 200 mg tablet sig: four (4) tablet po every eight (8) hours. :*360 tablet(s)* refills:*2* 16. bisacodyl 5 mg tablet sig: one (1) tablet po once a day as needed for constipation. :*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. hypertensive emergency 2. sle 3. headache, nos 4. abdominal pain discharge condition: bp better controlled. headache managed on oral meds discharge instructions: you were admitted with abdominal pain, high blood pressure, and headache. your abdominal pain resolved - no serious cause of this pain was found. your blood pressure medications were continued, and with an increased in one medication, the labetalol. your blood pressure improved. you should continue the clonidine 0.3mg patch changed on , hydralazine 100mg three times a day, aliskiren 150mg twice a day, and nifedipine 90mg daily. the dose of labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. please take all medications as listed below. for your headache, you had an mri and mra of the head, which did not show a new or serious abnormality. you were seen by the neurology and pain services. you should follow up at clinic with dr. on at 6:30 pm (in the evening). your pain was managed by oral dilaudid, 4mg. you should take this medication every 4 hours as needed. you were also started on gabapentin (also called neurontin) for the headache. the dose was slowly increased to twice a day. you may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). finally, you will likely need medications for constipation while you take dilaudid. take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. it is really important that you have a primary care doctor. you are scheduled with dr. (see below) next tuesday. you will need your inr checked since you are on coumadin. call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. followup instructions: please make sure you attend the following doctor appointments: 1) dr. (nephrologist) on tuesday, at 10am. phone number . 2) dr. , at , center, . phone:. date/time: 3:20 3) neurology: dr. . he is located on the of the building. phone: date/time: 6:30 pm md Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Renal dialysis status Anxiety state, unspecified Long-term (current) use of anticoagulants Other chest pain Personal history of venous thrombosis and embolism Other ascites Acquired absence of organ, eye Headache

allergies: penicillins attending: chief complaint: headache major surgical or invasive procedure: hemodialysis history of present illness: ms. is a 22 year old female with sle, lupus nephritis, esrd on hd, malignant htn, h/o ttp, and hocm who presents with ha and hypertensive urgency. awoke this a.m. with 8/10 left sided frontal ha - wasn't sure if it was d/t flare of uveitis that had started on monday or d/t htn. decided to skip hd and come to ed for evaluation. no vision changes, numbness, weakness, change in gait, chest pain, sob. + diarrhea x 1 day. . in ed patient was 217/140 but elevated to 254/152 --> received labetolol iv 30 mg x 1 and mso4 4mg and pressures dropped to sbps 208 and ha improved. repeat labetolol with 50 mg x 1 and repeated dose of morphine dropped pressures to 193/134 --> labetolol gtt started, asa given, and ha resolved. head ct negative for intracranial bleed and cxr unremarkable. . ros: cold for past week, no fevers, chills, cp, sob, n/v, + diarrhea. . upon arrival to the floor, patient's bp was 191/126 - labetolol gtt was not started. no sxs, no ha. she states that she is compliant with all her meds and her mother cooks with no salt and she has been adherent to diet. past medical history: 1. lupus - . diagnosed after she began to have swolen fingers, a rash and painful joints. 2. esrd secodary to sle - . was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in (t, th, sat). awaiting living donor transplant from mother. 3. htn - . normal bps run 180's/120's. has had 1 hypertensive crisis that precipitated seizures in the past. 4. uveitis secondary to sle - 5. hocm - per echo in 6. vaginal bleeding 7. mulitple episodes of dialysis reactions 8. anemia 9. coag neg. staph bacteremia and hd line infection - 10. h/o ue clot, was on coumadin, but no longer social history: lives in with mother and 16 year old brother. graduated school and then got sick so currently is not working or attending school. denies any t/e/d. family history: -no history of sle. -grandfather has htn. -distant history of dm. -no history of clotting disorders -no other history of other autoimmune diseases physical exam: vitals: 98.0, 173/51, 86, 15, 100% ra heent: l eye injected w/periorbital edema, r eye reactive w/ eomi, anicteric sclera; mmm; op clear neck: supple, no lad, no thyromegaly cardiac: rrr, nl s1 and s2, + s4, iii/vi systolic ejection murmur @ lusb radiating to apex and axilla, intensifies w/ valsalva; no rub lungs: ctab, no wheezes, rhonchi, crackles abd: soft, ntnd, nabs, no hsm, no rebound or guarding gu: no cvat ext: warm, 2+ dp pulses, no c/c/e; l femoral dialysis catheter neuro: aox3; cn ii-xii intact; strength/sensation grossly intact pertinent results: ua: mod bld, 100 protein (present on prior uas) . radiology: cxr: no acute cp abnormality . ekg: nsr, nml axis, nml intervals, borderline lae, lvh, j point elevation in v2,v3, twi i, avl, v5, v6. no change when compared to prior on . . ct head: no intracranial hemorrhage. brief hospital course: a/p: patient is a 22 year old female with sle, lupus nephritis, esrd on hd who presents with hypertensive urgency. . # hypertensive urgency - unclear precipitant. possibly secondary to pain from worsening uveitis. compliant with meds. denies illicits and tox screen negative. patient was started on labetolol drip in ed with good bp response and was subsequently transitioned to po anti-hypertensives in icu with maintenance of stable sbps in 150s-170s (baseline 170s-190s). per nephrologist's recommendations, home lisinopril was increased to 40 mg po bid from 40 mg po qd for better baseline bp control. no clinical evidence of end organ damage (ua difficult ro interpret in setting of crf). ce's x 1 negative. . # headache - no evidence by ct for intracranial bleed. headaches were well controlled with morphine sulfate and had resolved by time of discharge. . # uveitis - followed by outpatient optho specialist. optho not consulted per patient's request. . # esrd - secondary to lupus nephritis. on transplant list. patient received hemodialysis in house with 500 ml ultrafiltrate without complications. at dry weight of 45 kg per patient. began sevalamer 800 tid with meals. given difficulty in interpreting renin and aldosterone levels in acutely ill patients, these were not drawn and will need to be drawn at outpatient follow up. medications on admission: lisinopril 40 mg po qd labetalol 600 po tid valsartan 320 mg po qd clonidine 0.3 mg transdermal qw prednisone 40 mg po qd atropine 1 % prednisolone acetate 1 % q1h moxifloxacin eye drops qid lorazepam 1 mg po q4-6h prn discharge medications: 1. labetalol 200 mg tablet sig: three (3) tablet po tid (3 times a day). tablet(s) 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qthur (every thursday). 3. atropine 1 % drops sig: one (1) drop ophthalmic (2 times a day). 4. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 5. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 6. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic q1h (every hour). 7. lisinopril 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 8. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 9. prednisone 20 mg tablet sig: two (2) tablet po once a day. 10. blood pressure kit kit sig: one (1) kit miscellaneous once a day. disp:*1 kit* refills:*0* discharge disposition: home discharge diagnosis: hypertensive urgency discharge condition: good discharge instructions: please take all of your blood pressure medications as prescribed. . you should adhere to a low-salt diet, as increased levels of sodium can drive your blood pressure up. . you are being discharged with a prescription for a home blood pressure monitor which you can use to take daily measurements. you should call your primary care physician for systolic blood pressures greater than 180, or if you experience headaches, nausea, vomiting, chest pain, shortness of breath, or any other concerning symptoms. followup instructions: please resume hemodialysis according to your regular schedule. . you are scheduled to see dr. in the division of nephrology on wednesday, at 9:30 am. please call if you need to reschedule. . you are scheduled to follow-up with your primary care physician, . , on tuesday, at 3:30 pm. please call if you need to reschedule. . you have been referred to see dr. in the division of hematology for further evaluation of your anemia. this appointment is scheduled for at 3 p.m. his office is located on the of the building on the . please call dr. administrative assistant, , at if you need to confirm or reschedule. Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Unspecified iridocyclitis Awaiting organ transplant status

allergies: penicillins / percocet attending: chief complaint: hip pain major surgical or invasive procedure: none history of present illness: 24yo woman with hx sle, ckd(not currently on hd or pd), labile htn here with right leg pain and htn urgency. patient was recently d/ced on following admission for the same complaints. . patient took her hydralazine dose on am of admission. bp at presentation to the er was 250/140 (the patient reportedly has baseline sbps in 130-170s) she was given 900 labetolol and 50 hydralazine in the ed. bp following this was 175/124. her ekg was unchanged. k was 5.7. . patient also complaining of right hip pain. patient was d/ced on with oral dilaudid for hip/leg pain. she took this only for one day due to severe itching. denies any parasthesias/weakness. her rle/hip pain has been extensively worked up with negative lenis, lumbar spine mri and hip plain films in the past. she was given 4mg iv morphine in the er. . on admission to the floor, leg/hip pain somwhat improved with morphine.she denies any headache, vision changes, double vision, chest pain or sob. feels warm but no chills. past medical history: systemic lupus erythematosus. diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias. previous treatment with cytoxan, cellcept; currently on prednisone. complicated by uveitis () and esrd (). - ckd/esrd. diagosed . initiated dialysis . pd catheter placement . pt reluctant to start pd. - malignant hypertension. baseline bps 180's - 120's. history of hypertensive crisis with seizures. history of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - thrombocytopenia. ttp (got plasmapheresisis) versus malignant htn. - thrombotic events. svc thrombosis (); related to a catheter. negative lupus anticoagulant (, , 9/). negative anticardiolipin antibodies igg and igm x4 (-). negative beta-2 glycoprotein antibody (, 8/). - hocm: last noted on echo . - anemia. - history of left eye enucleation for fungal infection. - history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion. - history of coag negative staph bacteremia and hd line infection - and social history: single. recently moved into her own apartment. on disability. denies etoh, tobacco or recreational drug use. family history: negative for autoimmune diseases, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: vs: t 97.3 hr 81 bp 135/91 rr 16 100%ra gen:nad, happy, pleasant female heent:nc/at, l eye prosthesis, r perrl, eomi, mmm, facial swelling, l side>r, scerla anicteric neck: supple, no jvd, no lad, scars from prior cvl and hd lines cv:s1s2+, 2/6 sem lusb, loud p2, rrr, no ectopy pulm: cta b/l, good inspiratory effort abd: +bs, soft, nontender, slightly distended and resonant to percussion, pd catheter in place in left abdomen ext: no c/c/e, 2+dp b/l, l foream swollen>r, r hip is mobile without pain elicited on passive or active movement neuro: aaox3, nonfocal exam, cn 2-12 intact, moves all 4 extremities psych: mood/affect appropriate pertinent results: mri right hip (): there is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. on t1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. no sclerosis is seen on the corresponding plain films. there is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. there is no soft tissue abnormality, no muscular edema, and no fluid collections. impression: 1. small right hip joint effusion. 2. no bone marrow edema in the proximal femurs or the pelvis. 3. nonspecific small focus of low signal on t1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. tte (): the left atrium is moderately dilated. there is severe symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef 80%). a mild (18 mmhg) mid-cavitary gradient is identified. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. mild (1+) aortic regurgitation is seen. there is no systolic anterior motion of the mitral valve leaflets. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a small pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. impression: severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. mild aortic regurgitation. moderate pulmonary hypertension. findings consistent with hyperrtophic cardiomyopathy. compared with the prior study (images reviewed) of , pulmonary hypertension has developed (also present on the study from ). pericardial effusion is also new. v/q scan (): ventilation images obtained with tc-m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. chest x-ray shows cardiomgealy and left basilar atelectasis. impression: improved v/q scan from with no findings to suggest acute pulmonary embolism. b/l upper ext u/s (): grayscale and doppler son of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. there is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. flow is seen in the region, indicating that the thrombus is nonocclusive. elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. impression: 1. focal nonocclusive thrombus in the left subclavian vein. 2. otherwise, patent upper extremity veins as described. 02:15pm potassium-5.1 02:15pm hct-21.2* 08:45am potassium-5.7* 07:30am glucose-88 urea n-54* creat-8.6* sodium-136 potassium-5.8* chloride-108 total co2-15* anion gap-19 07:30am estgfr-using this 07:30am calcium-7.3* phosphate-5.3* magnesium-1.6 07:30am wbc-5.2 rbc-2.32* hgb-6.5* hct-20.1* mcv-87 mch-28.1 mchc-32.4 rdw-18.4* 07:30am neuts-78.0* lymphs-14.7* monos-3.9 eos-3.2 basos-0.3 07:30am plt count-107* 07:30am pt-20.8* ptt-43.3* inr(pt)-2.0* . cxr: there is no significant change when compared to the recent previous examination. the previously described left retrocardiac opacity is unchanged in appearance. cardiomegaly is also unchanged. the mediastinal contour, bony thorax and pulmonary vasculature are normal. impression: no significant change compared to study done roughly 7 hours prior. brief hospital course: 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on , given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on , the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patient's bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patient's pain is currently absent. . fyi **** per dr. --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. after discharge with either or .**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of . . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . floor course: fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral , nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose ). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother , contact. access: 2 pivs medications on admission: nifedipine 60 mg po qhs labetalol 900 mg po tid hydralazine 50 mg po tid clonidine 0.3 mg/hr patch qwed vitamin d once weekly dilaudid po prn benadryl prn lactulose 30 ml tid aliskiren 150 mg prednisone 5 mg daily coumadin 2mg po qday calcitriol 1 mcg daily discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 4. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 5. labetalol 300 mg tablet sig: three (3) tablet po three times a day. 6. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 7. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 8. hydralazine 50 mg tablet sig: one (1) tablet po q8h (every 8 hours). 9. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. 10. sodium bicarbonate 650 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 11. warfarin 2 mg tablet sig: one (1) tablet po daily (daily). 12. calcitriol 0.25 mcg capsule sig: four (4) capsule po daily (daily). discharge disposition: home with service facility: vna discharge diagnosis: primary: hypertensive urgency transient hypotension due to narcotics sciatica . secondary: end stage renal disease systemic lupus erythematosus anemia discharge condition: stable. blood pressures at baseline. hip/leg pain resolved. ambulating without assistance. discharge instructions: you were admitted to the hospital with high blood pressure and right leg/hip pain. we gave you pain medications and blood pressure lowering medications. your blood pressure then dropped which was caused by the pain medication, and you were transferred to the intensive care unit(icu) where you recovered quickly. during your stay in the icu, you developed a fever and were started on antibiotics. however, the cultures that were obtained were negative, and we discontinued the antibiotics. during your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. you had an mri of your hip done, which did not show an acute infection. you were seen by the kidney doctors and they recommended starting peritoneal dialysis. you were also given some blood for your anemia. please follow up with the peritoneal dialysis nurse at the scheduled day/time. please make an appointment to meet with your pcp in the next couple of weeks. your hip pain may benefit from physical therapy or outpatient anesthetic joint injection. please discuss these options with your rheumatologist. . please call the number given below to schedule outpatient physical therapy. . please restart your home medications. you were also started on sodium bicarb 650mg by mouth three times a day. . if you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. followup instructions: please follow up with your peritoneal dialysis nurse () on . provider: , md phone: date/time: 10:00 . please call to schedule outpatient physical therapy: Procedure: Peritoneal dialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Pneumonia, organism unspecified Chronic glomerulonephritis in diseases classified elsewhere Chronic kidney disease, Stage V Other primary cardiomyopathies Acidosis Systemic lupus erythematosus Hyperpotassemia Sciatica Other iatrogenic hypotension Thrombocytopenia, unspecified Anemia in chronic kidney disease Anemia of other chronic disease Hypocalcemia

allergies: penicillins / percocet attending: chief complaint: abdominal pain & hypertension major surgical or invasive procedure: hemodialysis picc line history of present illness: ms is a 24 year old woman with a history of ckd v (on hd) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior icu admissions for hypertensive urgency who presented to the ed complaining of two days' of abdominal pain, nausea, and loose stools. she was feeling well until after her hemodialysis session on wednesday. thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. she also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. the headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the ed. upon arrival to the ed, she was afebrile, bp 240/184, hr 109, rr 16, sat 99% on room air. she was given 4 mg of iv ondansetron, inch intropaste, 1 mg of iv hydromorphone x3, 1000cc of ns, and was put on a labetalol drip which had to be increased up to 2 mg/min. a head ct showed no acute abnormality (including hemorrhage) and an abdominal ct showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: t 97.9 bp 165/120 hr 93 rr 12 sat 100% ra gen: mildly fatigued, but no distress heent: oropharynx clear neck: no jvp, no lad chest: clear to auscultation throughout, no w/r/r cv: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or hsm, pd catheter in palce extr: no edema, 2+ pt pulses neuro: alert, appropriate, strength grossly intact in all four limbs skin: no rashes pertinent results: 05:53am blood wbc-4.3 rbc-2.81* hgb-8.6* hct-25.6* mcv-91 mch-30.7 mchc-33.8 rdw-19.3* plt ct-148* 05:53am blood pt-42.6* ptt-51.0* inr(pt)-4.7* 05:10am blood ret aut-2.5 05:53am blood glucose-83 urean-21* creat-5.1*# na-138 k-5.3* cl-105 hco3-24 angap-14 05:10am blood ld(ldh)-234 amylase-347* totbili-0.1 09:50pm blood alt-14 ast-51* alkphos-94 totbili-0.3 05:10am blood lipase-72* 05:53am blood calcium-8.2* phos-4.5 mg-1.7 05:10am blood hapto-142 04:02am blood caltibc-138* vitb12-445 folate-18.5 ferritn-220* trf-106* on admission: 09:50pm blood wbc-4.5 rbc-2.78* hgb-8.4* hct-25.2* mcv-91 mch-30.2 mchc-33.3 rdw-19.2* plt ct-158 09:50pm blood neuts-65.2 lymphs-23.4 monos-8.0 eos-2.9 baso-0.4 09:50pm blood pt-14.7* ptt-33.4 inr(pt)-1.3* 04:02am blood ret aut-2.5 09:50pm blood glucose-89 urean-25* creat-5.1*# na-139 k-4.8 cl-104 hco3-26 angap-14 09:50pm blood alt-14 ast-51* alkphos-94 totbili-0.3 09:50pm blood lipase-89* 09:50pm blood albumin-3.3* calcium-8.3* phos-4.9* mg-1.9 09:54pm blood glucose-75 lactate-1.3 na-139 k-4.8 cl-101 calhco3-23 micro: blood cx: , , , no growth fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). ct head : impression: 1. no acute intracranial pathology including no hemorrhage. 2. the hypodensities noted in the parietal white matter are stable. however in the setting of the hypertension, pres cannot be excluded. if further evaluation is required mr can be obtained. ct abdomin/pelvis impression: 1. moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. unchanged peritoneal enhancement. 2. stable liver hemangioma. cxr impression: small left pleural effusion. left lower lobe opacity which is either atelectasis versus pneumonia. brief hospital course: 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on the patient's sbp dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patient's pressures responded and additional narcotics were held due to her mental status. the patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patient's malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patient's heparin gtt was hled on because of access issues, but was restarted on after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patient's hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on . she was also given epo at hd. medications on admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qweek ergocalciferol 50,000 units qmonth nifedipine sr 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg hydromorphone 4 mg q4h prn clonazepam 0.5 mg alikiren 150 mg docusate 100 mg senna 8.6 mg prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn discharge medications: 1. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 2. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a month. 3. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 5. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 6. hydromorphone 4 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. :*84 tablet(s)* refills:*0* 7. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 8. aliskiren 150 mg tablet sig: one (1) tablet po bid (). 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 10. labetalol 200 mg tablet sig: four (4) tablet po tid (3 times a day). 11. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. 12. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 13. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as needed: please take as needed for anxiety prior to cpap at bedtime. :*30 tablet(s)* refills:*0* 14. cpap home cpap dx: osa prefer: autocpap/ pressure setting alt: straight cpap/ pressure setting 7 discharge disposition: home discharge diagnosis: primary: hypertensive urgency abdominal pain esrd on hd svc thrombus secondary: systemic lupus erythematosus malignant hypertension thrombocytopenia hocm anemia history of left eye enucleation history of vaginal bleeding thrombotic microangiopathy discharge condition: stable discharge instructions: it was a pleasure taking care of you while you were in the hospital. you were admitted to because of elevated blood pressure and abdominal pain. you were initially admitted to the icu and your blood pressure was controlled. you were stabilized and transferred back to th floor. your pressures remained stable throughout the rest of your stay. additionally, you had abdominal pain and diarrhea. your stool was tested for infections and was negative. your diarrhea resolved without intervention. your abdominal pain was controlled with pain medications. you had a sleep study in the hospital which showed that you had sleep apnea. please continue to take your medications as prescribed. 1. please do not take your coumadin until your doctor tells you to. please follow up with the appointments below. please call your pcp or go to the ed if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. followup instructions: you will have dialysis at dialysis on your normal schedule. you need to go to dialysis on saturday. please follow-up with the sleep clinic in @ 11:45 dr. please follow-up with your pcp weeks pcp: , . Procedure: Venous catheterization, not elsewhere classified Hemodialysis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus Other iatrogenic hypotension Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Other and unspecified noninfectious gastroenteritis and colitis Obstructive sleep apnea (adult)(pediatric) Hemangioma of intra-abdominal structures Other chronic pain Abdominal pain, unspecified site Abnormal coagulation profile Renal dialysis status Personal history of venous thrombosis and embolism

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea, hypertension major surgical or invasive procedure: hemodialysis history of present illness: 24f h/o sle, esrd on hd, h/o malignant htn, svc syndrome, pres, prior ich, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. she was recently discharged on after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ed, but was otherwised managed with oral antihypertensives and cpap. . she was doing well until the evening of when she notes the gradual onset of dyspnea. she denied f/c/cp/ha/abd pain/diarrhea, or constipation. she was having regular, soft, daily bms. . on she awoke, and describes n/v x 2, with increasing dyspnea, and headache. she did not want to wait until dialysis at 4pm and therefore presented to . . in ed vs= 97.7 100%ra. labs were notable for hct 23, plt 66, wbc 3.3, all roughly at baseline. cxr without acute process, ecg unchanged from prior. no ua sent, though she does make some urine. she was started on nitro gtt with modest improvement of sbps to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with bp 221/130 at the time of transfer. she refused abdominal ct. renal was consulted, but felt hd not indicated today. . . ros: negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +ha. denies visual changes, slurrring speech, numbness, weeakness. past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: denies tobacco, alcohol or illicit drug use. lives with mother and is on disability for multiple medical problems. family history: no known autoimmune disease. physical exam: vitals - 97.7 88 220/150 19 100%2l bc. general: a&ox3. nad, oriented x3. heent: nc/at; perrla on right, enucleated eye on left; op clear, nonerythematous, mmm. neck: supple, no lad, full rom. lungs: cta b, with few crackles at bases. cv: rr, nl s1, s2 +s3, no rubs appreciated. abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative , no rebound, gaurding. ext: wwp, 1+ dp/pt pluses, no clubbing, cyanosis or edema. neuro: cn 2-12 intact. moving all four extremities spontaneously. pertinent results: lab results on admission: 11:37am glucose-95 urea n-40* creat-7.4*# sodium-140 potassium-3.8 chloride-105 total co2-23 anion gap-16 alt(sgpt)-14 ast(sgot)-44* ld(ldh)-264* alk phos-115 tot bili-0.4 albumin-3.2* wbc-3.6* rbc-2.61* hgb-7.6* hct-23.4* mcv-90 mch-29.0 mchc-32.4 rdw-18.3* 11:37am neuts-71.6* lymphs-23.0 monos-3.7 eos-1.5 basos-0.2 plt count-66* pt-14.0* ptt-34.5 inr(pt)-1.2* 06:00pm ck-mb-5 ctropnt-0.17*ck(cpk)-58 cxr: impression: unchanged moderate cardiomegaly with pulmonary edema. again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. brief hospital course: 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. . # hypertensive urgency - on presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely hypertension. states she did take her po meds. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own. she was continued on cpap overnight and discontinued in the am. she was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. she did have hypoactive bowel sounds on admission. she was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with hd with plan to follow bms closley. her pain improved the am of discharge and she had no further vomiting. . # esrd on hd - she is currently getting hd satuth, though did not get hd on the day of presenation. as there was no acute indication for hd on presentation, she received hd on the following am, day of discharge. she was continued on sevelamer. . # anemia - chronic anemia, likely ckd and sle, currently above baseline, though has h/o gib. she received 2 unit prbcs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of ppi . . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - pt with goal inr , but this was stopped after recent admission supratherapeutic inr. inr currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continued on celexa. medications on admission: 1.nifedipine 90 mg po daily (daily). 2.nifedipine 60 mg tablet sustained release po hs (at bedtime). 3.lidocaine 5 % patch q24hr. 4.aliskiren 150 mg tablet sig: one (1) tablet po bid 5.citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6.fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch q72h 7.prednisone 4 mg po daily (daily). 8.clonidine 0.1 mg/24 hr patch qsat (every saturday). 9.clonidine 0.3 mg/24 hr patch qsat (every saturday). 10.sevelamer hcl 1600 mg po tid w/meals (3 times a day with meals). 11.gabapentin 100 mg capsule sig: one (1) capsule po qhd 12.labetalol 1000 mg tablet tablet po tid 13.hydralazine 100 mg tablet po q8h 14.warfarin 3 mg tablet po once daily at 4 pm. 15.pantoprazole 40 mg po q12h (every 12 hours). 16.levetiracetam 1000 mg po 3x/week (tu,th,sa). discharge medications: 1. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 2. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po hs (at bedtime). 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical q24h (every 24 hours). 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 5. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch transdermal every seventy-two (72) hours. 6. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 7. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 8. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 9. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for hypertension. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 12. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 13. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). tablet(s) 14. gabapentin 100 mg capsule sig: one (1) capsule po qhd (each hemodialysis). 15. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 16. levetiracetam 500 mg tablet sig: two (2) tablet po qtuthsa (tu,th,sa). discharge disposition: home with service facility: vna discharge diagnosis: primary: hypertensive emergency anemia, erythropoetin deficiency secondary: chronic renal failure on hemodialysis lupus nephritis discharge condition: hemodynamically stable. discharge instructions: you were admitted for hypertensive urgency and treated in the intensvie care unit with iv medications to decrease your blood pressure. you also received 2 units of blood and hemodialysis before you were discharged home. it is essential that you take all of your prescribed blood pressure medications and present regularly for your tuesday, thursday, saturday dialysis. please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. followup instructions: you have the following appointment scheduled. please contact your provider if you are unable to make these appointments. your dialysis is scheduled for tuesday, thursday, saturday. provider: , md phone: date/time: 2:00 provider: clinic phone: date/time: 3:15 Procedure: Hemodialysis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease Anemia of other chronic disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Nausea with vomiting Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Unspecified iridocyclitis Other specified peripheral vascular diseases Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

allergies: penicillins / oxycodone hcl/acetaminophen attending: chief complaint: feeling unwell, hypertensive urgency major surgical or invasive procedure: dialysis history of present illness: pt is a 22 yo female with lupus, end-stage renal disease on hd, htn, multiple other medical problems as below who presents with feeling unwell and found to be in hypertensive urgency. pt states that last thursday, five days ago, she started to feel unwell. states that she had chills, no fever, a "weird feeling in my stomach" with cramps, and no cough. no diarrhea. no dysuria. pt missed her dialysis session on saturday because she was feeling unwell (3 days ago). per patient she started to feel better that day, but today, started to feel unwell with the same symptoms. no sick contacts. . in the ed, vs on arrival were: hr: 73; bp: 222/128, 100% ra. she was given labetalol 20 mg iv, 40 mg iv, and then started on a labetaolol gtt.she was also calcium gluconate 1 am iv, kayexalate 30 mg po x 1, 10 units of insulin iv, and 1 amp of d50. . of note, pt was recently admitted to at the end of for left uveitis/endophthalmitis. she the developed endophthalmitis and had her l eye enucleation. she states that she went to her appt at 5 days ago. they said that her eye "looked good" and she was to continue on the same amount of prednisone that she is on. . her last admission she was also noted to have coag negative staph bacteremia. she was discharged on 14 day course of vancomycin but she somehow did not receive this at dialysis. she has now had 4 sets bld cx + for coag negative staph and was started on vancomycin. past medical history: 1. lupus - . diagnosed after she began to have swolen fingers, a rash and painful joints. 2. esrd secodary to sle - . was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in (t, th, sat). awaiting living donor transplant from mother. 3. htn - . normal bps run 180's/120's. has had 1 hypertensive crisis that precipitated seizures in the past. 4. uveitis secondary to sle - 5. hocm - per echo in 6. vaginal bleeding 7. mulitple episodes of dialysis reactions 8. anemia 9. coag neg. staph bacteremia and hd line infection - 10. h/o ue clot, was on coumadin, but no longer social history: lives in with mother and 16 year old brother. graduated school and then got sick so currently is not working or attending school. denies any t/e/d. family history: no family history of sle. gf: htn. no clotting disorders in family. no history of autoimmune disease. physical exam: vs: t: 97.8; bp: 203/133; hr: 100; rr: 15; o2: 100 ra gen: speaking in full sentences in nad heent: left eye patch. refuses to let examine/look. right eye reactive. sclera anicteric. op clear. neck: no lad cv: rrr s1s2. no m/r/g lungs: cta b/l with good air entry and flow abd: soft, nt, nd. back: no spinal, paraspinal, or cva tenderness ext: no edema. dp 2+ neuro: a&o x 3, ms intact. pertinent results: ekg: sinus at 75. normal axis. normal intervals. early repolarization in anterior precordium. no acute changes. lvh. . radiology: cxr pa/lat - large-bore inferior approaching right-sided dialysis catheter is unchanged in position terminating within the right atrium. the lungs are clear and cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. no evidence of pneumothorax or pulmonary edema. . 06:20am wbc-7.4 rbc-3.85*# hgb-11.2*# hct-35.3*# mcv-92 mch-29.1 mchc-31.8 rdw-20.9* 06:20am neuts-91.1* lymphs-7.7* monos-1.1* eos-0.1 basos-0 06:20am plt count-202 . 06:20am glucose-100 urea n-40* creat-5.2* sodium-138 potassium-6.3* chloride-109* total co2-18* anion gap-17 . 04:10pm wbc-5.6 rbc-3.47* hgb-10.3* hct-31.4* mcv-91 mch-29.6 mchc-32.7 rdw-20.6* . 04:10pm calcium-9.1 phosphate-3.6# magnesium-2.3 04:10pm lipase-54 04:10pm alt(sgpt)-20 ast(sgot)-38 alk phos-74 amylase-267* tot bili-0.3 04:10pm glucose-89 urea n-40* creat-4.9* sodium-139 potassium-5.2* chloride-109* total co2-20* anion gap-15 . and with blood cultures 4/4 + coag negative staphylococcus. and bld cultures no growth to date. . ecchocardiogram: severe symmetric lvh. normal lv cavity size. normal regional lv systolic function. hyperdynamic lvef >75%. moderate resting lvot gradient. lvot gradient increases with valsalva. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. no 2d or doppler evidence of distal arch coarctation. aortic valve: normal aortic valve leaflets (3). trace ar. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. tricuspid valve: normal tricuspid valve leaflets. mild tr. indeterminate pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. general comments: echocardiographic results were reviewed with the houseofficer caring for the patient. conclusions: the left atrium is elongated. the estimated right atrial pressure is 0-5mmhg. there is severe symmetric left ventricular hypertrophy with normal cavity size and dynamic systolic function (lvef>80%). regional left ventricular wall motion is normal. there is a moderate (25mmhg peak) resting left ventricular outflow tract obstruction that increased (64mmhg) with the valsalva manuever. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: marked symmetric left ventricular hypertrophy with dynamic systolic function and resting lvot gradient that increased with valsalva. compared with the prior study (images reviewed) of , the severity of left ventricular hypertrophy has increased and trace aortic regurgitation is now identified. dynamic lv systolic function and the resting intracavitary gradient are similar. . ue ultrasound 1. abrupt occlusion of the right internal jugular vein and its distal most aspect as it joins with the distal subclavian vein. 2. recanalization of the left subclavian vein with some peripheral residual clot. recommend analysis of the svc, central subclavians and internal jugular veins with dedicated magnetic resonance venography, which can be performed without intravenous contrast for a global assessment of the venous patency. brief hospital course: pt is a 22 yo female with sle, esrd on hd, amongst other problems who presented with symptoms likely bacteremia. found to be in hypertensive urgency after missing a run of dialysis. she is now transferred to the floor for further managment after dialysis x 1 and starting vancomycin. . in the micu she was started kept briely on a labetalol gtt, and then restarted on her home antihypertensives and dialyzed x 1 with resolution of hypertension. she was found to be bacteremic and was started on vancomycin. she felt well and was transferred to the floor. . 1. hypertensive urgency- pt with long history of very difficult-to-control htn. she was initially on a labetalol gtt as above, was dialyzed with resolution of her htn urgency. she was then transitioned to her her outpatient medication regimen of valsartan, lisinopril, clonidine, labetalol, terazosin, and nicardipine at max doses, but because of persistent htn to the 180's she was started on hydralazine 50mg po tid on discharge. . 2. coag negative staph bacteremia: most likely source is line sepsis. she was started on vancomycin and her blood cultures cleared after 2 days in the hospital. the patient felt strongly about keeping her hd line, which was felt to be reasonable because her infection was coag negative staph. ecchocardiogram did not show any valvular vegitations. she will continue on vancomycin for 3 weeks at hemodialysis. . 3. esrd on dialysis-euvolemic clinically. had dialysis inhouse. continued sevelamer. . 4. left uveitis/endopthalmitis-continued prednisone 30 mg po qday. will also continue bacitracin-polymyxin b. . 5. lupus- not on any other medications than above. . f/e/n- insists on regular diet . access: right dialysis catheter . prophylaxis: heparin sc, ppi per outpatient . code status: full code medications on admission: nephrocaps 1 cap po daily vancomycin 1000 mg iv hd protocol vancomycin 1000 mg iv x1 duration: 1 doses diphenhydramine 25 mg po q6h:prn labetalol 600 mg po tid heparin 5000 unit sc tid acetaminophen 325-650 mg po q4-6h:prn oxycodone (immediate release) 10 mg po q3h:prn bacitracin/polymyxin b sulfate opht. oint 1 appl both eyes q8h terazosin hcl 8 mg po bid gabapentin 100 mg po qtuesday, thursday, saturday sevelamer 800 mg po tid nicardipine 40 mg po q8h prednisone 30 mg po daily sulfameth/trimethoprim ds 1 tab po qmonday, wednesday, friday lorazepam 1 mg po q4-6h:prn senna 1 tab po bid:prn docusate sodium 100 mg po bid pantoprazole 40 mg po q24h clonidine tts 3 patch 1 ptch td qfri lisinopril 40 mg po bid valsartan 320 mg po daily ondansetron 4 mg iv q8h:prn oxycodone sr (oxycontin) 70 mg po q8h discharge medications: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qfri (every friday). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po qmonday, wednesday, friday (). 4. prednisone 20 mg tablet sig: 1.5 tablets po daily (daily). 5. nicardipine 20 mg capsule sig: three (3) capsule po q8h (every 8 hours). 6. lisinopril 20 mg tablet sig: two (2) tablet po bid (2 times a day). 7. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 8. terazosin 2 mg tablet sig: four (4) tablet po bid (2 times a day). 9. oxycodone 5 mg tablet sig: two (2) tablet po q3h (every 3 hours) as needed. 10. oxycontin 20 mg tablet sustained release 12 hr sig: 3.5 tablet sustained release 12 hrs po every eight (8) hours. 11. sevelamer 400 mg tablet sig: two (2) tablet po tid (3 times a day). 12. gabapentin 100 mg capsule sig: one (1) capsule po qtuesday, thursday, saturday (). 13. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 14. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous per hemodialysis for per hd days: per hemodialysis. 15. bacitracin-polymyxin b 500-10,000 unit/g ointment sig: one (1) appl ophthalmic q8h (every 8 hours). 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 17. gabapentin 100 mg capsule sig: one (1) capsule po qtuesday, thursday, saturday (). 18. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). 19. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for anxiety. 20. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous hd protocol (hd protochol): 1g q dialysis. 21. hydralazine 50 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: hypertensive urgency coagulase negative staphylococcus bacteremia secondary diagnosis: lupus esrd s/p l eye enucleation discharge condition: good. blood pressure is in the 130s-150s systolic. her vitals are stable, she is ambulatory, and taking in po discharge instructions: please follow up as below; i have also made a new cardiology appointment for you . take all medications as prescribed; other than giving you vancomycin we have added hydralazine (a blood pressure medicine), but otherwise we have not changed any of your medicines. if you have fevers, chills, light-headedness, or other problems then you should contact your doctor because this may be a sign that your infection is not resolving. you should go for hemodialysis as scheduled saturday where they should give you vancomycin. followup instructions: provider: , m.d. phone: date/time: 1:00 dr. tuesday at 3pm with dr. in cardiology. md Procedure: Hemodialysis Diagnoses: Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus End stage renal disease Anemia, unspecified Bacteremia Unspecified iridocyclitis Acquired absence of organ, eye Infection and inflammatory reaction due to other vascular device, implant, and graft Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease Other endophthalmitis

allergies: penicillins / percocet attending: chief complaint: hypertensive urgency and fevers major surgical or invasive procedure: none history of present illness: ms. is a 24 year old woman with esrd on hd, sle, malignant htn admitted with hypertensive urgency, subjective fevers, and pain. . of note, she had been hospitalized with hypertensive urgency. her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg tid from 800mg tid.bps were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. last hd was . . she reports feeling well at time of discharge , however woke this evening feeling sweaty, hot, and mildly sob. she did not check her temperature and denies any rigors. she had total body aching (worst in her left wrist at site of recent iv and abdomen at site of known hematoma). +palpitations overnight now resolved. no cp, sob, cough, diarrhea, dysuria, erythema/tenderness/drainage from hd catheter. denies recent joint symptoms with her lupus. no sick contacts. says she took her bp meds. . upon arrival to the ed, her vitals were 99.9 104 254/145 16 96% on ra. she was started on a nicardipine drip, given 1" nitropaste with improvement in her bp. did spike a fever while in the ed, currently 101f 101 173/106 given vancomycin and zoysn for ?pna as cxr with right sided haziness. also received 3mg iv dilaudid for body pains. lue ultrasound without evidence of dvt. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated dialysis but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 pshx: 1. placement of multiple catheters including dialysis. 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: single and lives with her mother and a brother. she graduated from high school. the patient is on disability. the patient does not drink alcohol or smoke, and has never used recreational drugs. family history: negative for autoimmune diseases including sle, thrombophilic disorders. maternal grandfather with htn, mi, stroke in 70s. physical exam: t 98.5 p 92 bp 173/116 rr 16 o2 100% on ra general pleasant young woman appearing comfortable heent cushingoid faces, l eye prosthesis, mmm pulm lungs clear bilaterally, no rales or wheezing cv regular s1 s2 ?soft systolic murmur abd soft +hematoma left abdomen unchanged from prior exam extrem warm full distal pulses. left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old piv skin no peripehral stigmata of endocarditis lines left groin hd catheter site without erythema, purulence, or tenderness neuro alert and awake, moving all extremities pertinent results: cxr : in comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. enlargement of the cardiac silhouette persists and there is no definite pleural effusion. suggestion of an area of increased opacification at the right base. this could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . lue us : impression: no dvt in the left upper extremity. . l wrist xray : there is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. no fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. no soft tissue calcification or radiopaque foreign body is identified. a tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. brief hospital course: 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg , labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist dr. , her icu physician and her to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled " care protocol". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inr's do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg . 11. osa: continued cpap medications on admission: clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday hydralazine 100mg po q8h labetalol 900mg po tid morphine 7.5mg q8h prn nifedipine 90mg po daily aliskiren 150 prednisone 4mg po qday clonazepam 0.5 mg celexa 20mg po qday gabapentin 300 mg acetaminophen 325-650 mg q6h prn ergocalciferol (vitamin d2) 50,000 unit po once a month coumadin 4 mg daily discharge medications: 1. hydralazine 100 mg tablet sig: one (1) tablet po every eight (8) hours. :*90 tablet(s)* refills:*2* 2. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). :*4 patch weekly(s)* refills:*2* 3. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). :*4 patch weekly(s)* refills:*2* 4. labetalol 300 mg tablet sig: three (3) tablet po three times a day. :*270 tablet(s)* refills:*2* 5. morphine 15 mg tablet sig: 0.5 tablet po q8h (every 8 hours) as needed for pain. :*15 tablet(s)* refills:*0* 6. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). :*30 tablet sustained release(s)* refills:*2* 7. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 8. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 9. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 10. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 11. warfarin 4 mg tablet sig: one (1) tablet po once a day. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). :*30 tablet, delayed release (e.c.)(s)* refills:*2* 13. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a month. 14. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous hd protocol (hd protochol) for 7 days. :*4 dose* refills:*0* discharge disposition: home discharge diagnosis: hypertensive urgency septic thrombophlebitis discharge condition: stable, afebrile, bp improved. discharge instructions: you were admitted to the hospital with hypertensive urgency. you required iv medications and were observed overnight in the icu. your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. you were found to have an infection at your prior iv site on your left hand. for this you were given iv vancomycin. you will need 7 days more of antibiotics which will be given with dialysis. please resume your usual dialysis schedule. your last dialysis was . please continue to take your medications as prescribed. you should hold your coumadin today. you can resume this on wednesday at your normal dose. you should have your inr checked at dialyis as usual on thursday. . if you develop any of the following concerning symptoms, please call your pcp or go to the ed: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. followup instructions: please follow up with your pcp weeks. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Systemic lupus erythematosus End stage renal disease Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of upper extremities, unspecified

allergies: penicillins attending: chief complaint: blurry vision major surgical or invasive procedure: none history of present illness: ms. is a 20 year old female with a past medical history significant for systemic lupus erythematosis who woke on day of admission with blurry vision. the patient was initially diagnosed at age 16 when her fingers swelled up and 6 months later a kidney biopsy confirmed the lupus nephritis. she's been medically managed on prednisone and had a trial of cytoxan which she did not tolerate due to nausea and vomitting. her hypertension has been controlled with enalopril, atenolol, and nifedipine until about 7 days prior to admission when she ran out of medication and for that reason has been non-adherent. on the day of admission, ms. called 911 and en route to this facility developed an intense headache, localizing to the right temporal region. in the ambulance she was discovered to have a systolic blood pressure of about 300. upon arrival at the ed, she developed chest pain and shortness of breath. morphine, labetelol 20 iv, atenolol 50 po, and enalapril 20 po were administered. she was then started on a nifedipine drip. later, the nifedipine was weaned for a concern of renal insufficiency and a ntg drip was started at which point her systolic blood pressure decreased to 180. a head ct was obtained which was negative but she did have papilledema per the ed notes. an ekg showed strain. the patient was admitted to the micu overnight. of note, it was discovered that her creatnine was up to 5 from a baseline of 1.5. past medical history: sle pregnancy termination in cri s/p cytoxan q 3months 2 years ago htn social history: lives with mom and 14 year old brother does not work but is considering going to college in occasional etoh, no tobacco, heroin, cocaine family history: aunts with hypertension grandmother died of myeloma several men with prostate cancer physical exam: vitals: 98.6, bp 142/95, hr 88 rr 20 o2 saturation 100% on ra wt 58.3 kg gen: pleasant cooperative watching tv heent: moon facies, perrla, mmm, dentition with caries, sclera nonicteric cv: rrr ii/vi murmur heard throughout the precordium pulm: ctab, no murmurs abd: +bs, soft, nd, nt ext: wwp, 2+dp bilaterally skin: jaws and upper extremities with coalescing annular plaques with a pink annular border and an atrophic hyperpigmented center consistent with discoid lupus. pertinent results: 07:50pm ck(cpk)-55 07:50pm ctropnt-0.04* 04:35pm urine blood-lg nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 04:35pm urine rbc-* wbc-* bacteria-occ yeast-none epi- 01:15pm glucose-129* urea n-31* creat-5.2*# sodium-138 potassium-3.9 chloride-105 total co2-19* anion gap-18 01:15pm ld(ldh)-517* tot bili-0.4 01:15pm haptoglob-<20* 01:15pm wbc-3.8* rbc-3.32* hgb-8.5* hct-26.8* mcv-81*# mch-25.7* mchc-31.9 rdw-18.7* 01:15pm plt smr-very low plt count-69*# 01:15pm pt-12.3 ptt-28.0 inr(pt)-1.0 renal ultrasound: impression: echogenic texture of both kidneys with nonspecific ill-defined bilateral areas. the arterial and venous flow are normal and there is no hydronephrosis. cxr: cardiac and mediastinal contours are normal. the lungs are clear. pulmonary vasculature is normal. the osseous structures are unremarkable. no chf ekg: lv strain and inverted t waves in limb leads ---- adamts13 (vwf cleaving protease) results units reference interval ------- ----- ------------------ adamts13 inhibitor <0.4 inhibitor units < = 0.4 adamts13 activity 55 % (low) > = 67 02:44pm blood pth-98* 04:12am blood hbsag-negative 02:17pm blood hcg-<5 02:31pm blood dsdna-positive a 11:41am blood c3-46* c4-8* 09:25am blood scleroderma antibody-test anticardiolipin ab anti-cardiolipin igg : 12.1 0 - 15 gpl anti-cardiolipin igm : 8.1 0 - 12.5 mpl ro & result reference range/units ssa antibody negative negative ssb antibody negative negative mycophenolic acid, serum mycophenolic acid 1.9 1.0 - 3.5 ug/ml mpa glucuronide 74 35 - 100 ug/ml brief hospital course: ms. is a 20 year old woman with hypertensive emergency, lupus nephritis, and ttp vs. malignant hypertension inducing thrombocytopenia. htn: ms. had a hypertensive emergency, as evidenced by ekg changes, papilledema, and head ct changes. this was thought likely secondary to a lupus flare, arf and poor medication compliance. she was started back on metoprolol and nifedipine, but her ace i was held for the renal failure. the metoprolol was changed to toprol xl and a clonidine patch were added for better control and a simplified regimen as there was concern for patient compliance. titration of these medications on the medical floor and addition of hydralazine did not result in adequate bp control as the patient had several systolic blood pressure readings in the 250s. she was then transferred to the intensive care unit for uncontrolled bp accompanied by head ache. once there, she received iv antihypertensives and hd was initiated. several lbs were taken off, facilitating bp control with oral medications. she was transferred back to the medical floor and stabilized on a regimen of clonidine patch qweek, tid labetolol, and qd lisinopril. rheum: ms. has sle with discoid rash and arf. she was started on a prednisone burst with calcium supplementation. she was also started on plaquanil for 1-2 months for her discoid rash. she will be followed by dr. in clinic, who will arrange for her to see an ophthalmologist. of note, her complement levels were low, her ds dna was positive and her anti-cardiolipin igg and igm were within normal limits. renal: ms. presented with acute on chronic renal insufficiency. her rise in creatinine was dramatic, from baseline of 1.2 in to 5.2 at presentation. this was thought to be multifactorial, from both htn and an exacerbation of sle. her ace inhibitor was initially held, and her creatinine continued to worsen. of note, her ua remained somewhat bland, without acanthocytes. her blood pressure remained difficult to control, requiring another trip to the micu for administration of iv antihypertensives. it was decided that some of this was attributed to volume overload, so hd was initiated. a tunnel line was placed and the patient tolerated the procedure and the hd well. it was thought that the hd would be temporary but that the patient would eventually progress to esrd in the near future. she was also started on mycophenolate mofetil in the hopes of slowing her progression to esrd and giving her a few months before having to start hd as more permanent renal replacement. she was discharged with instructions to come for hd mondays, wednesdays, and fridays. heme: ms. presented with arf, thrombocytopenia, anemia, and leukopenia. her haptoglobin was low and ldh was high, concerning for hemolysis. dic was considered unlikely since her coagulation studies were within normal limits but , ttp/hus were considered a possibility. a peripheral smear showed schistocytes, so the heme service was consulted, however this presentation could also be secondary to a malignant hypertension inducing shearing of erythrocytes and platelets. her arf could be attributed to her hypertension as well. given the concern for ttp, the heme service initiated plasmapheresis with the assistance of the blood bank. the patient had 7 plasmapheresis treatments, one of which was complicated by symptomatic hypocalcemia evidenced by abdominal pain. she was plasmapheresed until her platelets reached 150. of note, her adamst 13 studies were not consistent with ttp, although these studies are still investigational. she was also started on folate and iron for her anemia. gi: ms. had one episode of hematemesis during plasmapheresis. this was comprised of approximately 5 cc of clots of blood concurrently with a hematocrit drop. with this concern for gib, ms. was transferred back to the micu where an egd showed diffuse linear erythema of the mucosa with no bleeding in the stomach body. these findings were compatible with mild gastritis but did not account for the hct drop. she was started on a ppi and asked to avoid nsaids. medications on admission: atenolol 50 nefedipine and enalopril in unknown quantities prednisone 10 qd discharge medications: 1. hydroxychloroquine sulfate 200 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. prednisone 20 mg tablet sig: two (2) tablet po once a day for 2 weeks. disp:*28 tablet(s)* refills:*0* 5. prednisone 10 mg tablet sig: three (3) tablet po once a day for 7 days: start 30 mg each day for a week after you've finished your week of prednisone 40 mg. disp:*21 tablet(s)* refills:*0* 6. prednisone 20 mg tablet sig: one (1) tablet po once a day for 7 days: start 20 mg each day for a week after you've finished your week of prednisone 30 mg. disp:*7 tablet(s)* refills:*0* 7. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily): this may turn your stool dark, be sure to take colace if you need a stool softener. disp:*qs tablet(s)* refills:*2* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. 1 blood pressure cuff please take your blood pressure once per day. call the doctor if your blood pressure is 160/100 or greater. 10. prednisone 10 mg tablet sig: one (1) tablet po once a day for 7 days: start 10 mg each day for a week after you've finished your week of prednisone 20 mg. disp:*7 tablet(s)* refills:*0* 11. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 12. clonidine hcl 0.3 mg/24 hr patch weekly sig: one (1) transdermal once a month. disp:*4 4* refills:*2* 13. labetalol hcl 200 mg tablet sig: four (4) tablet po tid (3 times a day). disp:*360 tablet(s)* refills:*2* 14. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 15. nifedipine 60 mg tablet sustained release sig: two (2) tablet sustained release po bid (2 times a day). disp:*120 tablet sustained release(s)* refills:*2* 16. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 17. isosorbide dinitrate 20 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 18. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: malignant hypertension with hypertensive emergency discoid lupus nephritis acute renal failure ttp vs. malignant hypertension induced thrombocytopenia discharge condition: good discharge instructions: your new pcp is . . you can reach her at . take your blood pressure medications every day. measure and record your blood pressure every day. since you don't yet have a cuff at home that works, try having your pressure checked at a pharmacy until you get your own cuff. please bring your record to your appointment. please come to the of on monday to have your blood drawn to check your renal function. the lab is open starting at 7:30 am. you will be taking an increased dose of prednisone for now, but it will be tapered weekly. please also take your mmf, nifedipine, clonodine, and labetolol. these medicines are all available on the mass health formulary and we are working with case management to accelerate this for you. please come to hemodialysis at on . please call when you get home for an appointment to schedule the placement of your av fistula. you should have this placed as soon as possible. her number is . stick to a low salt renal diet as described in the materials given to you last week. avoid chinese food, prepared foods, tv dinners, lunch meats etc. your forms have been filled out for the ride. followup instructions: provider: , md where: lm phone: date/time: 11:00 provider: , md where: phone: date/time: 3:30 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Hemodialysis Venous catheterization for renal dialysis Closed [percutaneous] [needle] biopsy of kidney Therapeutic plasmapheresis Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Systemic lupus erythematosus Acute kidney failure, unspecified Hemorrhage complicating a procedure Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other chest pain Thrombotic microangiopathy Hematemesis Other specified disorders resulting from impaired renal function Raynaud's syndrome

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea, weakness major surgical or invasive procedure: none history of present illness: 25f with sle since age 16, esrd on hd, malignant htn, and h/o pres, admitted with htn urgency. last dialyzed on saturday . pt has had multiple recent admission over past 1 month, most recently 2 wks ago for htn urgency and dyspnea. during that time, she was started on labetalol gtt, with improvement overnight, and dialyzed on schedule. tte showed normal ef but severe lvh, small to mod pericardial effusion w/o tamponade. . pt was feeling well until yesterday am, when she began c/o gen weakness and fatigue, w/ worsening doe, orthopnea. no chest pain, , sacral edema, fevers, cough, n/v/d, or other sx. she was feeling so unwell that she missed her hd session yesterday and came to the ed. says she took all of her bp meds yesterday. . in ed, bp was 150s/120 with normal oxygenation on ra. cxr showed mild pulmonary edema w/o infiltrate; she received levaquin and vancomycin x1 dose, with labetalol 20 mg iv x1. then transferred to micu. . past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: home: lives with mother occupation: on disability, previously employed with various temp jobs etoh: denies drugs: denies tobacco: denies family history: no history of autoimmune disease physical exam: vitals: 97.9 90 172/128 29 100%ra general: age appropriate female in nad heent: pupil reactive on right, enucleated eye on left; op clear without lesions, exudate, or erythema. neck supple, no lad. lungs: minimal bibasilar rales cv: nl s1+s2, no m/r/g abd: s/nd +bs, ttp throughout. no rebound or guarding. ext: no c/c/e. 1+ dp/pt bilaterally neuro: aaox3. cn 2-12 intact. strength 4/5 bilaterally upper and lower pertinent results: 05:50pm pt-14.1* ptt-37.9* inr(pt)-1.2* 05:47pm glucose-95 lactate-1.1 na+-134* k+-5.4* cl--102 tco2-21 05:30pm wbc-4.3 rbc-2.73* hgb-7.6* hct-24.6* mcv-90 mch-27.9 mchc-31.0 rdw-18.0* 05:30pm neuts-81.1* lymphs-15.2* monos-2.2 eos-1.3 basos-0.1 05:30pm hypochrom-1+ anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-1+ polychrom-occasional schistocy-occasional teardrop-occasional 05:30pm plt count-93* 03:48am blood wbc-4.1 rbc-2.49* hgb-6.9* hct-22.5* mcv-90 mch-27.6 mchc-30.6* rdw-18.7* plt ct-101* 03:48am blood plt ct-101* 03:48am blood glucose-91 urean-55* creat-7.6* na-132* k-6.0* cl-102 hco3-22 angap-14 03:48am blood calcium-8.8 phos-5.4* mg-2.2 . cxr: ap view of the chest: severe cardiomegaly is stable. there are bilateral hazy perihilar opacities with mild upper zone vascular redistribution compatible with mild pulmonary edema, worse in the interval. small left pleural effusion is stable. there is a retrocardiac opacity, likely representing atelectasis. no pneumothorax is visualized. the osseous structures are unchanged. impression: mild pulmonary edema, slightly worse compared to prior. . echo : the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. there is severe symmetric left ventricular hypertrophy with normal cavity size and regiona/global systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the right ventricular free wall is hypertrophied. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is a small circumferential pericardial effusion without evidence for hemodynamic compromise. compared with the prior study (images reviewed) of , the estimated pulmonary artery systolic pressure is higher and the pericardial effusion is minimally larger. . brief hospital course: 25f with sle since age 16, esrd on hd, malignant htn, and h/o pres, admitted with htn urgency and dyspnea, probable volume overload. # dyspnea: on admission was thought secondary to volume overload given exam and cxr consistent with increased pulmonary vascular congestion. less likely to be infiltrate lack of radiographic infiltrate, leukocytosis, or increased sputum production, so antibiotics were not continued. pt has small cardiac effusion likely chronic serositis?????? may be contributing to dyspnea and resulting in a restrictive physiology. she received a repeat echo showed only a mild enlargement of this effusion (no tamponade) and there were no concerning ekg changes. she was treated with and was transferred to the floor in stable condition. unfortunately on while in the unit pt became hypotensive with sbp in 60s. pt was given 2l ns boluses without significant improvement in sbp. she was drowsy but able to converse. ekg showed sinus rhythm. during the 3rd l of fluid, pt became unresponsive and appeared to be having respiratory distress. a code blue was called at that point and when a pulse was checked, it was absent. resuscitation efforts for pea arrest were initiated. she underwent a prolonged code with appropriate interventions for pea arrest; due to concern for possible pe (she had known svc thrombosis and had not been anticoag due to noncompliance), she even received tpa. unfortunately, all efforts to resuscitate the patient were unsuccessful. her mother who is a employee was contact in the beginning of the code and was able to be present with her several times during the resuscitation. she received emotional support from our social worker, several nurses, as well as her work colleagues. her mother did agree to an autopsy evaluation, results pending. her nephrologist dr. was notified of her death by one of his colleagues. medications on admission: protonix 40 mg po bid clonidine 0.4 mg mg/24hr patch nifedipine sr 90 mg daily aliskiren 150 mg po bid citalopram 20 mg daily prednisone 4 mg daily lidocaine patch daily - 12 hours on 12 hours off sevelamer 400 mg po tid with meals gabapentin 100 mg qhd labetalol 1000 mg po tid hydralazine 100 mg po q8h hydromorphone 2 mg tabs, 1-2 tabs q4h prn levetiracetam 1000 mg po qt,r,sa senna 1 tab po bid prn colace 100 mg po bid alprazolam 0.25 po bid prn acetaminophen 325 mg, 1-2 tabs q6h prn hydralazine 100 mg po prn for sbp>100 discharge medications: none - pt deceased discharge disposition: expired discharge diagnosis: cardiopulmonary arrest, respiratory failure dyspnea hypertensive urgency secondary diagnoses: - systemic lupus erythematosus - end stage renal disease on - malignant hypertension - thrombocytopenia - svc thrombosis - hocm - anemia - history of left eye enucleation for fungal infection - h/o vaginal bleeding s/p depoprovera injection - coag neg staph bacteremia and hd line infections , - thrombotic microangiopathy - obstructive sleep apnea on cpap - left abdominal wall hematoma - mssa bacteremia associated with hd line -. discharge condition: pt expired discharge instructions: pt expired followup instructions: pt expired md Procedure: Venous catheterization, not elsewhere classified Insertion of endotracheal tube Hemodialysis Injection or infusion of thrombolytic agent Transfusion of packed cells Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Systemic lupus erythematosus Hyperpotassemia Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Esophageal reflux Cardiac arrest Compression of vein Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Other ascites Other specified peripheral vascular diseases Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Personal history of noncompliance with medical treatment, presenting hazards to health Mild dysplasia of cervix Constrictive pericarditis

allergies: penicillins / oxycodone hcl/acetaminophen attending: chief complaint: headache major surgical or invasive procedure: left eye enucleation history of present illness: 22 y/o female lupus, esrd, malignant htn, who presents to the ed with headache and hypetension after getting hd. on arrival to ed patient's bp was 235/130. she got 10mg of hydral, 20mg of lopressor, 0.2 of clonidine with no improvment of blood pressure. she was started on labetolol gtt and sbp remained at 267. she was then started on nipride gtt and blood pressure reduced to 161/104. patient denied any chest pain, shortness of breath, or abdominal pain. her ekg done in the ed showed no new changes just c/w lvh. has been using a lower dose clonidine patch because the pharmacy did not have 0.3mg clonidine patch. otherwise she states no change or missed doses of her medication. patient ha localized to behind her l eye. she states that this is her typical uveitis pain that she gets. past medical history: 1. lupus - . diagnosed after she began to have swolen fingers, a rash and painful joints. 2. esrd secodary to sle - . was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in (t, th, sat). awaiting living donor transplant from mother. 3. htn - . normal bps run 180's/120's. has had 1 hypertensive crisis that precipitated seizures in the past. 4. uveitis secondary to sle - 5. hocm - per echo in 6. vaginal bleeding 7. mulitple episodes of dialysis reactions 8. anemia 9. coag neg. staph bacteremia and hd line infection - 10. h/o ue clot, was on coumadin, but no longer social history: lives in with mother and 16 year old brother. graduated school and then got sick so currently is not working or attending school. denies any t/e/d. family history: -no family history of sle. -grandfather has htn. -distant history of dm. -no history of clotting disorders -no other history of other autoimmune diseases physical exam: pe: t 98.6 bp 190/106 hr 90 o2sat 100% ra gen: patient holding cloth on forehead heent: op clear, mmm; l eye: eyelid swollen with watery discharge, + scleral injections. no vision in left eye lungs: cta b/l cardiac: rrr s1/s2 grade iii/vi sem abd: soft nt nabs ext: no edema; left fem dialysis line in place neuro: aaox3, normal ms, sensory intact pertinent results: ct head: 1. no evidence of acute intracranial hemorrhage. 2. hyperdensity and abnormal configuration of the left globe, most amenable to direct inspection. the appearance is changed from , though it appears similar to a prior scan of . . ecg: sinus rhythm. left ventricular hypertrophy. anterolateral t wave changes are probably due to left ventricular hypertrophy. compared to the previous tracing of no significant change. . ecg: normal sinus rhythm. voltage criteria for left ventricular hypertrophy. non-specific t wave flattening. compared to the previous tracing of no diagnostic interim change. . ecg: normal sinus rhythm. compared to tracing #1 no diagnostic interim change. . mr brain/head: 1. left globe subchoroidal and vitreous hemorrhage with possible retinal detachment; lens not clearly visualized, which could be due to resorption/displacement. patient needs ophthalmologic examination, for better evaluation. 2. no evidence of cerebral venous sinus thrombosis. 3. hypoplastic left transverse, sigmoid, anterior-superior sagittal sinuses, and inferior sagittal sinus. 4. prominent ventricles, likely due to parenchymal involution from chronic disease; no associated white matter changes. . 8:57 pm eye source: superficial. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (preliminary): no growth. . 03:00pm urine color-yellow appear-clear sp -1.012 03:00pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 03:00pm urine rbc-* wbc-0-2 bacteri-few yeast-none epi- 05:55pm urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-neg . 03:00pm blood wbc-6.2 rbc-4.82 hgb-13.4 hct-43.1 mcv-89 mch-27.9 mchc-31.2 rdw-19.0* plt ct-163 03:00pm blood neuts-75.0* lymphs-18.4 monos-2.2 eos-3.2 baso-1.3 03:00pm blood hypochr-3+ anisocy-2+ poiklo-1+ macrocy-1+ microcy-1+ 03:00pm blood plt ct-163 03:00pm blood glucose-83 urean-11 creat-2.6*# na-140 k-3.9 cl-98 hco3-33* angap-13 . 08:17am blood wbc-4.9 rbc-3.88* hgb-10.7* hct-33.1* mcv-85 mch-27.5 mchc-32.2 rdw-17.9* plt ct-215 07:30am blood wbc-5.6 rbc-4.31 hgb-11.6* hct-38.0 mcv-88 mch-27.0 mchc-30.6* rdw-17.9* plt ct-229 08:17am blood plt ct-215 07:30am blood plt ct-229 08:17am blood glucose-89 urean-43* creat-4.1* na-139 k-4.3 cl-102 hco3-25 angap-16 07:30am blood glucose-78 urean-47* creat-4.5*# na-133 k-5.2* cl-95* hco3-23 angap-20 08:17am blood calcium-10.0 phos-4.1 mg-1.9 07:30am blood calcium-11.5* phos-5.2* mg-2.1 . 03:00pm blood neuts-75.0* lymphs-18.4 monos-2.2 eos-3.2 baso-1.3 03:00pm blood hypochr-3+ anisocy-2+ poiklo-1+ macrocy-1+ microcy-1+ 04:04pm blood ck(cpk)-13* 04:04pm blood ck-mb-3 ctropnt-<0.01 07:10pm blood pth-71* 09:56pm blood type-art ph-7.30* 09:56pm blood freeca-1.35* . brief hospital course: 1) malignant htn: pt on lisinopril, valsartan, clonidine patch, labetolol, nicardipine as an outpatient with a baseline bp 160s-180s/80s-100s. pt was in the icu intermittently on a labetolol drip. labetolol was increased and terazosin added and titrated up. her hypertension was exacerbated by left eye pain/headache, which was managed as below. plasma metanephrines, renin, aldosterone pending. . 2) left uveitis/endophthalmitis: the patient was evaluated by ophthomology, who noted normal ocp and felt her findings were consistent with uveitis. she was treated with atropine/prednisolone eye drops. neurology was consulted to assist with evaluation of other causes of headache; they felt her symptoms were also most likely secondary to uveitis. she had a mri/mrv of her head which was without evidence of sinus thrombosis. she required high doses of narcotics. she developed endophthalmitis, sent for l eye enucleation given risk for autoimmune attack in contralateral eye. she is to have daily eye dressing changes with a sterile eye patch and bacitracin ointment. she will follow up with oculoplastics at and follow up with her ophthalmologist. she will continue prednisone 30 mg daily for the next 3 days then taper to 20 mg daily until her ophthalmology follow up. she was seen by id and will also follow up with dr. . she was started on bacrim ppx while on prednisone. . 3) exrd: tues/th/sat dialysis; continue sevelamer. follow up with dr. . . 4) forearm rash: she will apply eucerin lotion and follow up with dr. of dermatology . . 5) sle: continue prednisone, mycophenolate. . 6) code full medications on admission: cellcept 500mg clonidine 0.3mg/24 hour diovan 320mg daily labetolol 600mg tid lisinopril 40mg daily ativan 1mg prn nicardipine 40mg q8 prednisone 40mg daily discharge medications: 1. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 2. lisinopril 20 mg tablet sig: two (2) tablet po bid (2 times a day). 3. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed. 5. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qfri (every friday). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). disp:*90 tablet(s)* refills:*2* 8. nicardipine 20 mg capsule sig: two (2) capsule po q8h (every 8 hours). 9. sevelamer 400 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 10. gabapentin 100 mg capsule sig: one (1) capsule po qtuthsa (tu,th,sa). disp:*30 capsule(s)* refills:*2* 11. terazosin 2 mg tablet sig: four (4) tablet po bid (2 times a day). 12. bacitracin-polymyxin b 500-10,000 unit/g ointment sig: one (1) appl ophthalmic q8h (every 8 hours). disp:*qs 1 month* refills:*2* 13. oxycontin 40 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po three times a day: take with 3 10 mg tabs for a total of 70 mg tid. disp:*90 tablet sustained release 12 hr(s)* refills:*0* 14. oxycontin 10 mg tablet sustained release 12 hr sig: three (3) tablet sustained release 12 hr po once a day: take with 40 mg tab for a total of 70 mg tid. disp:*90 tablet sustained release 12 hr(s)* refills:*0* 15. eucerin lotion sig: one (1) app topical twice a day. disp:*qs 1 month* refills:*2* 16. eye pad pad sig: one (1) sterile pad miscellaneous once a day. disp:*30 pads* refills:*2* 17. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day). disp:*450 tablet(s)* refills:*2* 18. oxycodone 5 mg tablet sig: two (2) tablet po q3h (every 3 hours) as needed. disp:*120 tablet(s)* refills:*0* 19. prednisone 10 mg tablet sig: as directed tablet po once a day: take 3 tabs daily for next 3 days, then take 20 mg daily until your ophthalmology follow up. disp:*60 tablet(s)* refills:*2* 20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 21. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 22. vancomycin 1,000 mg recon soln sig: one (1) g intravenous qhd for 12 days. disp:*12 g* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: endophthalmitis s/p enucleation left eye malignant hypertension bacteremia end stage renal disease discharge condition: stable discharge instructions: continue your medications as listed. please continue to change your eye dressing with bacitracin ointment and a sterile eye pad daily as assisted with vna. please make sure you follow up with dr. and dr. of ophthalmology as well as your pcp and nephrologist. followup instructions: 1. provider: , date/time: 3:20. this appointment is in your pcp's office to review your pain medication. building, , south suite. 2. please follow up with dr. of oculoplastics as directed. 3. please also follow up with dr. of ophthalmology in 2 weeks. 4. please follow up with dr. in weeks. 5. you can follow up with dr. of dermatology in the clinic on monday at 1pm to assess your forearm rash. Procedure: Hemodialysis Other enucleation of eyeball Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies Systemic lupus erythematosus Anemia in chronic kidney disease End stage renal disease Long-term (current) use of steroids Hematoma complicating a procedure Bacteremia Rash and other nonspecific skin eruption Infection and inflammatory reaction due to other vascular device, implant, and graft Other candidiasis of other specified sites Acute endophthalmitis Scleritis, unspecified Orbital hemorrhage Mycotic corneal ulcer Acute and subacute iridocyclitis, unspecified

allergies: penicillins / percocet / morphine attending: chief complaint: dyspnea, hypertension major surgical or invasive procedure: 1. ultrasound guided tap 2. venogram history of present illness: ms. is a 24 year old female with a history of sle, esrd on hd, h/o malignant htn, svc syndrome, pres, prior ich, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain that presented to the ed with critically high blood pressure and dyspnea. she was recently discharged on for hypertensive urgency and dyspnea. she was treated with labetolol gtt, , and her home medications with improvement of her bp. she was discharged home in stable condition on . she had been doing well at home, but missed her hd session on due to transportation issues. she has been taking her medications without any difficulty. on the morning of admission, she noted increase dyspnea, and had a dry cough, although this is not particularly new. she presented to the er for dyspnea. she continues to have the chronic abdominal pain which is unchanged, and is controlled right now. in the emergency department, vs= 98.1, 240/140, 128, 30, 96%ra. on initial evaluation, she was noted to have sbp 70s on the right arm, 240s on the left arm. she did not complain of any pain. she underwent cta torso to eval for dissection which was negative for dissection or pe. the imaging showed persistent svc thrombus. there was also note of bilateral ground glass and nodularities therefore was given levofloxacin 750 mg iv x 1. she was given labetalol iv, then started on a labetalol gtt. her bp remained elevated, therefore she was transferred to the icu for bp control and then . she was also given dilaudid 1 mg iv x 1 as well. ms. was taken to the micu and treated for malignant hypertension. she was given hemodialysis and her blood pressure stabilized. she was transferred to the medical floor. she continued to receive tuesday, thursday, and saturday. on , she had a paracentesis of her abdomen. she is complaining of focal tenderness around the point of insertion. on , she was transferred back to the micu because of stridor that was treated with heliox. she was stabilized, and came back to the floor on . on , ms. had a venogram. on , an angiography intervention for an occlusion of her left brachiocephalic vein was discontinued because her occlusion was not as drastic as prior imaging indicated when tested with a 22 gauge needle. ms. was discharged on with stable blood pressures and abdominal pain controlled. past medical history: 1. systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since . -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. ckd/esrd: diagnosed in and has previously been on pd and now hd 3. malignant hypertension with baseline sbp's 180's-220's and history of hypertensive crisis with seizures. 4. thrombocytopenia 5. thrombotic events with negative hypercoagulability work-up - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy 12. obstructive sleep apnea on cpap 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, . 15. pericardial effusion 16. cin i noted in , not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. gastric ulcer 18. pres social history: denies tobacco, alcohol or illicit drug use. lives with mother and is on disability for multiple medical problems. family history: no known autoimmune disease. physical exam: general: a&ox3. nad, oriented x3. heent: nc/at; perrla on right, enucleated eye on left; op clear, neck: supple, no lad lungs: cta b, with few crackles at bases. cv: rrr, s1, s2 abdomen: soft, minimally distended, diffuse mild tenderness to palpation ext: palpable dp/pt pulses, no clubbing, cyanosis or edema. neuro: cn 2-12 intact. moving all four extremities spontaneously. pertinent results: 07:50am blood wbc-2.8* rbc-2.51* hgb-7.3* hct-23.1* mcv-92 mch-29.1 mchc-31.8 rdw-21.1* plt ct-134* 10:30am blood wbc-3.5* rbc-2.36* hgb-6.8* hct-21.6* mcv-92 mch-28.9 mchc-31.6 rdw-20.5* plt ct-121* 07:50am blood pt-14.7* ptt-35.0 inr(pt)-1.3* 07:50am blood glucose-154* urean-20 creat-4.4* na-138 k-4.0 cl-103 hco3-23 angap-16 10:30am blood vanco-17.8 09:35am blood wbc-3.8* rbc-2.39* hgb-7.0* hct-21.6* mcv-90 mch-29.2 mchc-32.4 rdw-19.8* plt ct-120* 12:30pm blood wbc-3.6* rbc-2.49* hgb-7.0* hct-22.5* mcv-90 mch-28.3 mchc-31.3 rdw-18.8* plt ct-121* 09:35am blood plt ct-120* 09:35am blood pt-19.7* ptt-38.4* inr(pt)-1.8* 12:30pm blood plt ct-121* 12:30pm blood pt-29.5* ptt-43.9* inr(pt)-2.9* 09:35am blood glucose-90 urean-19 creat-4.2*# na-138 k-4.2 cl-102 hco3-25 angap-15 12:30pm blood glucose-72 urean-34* creat-6.0*# na-137 k-4.5 cl-102 hco3-24 angap-16 12:30pm blood calcium-8.2* phos-4.6* mg-1.6 05:44am blood calcium-8.9 phos-5.1* mg-1.7 12:27pm blood -positive * titer-1:80 12:27pm blood c3-69* c4-17 12:30pm blood vanco-16.7 08:57am blood vanco-15.9 04:16am blood vanco-19.2 07:27am blood type-art po2-66* pco2-52* ph-7.30* caltco2-27 base xs--1 02:06pm blood lactate-1.0 brief hospital course: 24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on for dyspnea and hypertensive urgency. 1. hypertensive urgency - pt presented to er with sbp in 240s and c/o dyspnea. her blood pressures were reported as unequal and cta in er was done. this study showed no signs of dissection. pt's blood pressure was controlled with labetalol gtt. at time of transfer, she denied cp and sob. ce's were flat. she was started on her home bp regimen of oral labetalol on , and nifedipine/hydralazine/aliskerin soon after admission. pt was also continued on her hd regimen for esrd, for volume control. . 2. angioedema - pt developed facial swelling and shortness of breath while on medical floor. she was taken to icu and responded favorably to heliox. patient returned to floor and has been comfortably breathing since. given history of svc, venogram was ordered that did not indicate a complete occlusion of the left brachiocephalic vein, as previously thought, with help of 22 gauge needle. 3. cough: pt presented with chronic cough/dyspnea without fevers. chest ct revealed bilateral infiltrates and nodularities, noted possibly infectious vs edema. pt was started on vanc/zosyn given recent hospitalization, brief temp spike, and pulm infiltrates. abx were stopped after cultures were neg. at time of transfer, pt's dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. . 4. chronic abdominal pain - pt has had chronic abdominal pain, which was well controlled at time of transfer. she was continued on her current outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch. her lfts and lipase were wnl. she had no signs of sbo. . 5. bacteremia - gpc in pairs and clusters; started on vanco on . . 6. ascites - unclear etiology and new findings for her. pt is to get workup with liver team as outpatient. her seems to have slightly improved this finding. her coags were unremarkable. she was seen by hepatology in house who did not have any specific recommendations at this time but asked to see her in follow up as an outpatient. . 7. esrd on hd - hd satuth,. pt was continued on her hd regimen while in house. sevelamer was continued as well. . 8. anemia/pancytopenia - chronic anemia, baseline pancytopenia, likely ckd and sle, currently above baseline, though has h/o gib. pt's pancytopenia remained stable; c3 and c4 studies were performed and it was felt that her sle was not active at this time. guiac stools were neg. epo was continued at hd. . 9. h/o gastric ulcer - ppi was continued throughout hospitalization. . 10. sle - pt was continued on home regimen of prednisone 4mg po qdaily. . 11. h/o svc thrombosis - patient's warfarin was discontinued after discussion with dr. . she frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether. . 12. seizure disorder - pt was continued on home regimen keppra 1000 mg po 3x/week (tu,th,sa). . 13. depression - pt was continued on her home celexa. . medications on admission: 1.nifedipine 90 mg po daily (daily). 2.nifedipine 60 mg tablet sustained release po hs (at bedtime). 3.lidocaine 5 % patch q24hr. 4.aliskiren 150 mg tablet sig: one (1) tablet po bid 5.citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 6.fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch q72h 7.prednisone 4 mg po daily (daily). 8.clonidine 0.1 mg/24 hr patch qsat (every saturday). 9.clonidine 0.3 mg/24 hr patch qsat (every saturday). 10.sevelamer hcl 1600 mg po tid w/meals (3 times a day with meals). 11.gabapentin 100 mg capsule sig: one (1) capsule po qhd 12.labetalol 1000 mg tablet tablet po tid 13.hydralazine 100 mg tablet po q8h 14.warfarin 3 mg tablet po once daily at 4 pm. 15.pantoprazole 40 mg po q12h (every 12 hours). 16.levetiracetam 1000 mg po 3x/week (tu,th,sa). discharge medications: 1. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po every twelve (12) hours. 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qthur (every thursday). 3. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po at bedtime. 4. nifedipine 30 mg tablet sustained release sig: three (3) tablet sustained release po qam (once a day (in the morning)). 5. aliskiren 150 mg tablet sig: one (1) tablet po bid (2 times a day). 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 9. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 10. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal every thursday. 11. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 12. gabapentin 100 mg capsule sig: one (1) capsule po qhd (each hemodialysis). 13. labetalol 200 mg tablet sig: five (5) tablet po tid (3 times a day): please hold if systolic blood pressure < 100 or hr < 55. 14. hydralazine 50 mg tablet sig: two (2) tablet po q8h (every 8 hours). 15. levetiracetam 500 mg tablet sig: two (2) tablet po 3x/week (tu,th,sa). 16. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 17. vancomycin 500 mg recon soln sig: one (1) recon soln intravenous hd protocol (hd protochol). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*2* 19. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 20. dilaudid 2 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain: do not drive or operate heavy machinery with this medication as it can cause drowsiness. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: malignant hypertension angioedema ascites end stage renal disease secondary: chronic abdominal pain anemia/pancytopenia lupus gastric ulcer svc thrombosis seizure disorder depression discharge condition: hemodynamically stable with blood pressures 130-140 / 60-90 discharge instructions: you were admitted to on because of critically high blood pressure. while here, you were given iv antihypertensive medications, and then you were switched to antihypertnsive medications by mouth. you received multiple sessions of hemodialysis. you had a distended, tender belly, and you underwent a ultrasound guided tap to remove the fluid in your abdomen. on , you developed throat and facial swelling, and you were transferred from the medical floor to the icu. you were given medication to help open your airway; you were stabilized and went to hemodialysis several times. you were transferred back to the medical floor. you had a venogram on , and the results at this time are still pending. you had blood cultures drawn that were positive for bacteria. you received iv antibiotics while at hemodialysis. you will continue to receive these antibiotics at your appointments. please keep all of your medical appointments. please go to the nearest emergency room if you experience any of the following: 1. chest pain 2. headaches 3. lightheadedness 4. changes in vision 5. nausea and vomiting followup instructions: please continue your regular hemodialysis schedule. you have the following appointments scheduled. please call if you need to cancel or change your appointments. provider: ,schedule hemodialysis unit date/time: 12:00 provider: , md phone: date/time: 2:00 provider: clinic phone: date/time: 3:15 Procedure: Hemodialysis Percutaneous abdominal drainage Non-invasive mechanical ventilation Transfusion of packed cells Phlebography of other specified sites using contrast material Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Systemic lupus erythematosus Thrombocytopenia, unspecified Anemia in chronic kidney disease Anemia of other chronic disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Unspecified disease of pericardium Bacteremia Compression of vein Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Unspecified accident Other ascites Other specified peripheral vascular diseases Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Angioneurotic edema, not elsewhere classified Infection and inflammatory reaction due to other vascular device, implant, and graft Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Stridor

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress major surgical or invasive procedure: intubation history of present illness: 8 yo h/o copd, htn, hl who presented to the ed the early morning of with respiratory distress. t 96.8, bp 118/54, hr 70, rr 18 on bipap 5/5. found to have wbc 21 with 4% bandemia, cr 2.1 (baseline 0.9), lactate 3.3, trop <0.01. cxr showed a rml pneumonia. she received vancomycin and levofloxacin. given her respiratory distress, she was started on bipap, improved, and was taken off bipap. however, around 7 a.m. on her respiratory status worsened with abg 6.98/81/159. extremities were cool. she was intubated. . about 1 hour after intubation, she went into pea arrest, requiring epi x 2 and atropine x 2 and 4 minutes of cpr. a right ij sepsis line was placed. ivf, ceftriaxone, and pip-tazo were given. she was also started on norepinephrine for hypotension, with sbp improving to 110s. a bedside u/s showed no ptx and no pericardial effusion. repeat abg was 6.75/112/227/18; tidal volume was increased, paralytics given, a-line placed. sbp continued to drop, and phenylephrine and then vasopressin were started. sbp transiently improved with disconnection from the ventilator and manual bagging. got total of 8 l of ns. got methylpred 125 x 1. . admitted to micu. . ros not obtained as patient was intubated. past medical history: emphysema hypertension hyperlipidemia social history: tobacco abuse per omr, not obtained as patient is intubated family history: mother dies of a brain tumor of unknown type in her 50's and father died of massive mi in his 60's. no other hx of dmii, cad, cad or emphysema in the family physical exam: general: intubated elderly woman heent: nc/at, sclera anicteric, et in place neck: jvp not elevated lungs: coarse breath sounds bilaterally from anterior 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: cool, weak pedal pulses, no edema pertinent results: 02:50am wbc-21.2*# rbc-4.69 hgb-14.3 hct-43.0 mcv-92 mch-30.4 mchc-33.2 rdw-12.7 02:50am neuts-81* bands-4 lymphs-5* monos-3 eos-0 basos-0 atyps-0 metas-3* myelos-1* promyelo-3* 02:50am plt smr-normal plt count-212 02:50am ck-mb-notdone 02:50am ctropnt-<0.01 02:50am ck(cpk)-17* 02:50am glucose-130* urea n-46* creat-2.1*# sodium-139 potassium-3.9 chloride-100 total co2-21* anion gap-22* 02:54am lactate-3.3* . echo : left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. there is moderate global left ventricular hypokinesis (lvef = 30 %). right ventricular chamber size is normal. with moderate global free wall hypokinesis. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , biventricular systolic dysfunction is new. . cxr : severe emphysema with new right lower lung consolidation since , likely representing pneumonia. nodular densities also noted, more prominent than that seen on ct of ; given rapid growth, these likely are infectious/inflammatory in etiology, however malignancy cannot be excluded. given these abnormalities, ct chest is recommended to exclude right hilar mass. brief hospital course: upon arrival to micu, patient was intubated, and despite weaning off of sedatives, she was unresponsive with fixed, dilated pupils. her bp dropped and she required up to 4 pressors. the patient expired after a few hours with family by her bedside. medications on admission: albuterol inh atenolol 25 mg qday fluticasone-salmeterol inh simvastatin 40 mg qday tiotropium inh verapamil sr 180 mg qday aspirin 325 mg qday calcium + d discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Acute respiratory failure Defibrination syndrome Cardiac arrest Septic shock Dehydration

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob major surgical or invasive procedure: cardiac catheterization intubation history of present illness: pt is 66 yo f with copd, htn, h/o recurrent pna, who presents with sob. 3 days ago, pt began to experience headache, sore throat, non-productive cough, sob, and chills. she says 3 people at work have been sick with headache, sore throat, and cough and that now "she caught it." last pm, pt had worsening sob and called 911 because she "couldn't catch her breath." denies cp, n/v/d, muscle aches. . in the , pt was found to have decreased air movement and wheezes on exam. she also had positive trop, but non-diagnostic ekg per cardiology. she was given albuterol/atrovent nebs, solumedrol 125mg iv, vanc 1g iv, zosyn 4.5g iv, and morphine 2mg iv. she was also tachycardic to 150's, so was given diltiazem 5mg iv. . pt currently c/o sob, but says her breathing has improved sincer her presentation to the ed. denies cp. past medical history: - copd (last 's show fev1 59%, fev1/fvc 60%, seen by dr. on ) - h/o recurrent pna (last discharged from on ) - chronic sinusitis - htn - hyperlipidemia meds: atenolol 50 mg qd lipitor 10 mg qd spiriva 1 capsule qd advair 100/50 1 puff fluticasone nasal spray 2 puffs qd social history: married to husband who is disabled due to stroke. has one child. works as a membership saleswoman for a gym but teaches occasional classes. drinks a glass of wine occassionally with meals, smoked 5 cig/day for 30 yrs, reports quitting smoking 6mo ago. no ivdu and is sexually monogamous with her husband. family history: mother dies of a brain tumor of unknown type in her 50's and father died of massive mi in his 60's. no other hx of dmii, cad, cad or emphysema in the family physical exam: vitals: t 96.1 bp 152/86 hr 149 rr 26 o2sat 99% on nebulizers gen: moderate resp distress, but able to speak sentences. tremulous. heent: op clear, no exudate. neck: supple. no jvd. cardio: regular, tachycardiac, no murmurs appreciated resp: decreased air movement throughout. diffuse end-expiratory wheezes. abd: soft, nt, nd, +bs ext: no c/c/e neuro: a&ox3 pertinent results: 04:15am pt-11.7 ptt-27.7 inr(pt)-1.0 04:15am plt count-160 04:15am neuts-74.3* lymphs-17.9* monos-6.0 eos-1.6 basos-0.3 04:15am wbc-9.1 rbc-5.20 hgb-15.9 hct-46.0 mcv-89 mch-30.6 mchc-34.5 rdw-12.6 04:15am calcium-9.2 phosphate-4.1 magnesium-2.0 04:15am ck-mb-7 04:15am ctropnt-0.14* 04:15am ck(cpk)-123 04:15am estgfr-using this 04:15am glucose-144* urea n-12 creat-0.6 sodium-140 potassium-4.0 chloride-104 total co2-22 anion gap-18 04:31am lactate-1.1 07:27am type-art po2-146* pco2-51* ph-7.28* total co2-25 base xs--2 12:08pm ck-mb-25* mb indx-7.7* ctropnt-0.39* 12:08pm ck(cpk)-324* 04:47am blood wbc-12.8* rbc-4.82 hgb-14.7 hct-42.1 mcv-87 mch-30.4 mchc-34.8 rdw-12.3 plt ct-291 03:04am blood neuts-86* bands-0 lymphs-6* monos-4 eos-0 baso-0 atyps-3* metas-0 myelos-1* 03:04am blood hypochr-normal anisocy-normal poiklo-normal macrocy-1+ microcy-normal polychr-normal 04:47am blood plt ct-291 03:04am blood pt-12.3 ptt-44.1* inr(pt)-1.1 04:47am blood glucose-119* urean-25* creat-0.7 na-143 k-3.4 cl-104 hco3-30 angap-12 03:04am blood alt-27 ast-14 ld(ldh)-281* alkphos-46 amylase-31 totbili-0.4 04:00pm blood ck-mb-5 ctropnt-0.11* 04:56am blood ck-mb-17* mb indx-2.6 ctropnt-0.25* 02:54am blood ck-mb-34* mb indx-7.3* ctropnt-0.51* 08:00pm blood ck-mb-37* mb indx-7.2* ctropnt-0.66* 12:08pm blood ck-mb-25* mb indx-7.7* ctropnt-0.39* patient/test information: indication: shortness of breath. height: (in) 67 weight (lb): 118 bsa (m2): 1.62 m2 bp (mm hg): 164/91 hr (bpm): 145 status: inpatient date/time: at 15:22 test: portable tte (complete) doppler: full doppler and color doppler contrast: none tape number: 2007w000-0:00 test location: west ccu technical quality: suboptimal referring doctor: dr. measurements: left atrium - long axis dimension: 4.0 cm (nl <= 4.0 cm) left ventricle - ejection fraction: 45% (nl >=55%) interpretation: findings: this study was compared to the report of the prior study (images not available) of . left atrium: mild la enlargement. right atrium/interatrial septum: the ivc is normal in diameter with >50% decrease collapse during respiration (estimated rap 5-10 mmhg). left ventricle: suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. mildly depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. aortic valve: aortic valve not well seen. trace ar. mitral valve: mitral valve not well seen. no mr. tricuspid valve: tricuspid valve not well visualized. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor echo windows. results were reviewed with the cardiology fellow involved with the patient's care. conclusions: the left atrium is mildly dilated. the estimated right atrial pressure is mmhg. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded but there appears to be distal left ventricullar and apical akinesis. overall left ventricular function is mildly depressed with an ef of ~45%. right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. trace aortic regurgitation is seen. the mitral valve is not well seen. no mitral regurgitation is seen. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , the regional left ventricular dysfunction is new. cardiology report c.cath study date of brief history: 66 year old female with acute respiratory failure, elevated cardiac enzymes, and an anterior wall motion abnormality on echocardiogram. intubated and sedated presently. no known history of cad. indications for catheterization: coronary artery disease, canadian heart class iv, stable. procedure: left heart catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 french left catheter, advanced to the ascending aorta through a 5 french introducing sheath. coronary angiography: was performed in multiple projections using a 5 french jl4 and a 5 french jr4 catheter, with manual contrast injections. conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. hemodynamics results body surface area: 1.57 m2 hemoglobin: 12.8 gms % fick **pressures right atrium {a/v/m} 14/14/13 right ventricle {s/ed} 44/14 pulmonary artery {s/d/m} 42/21/30 pulmonary wedge {a/v/m} 26/23/21 aorta {s/d/m} 96/54/65 **cardiac output heart rate {beats/min} 70 rhythm sinus o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 12 card. op/ind fick {l/mn/m2} 16.4/10.4 **resistances systemic vasc. resistance 254 pulmonary vasc. resistance 44 fick **% saturation data (fl) svc high 92 ra high 89 ivc high 97 rv inflow 92 pa main 93 ao 99 other hemodynamic data: the oxygen consumption was assumed. **arteriography results morphology % stenosis collat. from **right coronary 1) proximal rca normal 2) mid rca discrete 30 2a) acute marginal normal 3) distal rca normal 4) r-pda normal 4a) r-post-lat normal **arteriography results morphology % stenosis collat. from **left coronary 5) left main discrete 30 6) proximal lad discrete 40 6a) septal-1 normal 9) diagonal-1 normal 12) proximal cx normal 13) mid cx normal 13a) distal cx normal 14) obtuse marginal-1 discrete 50 technical factors: total time (lidocaine to test complete) = 30 minutes. arterial time = 10 minutes. fluoro time = 9 minutes. contrast injected: non-ionic low osmolar (isovue, optiray...), vol 60 ml anesthesia: 1% lidocaine subq. anticoagulation: other medication: midazolam 5 mg iv fentanyl 75 mcg iv cardiac cath supplies used: - allegiance, custom sterile pack comments: 1. selective coronary angiography in this right dominant system revealed mild cad. the lmca had a 30% distal stenosis. the lad had a 40% mid vessel stenosis. the lcx had a 50% stenosis in a small om branch. the rca had a 30% mid vessel stenosis. 2. left ventriculography was not performed. 3. resting hemodynamics demonstrated a rvedp of 13 mmhg. there was mild pulmonary arterial hypertension with a pulmonary pressure of 42/21 mmhg. there was elevated left sided filling pressures with a pulmonary capillary wedge pressure of 21 mmhg. central aortic pressure was low at 96/54 (mean 70) mmhg. cardiac index elevated at 11 l/min/m2 consistent with possible sepsis. final diagnosis: 1. three vessel coronary artery disease. 2. markedly elevated cardiac index. cardiology report echo study date of patient/test information: indication: left ventricular function. height: (in) 67 weight (lb): 118 bsa (m2): 1.62 m2 bp (mm hg): 153/63 hr (bpm): 68 status: inpatient date/time: at 14:56 test: portable tte (complete) doppler: full doppler and color doppler contrast: none tape number: 2007w013-1:17 test location: west micu technical quality: suboptimal referring doctor: dr. measurements: left atrium - long axis dimension: 2.6 cm (nl <= 4.0 cm) left atrium - four chamber length: 3.1 cm (nl <= 5.2 cm) right atrium - four chamber length: 3.6 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.4 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 2.5 cm left ventricle - fractional shortening: 0.43 (nl >= 0.29) left ventricle - ejection fraction: >= 65% (nl >=55%) aorta - valve level: 2.5 cm (nl <= 3.6 cm) aortic valve - peak velocity: 1.9 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.25 mitral valve - e wave deceleration time: 206 msec tr gradient (+ ra = pasp): 22 mm hg (nl <= 25 mm hg) interpretation: findings: this study was compared to the prior study of . left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness. normal lv cavity size. overall normal lvef (>55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. general comments: suboptimal image quality - poor echo windows. conclusions: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is an anterior space which most likely represents a fat pad. compared with the prior study of , left ventricular function appears improved. brief hospital course: this is a 66 yo f with copd, h/o recurrent pna's, htn, and hyperlipidemia who presented with respiratory distress. she was admitted to the micu and the following issues were addressed during her hospitalization. . #) resp failure: the patient was admitted to the micu for respiratory distress attributed to a copd exacerbation. although her cxr did not show an infiltrate, she was started empirically on nebulizer treatments and antibiotics. likely secondary to copd exacerbation due to infection. she was started on ceftriaxone and azithromycin. she was also started on methylprednisilone for her copd flare. the patient failed extubation on and . shortly after both extubation attempts, the patient's sbp climbed to the 200s and the patient experienced respiratory distress. therefore, her failure to extubate was attributed to both her copd exacerbation and likely flash pulmonary edema in the setting of hypertension. after her first extubation failure, her antibiotic coverage was broadened to vanc/zosyn to cover for nosocomial pna although no infiltrate was seen on cxr. she was also continued on iv steroids. she completed a 5 day course of azithromycin and a seven day course of vancomycin/pip-tazo. sputum cx from grew 1+ gpcs, sputum from grew aspergillus, and sputum from likely grew mold thought to be a contaminant. there was no other evidence of fungal infection. blood cultures, repiratory viral antigens, and viral cx were all negative. the patient was diuresed and her htn was controlled on a nitro gtt. she was succesfully extubated. she continued to have improving oxygenation, weaning to 2l oxygen and was transferred to the floor for 12h, after which she was discharged home on home oxygen . # elevated cardiac enzymes: the patient had st elevations on ekg and elevated ce with max ck 650 and trop 0.66. she was placed on a heparin. she underwent a cardiac catheterization which showed mild 3 vd and markedly increased ci. acs was thought to be unlikely and the heparin gtt was discontinued. echo from showed lvef >55% and no wall motion abnormalities. she was started on asa and atorvastatin. a bb was not started her severe copd exacerbation. . # arrhythmia: the patient had an episode of fascicular vt with hypotension on which lasted 10-15 minutes. it resolved with metoprolol 12.5 po. post-ekg showed a changed axis from prior. cards was consulted and recommended starting the patient on verapamil. . #) htn: the patient had a labile bp throughout her admission. the patient's bp was controlled via an esmolol gtt initially which was weaned once she was intubated and sedated. she was placed on a nitro gtt prior to her successful extubation with good effect. she was transitioned to lisinopril and verapamil for bp control. . #) h/o recurrent sinusitis: she was continued on fluticasone nasal spray. . medications on admission: meds on transfer: insulin sc (per insulin flowsheet) acetaminophen 325-650 mg po q4-6h:prn lisinopril 40 mg po daily aspirin 325 mg po daily pantoprazole 40 mg po q24h atorvastatin 10 mg po daily prednisone 60 mg po daily order date: @ 1118 docusate sodium (liquid) 100 mg po bid senna 1 tab po bid:prn fluticasone-salmeterol (100/50) 1 inh ih fluticasone propionate nasal 2 spry nu daily tiotropium bromide 1 cap ih daily guaifenesin-codeine phosphate ml po q4h:prn cough verapamil sr 180 mg po q24h . discharge medications: 1. oxygen therapy patient requires 2-4 l of continuous oxygen given via nasal canula. 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). :*30 cap(s)* refills:*0* 3. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). :*1 disk with device(s)* refills:*2* 4. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) spray nasal daily (daily). :*1 qs* refills:*2* 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. :*30 tablet(s)* refills:*0* 7. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*0* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). :*30 tablet, delayed release (e.c.)(s)* refills:*0* 9. prednisone 10 mg tablet sig: as directed tablet po once a day: take 6 tablets a day for 2 more days, then 5 tablets a day for 1 week then 4 tablets a day for 1 week, then 3 tablets a day for 1 week, then 2 tablets a day for 1 week, then 1 tablet a day for another week. after that take 5mg a day until further notified by your pcp. :*117 tablet(s)* refills:*0* 10. prednisone 5 mg tablet sig: one (1) tablet po once a day: start after 10mg tablets are finished. continue until otherwise noted by your pcp. :*30 tablet(s)* refills:*0* 11. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). :*60 tablet(s)* refills:*0* 12. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q4h (every 4 hours) as needed for cough. :*1 qs* refills:*0* 13. verapamil 180 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). :*30 tablet sustained release(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: copd hospital acquired pneumonia pulmonary edema elevated cardiac enzymes hypertension arrythmia discharge condition: good, tolerating pos, satting >95% on 2l, ambulating without assistance discharge instructions: you were admitted with respiratory failure and were intubated and treated with steroids, antibiotics, nebulizers, and diuresis and discharged with mild oxygenation requirement . please seek medical attention should your shortness of breath worsen, or should you develop chest pain, lightheadedness, dizziness. . take all your medications exactly as prescribed, and follow up as below. followup instructions: please maek an appointment with your pcp, . at within the next week to follow up provider: breathing tests phone: date/time: 1:40 provider: , intepretation billing date/time: 2:00 provider: . phone: date/time: 2:00 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Left heart cardiac catheterization Insertion of endotracheal tube Non-invasive mechanical ventilation Arterial catheterization Diagnoses: Pneumonia, organism unspecified Acidosis Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Acute respiratory failure Other specified cardiac dysrhythmias Other and unspecified angina pectoris Acute myocardial infarction of other specified sites, initial episode of care

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered ms major surgical or invasive procedure: none history of present illness: yo m w/ pmh multiple mylemoa, with plasmacytoma of left clavicle dx in s/p xrt (last ~) with recent admission () for dehydration and pna presents with one day of altered ms . pt recently returned home from rehab 5 days ago after completing treatment for pna with vanc/zosyn. . in ed, found to be hypotensive to 90's systolic which was responsive to fluids. also febrile, w/ t 101. labs notable for hct down to 25 (from baseline 28-30), cr elevated to 2.4 (from baseline 1.1-1.3), elevated trop/cks. pt was trace guiac + on exam. cxr showed improved left upper lobe opacity. in , pt received 2.5 l ns and one unit prbc. pt received one dose of vanc and 1 dose zosyn. his ecg showed inferolateral st depressions. cardiology was called and felt that his troponin leak was due to septic shock and not an acute mi - they recommended treatment for . he was then transferred to the floor. shortly after arriving on the floor, his bp dropped into the 70's systolic and micu eval was requested. on arrival he was found to have sbp in the 70's and to be minimally responsive. his sats were in the low eighties. an ecg was repeated and he again had inferolateral st depressions. he had one piv. ns was agressively started and a second piv was placed and fluids given. he was put on a nrb and sats were in the mid nineties, and a gas showed adequate oxygenation and ventilation. his blood pressure did not respond to ivf so he was started on levophed through his lt. piv awaiting micu transfer. past medical history: past onc hx the patient was referred to dr. for a left clavicular mass in . the patient had a history of fx in the left humerous. in early , he developed a mass in his left shoulder. at first this was thought to be a deformity post-fracture but it continued to grow so it was decided to biopsy it. on needle biopsy the mass was found to be a plasmacytoma. an spep was done that showed an iga lambda monoclonal protein and lambda light chains in the serum, a 24 hour urine and upep revealed that the patient excreted about 7300 mg per day of light chains per day. he was originally treated with decadron in . he was being treated with xrt (last ~). . pmhx hypertension coronary artery disease s/p mi , peptic ulcer s/p gib benign prostatic hypertrophy h/o temporal arteritis h/o pemphigoid h/o anemia h/o small bowel volvulus s/p appendectomy s/p status post inguinal hernia repair x2 h/o colonic polyps sigmoid diverticulosis rheumatoid arthritis "sleepwalking" h/o neck problems (?). . past surgical history: 1. s/p appendectomy 2. s/p status post inguinal hernia repair x2 social history: the patient is married, lives in his own home. his son helps care for both he and his wife. previously worked as a psychoanalyst. he was in the army in world war ii in . he had no chemical or toxin exposure, no radiation exposure. family history: noncontributory physical exam: vitals - t 99.1 (axillary), hr 113, bp 84/40 -> sbp 62, rr 18, o2 94% 2l nc general - pt moaning, non-responsive to verbal commands heent - cvs - distant heart sounds, appeared regular, tachycardic, no noted m/r/g lungs - could not clearly ascultate pt's moaning abd - soft, + palpable aortic pulse, could not assess for tenderness, normoactive bowel sounds. g tube site with significant purulence. ext - no le edema b/l, bt. heel ulcerations, grade neuro - awake, not alert, minimally responsive pertinent results: 02:30pm pt-13.6* ptt-33.5 inr(pt)-1.2* 02:30pm plt smr-normal plt count-265 02:30pm neuts-66 bands-4 lymphs-13* monos-6 eos-8* basos-1 atyps-0 metas-1* myelos-1* 02:30pm wbc-11.0 rbc-2.78* hgb-8.8* hct-25.4* mcv-91 mch-31.6 mchc-34.5 rdw-15.5 02:30pm ck-mb-10 mb indx-2.1 ctropnt-2.67* 02:30pm glucose-84 urea n-43* creat-2.4*# sodium-125* potassium-4.6 chloride-86* total co2-30 anion gap-14 02:45pm lactate-1.6 k+-4.7 09:30pm calcium-7.6* phosphate-4.5# magnesium-2.3 09:30pm ck-mb-9 ctropnt-2.46* 11:25pm lactate-2.4* brief hospital course: pt is a yo man with mmp including multiple myeloma, with plasmacytoma of left clavicle , s/p recent admission for dehydration and pna (d/ced ) who was readmitted with and 1 day ms changes. on presentation to floor, pt hypotensive, low grade fever, unresponsive, therefore got micu evaluation and pt was transferred to micu. upon transfer to the micu, patient was intubated, started on levophed, and started on vancomycin, cefepime, and flagyl for antibiotic coverage. approximately 24 hours after admission, patient developed tachycardia and with mottled and cool extremities. son (his hcp) was called with initial decline in vital signs and pt's code status was then changed from full code to do not administer cpr. patient then received a total of 3l ns, levophed was increased, 3 amps bicarb were administered, patient was started on dopamine, and patient was administered epinephrine. patient's bp then diminished to 0 and heart rhythm was pea. time of death was called at 12:15am on . medications on admission: prednisone 5mg qd protonix 40 qd isosorbide mononitrate cr 30mg qd tramadol prn aricept 10 qd nameda 10 asa discharge medications: none discharge disposition: expired discharge diagnosis: 1. septic shock 2. pneumonia discharge condition: expired discharge instructions: none followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Septic shock Multiple myeloma, without mention of having achieved remission Dehydration

history of present illness: the patient is a -year-old man with a history of peptic ulcer disease, coronary artery disease, status post myocardial infarction in as well as , temporal arteritis, who presented with melenas and chest pain. the patient reported melanotic stools times 5 since 4 p.m. on the day prior to admission. no hematemesis or hematochezia. stools were loose. the patient had a history of melena in . the patient also reported being lightheaded, fatigued with an increase in his ch set discomfort for which he was taking sublingual nitroglycerin with relief. on the a.m. of presentation, the symptoms persisted; the patient contact his pcp who sent him to the . in the ed, the p was found to have a hematocrit of 22.9 decreased from a baseline of 32 to 38. he was given iv protonix, iv fluids, and transfused the first of 2 units of packed red blood cells. gastroenterology was consulted. the patient initially had an ekg with slight inferior changes while the patient was pain free. the patient then had an episode of substernal chest pain in the ed with 3 to changes in v3 to v4. past medical history: significant for upper gastrointestinal bleed in . an esophagogastroduodenoscopy showed an ulcer in the pylorus and chronic gastritis, coronary artery disease, status post myocardial infarction in and , benign prostatic hypertrophy, history of temporal arteritis, pemphigoid, history of anemia, history of small bowel volvulus, status post appendectomies, status post inguinal hernia repair x2, history of colonic polyps, and sigmoid diverticulosis. allergies: the patient has no known drug allergies. medications: the patient was on: 1. celebrex. 2. aspirin. 3. prednisone. 4. atenolol. 5. imdur. 6. nitroglycerin p.r.n. social history: he is a retired physician, . remote tobacco history. social alcohol use, which is infrequent. married with 1 son. family history: noncontributory. physical examination on admission as follows: vital signs: vital signs of 98.9 temperature, blood pressure 128/80, pulse 72, respiratory rate of 13, and oxygen 100% on 3 liters. general: the patient appeared comfortable. heent: examination was unremarkable except for pale conjunctiva, dry mucosa. laboratory data: significant for the hematocrit of 23 as stated above, a potassium of 5.3, a bun 78. initial ck was 107 with an mb of 6 and a troponin of 0.02. inr was 1.0. urinalysis was unremarkable. as stated above, the patient had 2 ekgs and the second of which showed 2 to changes in v3 to v6. chest x-ray showed no acute cardiopulmonary process, so the patient was admitted to the hospital. concise summary of hospital course as follows: gi: the patient was felt to likely have another bleeding ulcer as the etiology of his melanotic stools and anemia. the patient had a history of helicobacter pylori in the past that was treated. the patient was felt to require egd to evaluate for recurrent infection as well as ongoing bleeding. the patient was initially admitted to the icu. gastroenterology was consulted. the patient was taken for egd on , which showed a deep antral ulcer, no acute bleeding. the ulcer was injected. the patient was initially continued on iv b.i.d. protonix. hematocrits were followed and the patient was maintained on 2 peripheral iv's at all times, and aspirin was held. the patient has another episode of melanotic stool. on , he was taken for another egd, at that time which showed the ulcer was not bleeding. as a result, the patient was felt to be stable for discharge to home from a gi perspective with continuation of the b.i.d. protonix. the patient to follow up for a repeat endoscopy in 8 weeks as an outpatient. cardiac: cardiac enzymes had been significant for elevated troponin on admission. cardiology was contact who did not recommend cardiac catheterization or coronary artery bypass graft. the patient initially received heparin and was restarted on aspirin, which was approved by gi as long as the patient had serial hematocrits. the patient was transfused to keep the hematocrit above 30. he was restarted on atenolol. the patient was also on imdur for a longer-acting vasodilator effect. the patient had a couple of episodes of further chest pain during the admission but had no further ekg changes. pulmonary: the patient had some desaturations to 70's and 80's with ambulation without improvement with oxygen with ambulation, but at this time the patient was completely asymptomatic and the patient's oxygen saturation recovered spontaneously to the high 90's on room air with rest. as a result, this was felt to possibly be not reflective of the patient's pulmonary status, but reflective of some peripheral vascular changes with ambulation. the patient was not felt to need inpatient workup and will follow up with pcp as an outpatient. hematology: the patient with acute blood loss anemia, received a total of 4 units of packed red blood cells, had serial hematocrits while on heparin gtt and was transfused to keep the hematocrit above 30. musculoskeletal: the patient was restarted on his prednisone for polymyalgia rheumatica and temporal arteritis. discharge diagnoses: gastric ulcer. gastrointestinal bleed. demand ischemia, elevated troponins, and ekg changes in the setting of acute blood loss anemia. discharge medications: 1. nitroglycerin sublingual. 2. prednisone 5 mg p.o. daily. 3. atenolol 25 mg p.o. q. p.m., 50 mg p.o. q. a.m. 4. protonix 40 p.o. b.i.d. 5. aspirin 325 mg. 6. isosorbide mononitrate. discharge followup: follow up with cardiology on , , at 9:15 a.m. the patient's primary cardiologist is dr. . dr. was not available so the patient followed up with dr. . the patient also followed up with dr. for outpatient endoscopy on at 12:30 p.m. and the patient was suggested to pursue cardiac rehabilitation in 4 to 6 weeks. , Procedure: Other endoscopy of small intestine Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Acute gastric ulcer with hemorrhage, without mention of obstruction Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Polymyalgia rheumatica

history of present illness: the patient is a 35 year old gentleman who woke up with severe headache, woke up with a frontal headache that was constant. took advil and tylenol without relief. headache persisted. he went to an outside hospital, where an mri of the brain showed hydrocephalus and a cystic mass around the pineal gland. the patient was transferred to for further management. past surgical history: gastric wrap. past medical history: no other medical history. physical examination: heart rate 84, blood pressure 133/78, respiratory rate 12, oxygen saturation 97 percent in room air. the patient is lying in bed with his eyes covered. he is alert and oriented times three. pupils equal, round and reactive to light, extraocular movements full with positive photophobia and neck stiffness. cardiovascular: regular rate and rhythm. lungs: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended. extremities: no peripheral edema. neurologic examination: cranial nerves ii through xii intact; strength 5/5 in all muscle groups. hospital course: the patient was admitted to the intensive care unit for close neurologic observation. he had a vent drain placed on due to hydrocephalus. on , the patient was taken to the operating room and had transcallosal resection of a third ventricle tumor and continued with his vent drain in placed. the patient was monitored in the pacu overnight, where he remained neurologically stable. on , the patient was monitored on the step- down unit. he was awake, alert and oriented. speech was fluent. the patient complained of double vision on lateral gaze. his strength was in all muscle groups. his dressing was clean, dry and intact. the patient had an mri of his entire spine that showed no evidence of metastatic disease. the patient continued to have his vent drain in place. postoperatively, neurologically, the patient was awake, alert and oriented times two, having difficulty with short term memory postoperatively. on , the drain was raised to 15 cm above the tragus. the patient continued to have difficulty with short term memory but was otherwise intact neurologically. on , the patient's drain was raised to 20 cm above the tragus. the patient continued to remain neurologically stable. his decadron was weaned down to 3 mg twice a day. on , pathology of the mass that was removed was consistent with ependymoma. the patient's drain was raised to 25 cm above the tragus. the patient remained neurologically stable and was out of bed to chair. on , the drain was clamped. the patient remained neurologically stable. on , the patient had a head ct scan done, which showed no change in the size of his ventricles. the drain was removed on and the patient remained neurologically stable. disposition: the patient was discharged to home . follow-up in the brain clinic in one week for staple removal. the patient's condition was stable at the time of discharge. discharge medications included percocet one to two tablets po every four hours as needed, decadron 2 mg po every 12 hours, pantoprazole 40 mg po once daily. his condition was stable at the time of discharge. , Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Ventricular shunt to extracranial site NEC Diagnoses: Malignant neoplasm of ventricles Obstructive hydrocephalus Esophageal reflux

allergies pcn. neuro: arrived on propofol gtt. changed to precedex at 0.5 mcg/kg/hr. able to open eyes to request and minimally move extremities to request. perrl. cv: labile bp (sbp 70-150's). ntg gtt to continue for radial artery graft. neo gtt titrated to maintain map greater than 60. ci > 2.0. received 1l lr. hct 32. ct's oozy initially. given protamine 50 mg x 1 with decrease in ct o/p. k+ and ca++ levels repleted. palpable pp's bilat. resp: bs clear. stable abg. weaned to 50% fio2 with o2 sats 100%. cxr done. gi/gu: abd soft, no bs. vigorous u/o. endo: received 3 u iv regular insulin per protocol. skin: intact. left arm, sternal, and right leg dsg's dry and intact. 2x2 guaze on right thigh w/ serousang dng. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pneumonia due to other gram-negative bacteria Pure hypercholesterolemia Tobacco use disorder

history of present illness: this is a 48-year-old man in generally good health with a new onset of dyspnea on exertion and angina who underwent a cardiac catheterization on which revealed two vessel coronary artery disease with an ejection fraction of 40%. there was disease in the proximal lad with a stenosis at d1 of 70% and 95% osteal d1 lesion, 95% distal rca lesion with occluded pda, mild pvb disease and collaterals left to right. given these findings, he was referred to dr. for coronary artery bypass grafting. past medical history: significant for hypercholesterolemia. past surgical history: significant for appendectomy. medications: included gemfibrozil, atenolol, aspirin. hospital course: the patient was admitted to the on where he underwent a cabg times three as follows: lima to lad, left radial to d1 saphenous vein graft to pda performed by dr. , assisted by dr. . postoperative ejection fraction was 50-55%. the patient was transferred to the cardiothoracic surgery recovery unit on nitroglycerin and neo-synephrine. the patient had a temperature immediately postoperatively and sputum cultures were sent that grew out gram negative rods for which she was subsequently treated with levofloxacin. the patient otherwise did well and was transferred to the floor by postoperative day #3. he did have another fever spike on postoperative day #3 at which point the levofloxacin was begun for the gram negative rods in the sputum. he also had one episode where he complained of epigastric pain and ekg was obtained which demonstrated a right bundle branch block. enzymes were recycled and were downward trending. he did undergo a blood transfusion on postoperative day #4 for a hematocrit of 20 and tachycardia with mild hypotension. the patient otherwise did very well. by postoperative day #5 was without complaints. on physical exam, heart rate was 85, blood pressure 116/70, clear to auscultation on the right with bronchial breath sounds at the left base and egophony. his sternum was stable with a regular rate and rhythm. his abdomen was soft. his extremities were with minimal edema. given these findings and the fact that he was ambulating extremely well, it was felt that he was stable for discharge. he was discharged on lopressor 12.5 mg po bid, potassium chloride 20 meq po q d for 7 days, lasix 20 mg po bid for 7 days, colace 100 mg po bid, zantac 150 mg po bid, aspirin 81 mg po q d, motrin prn, imdur 30 mg po q d, niferex 150 mg po q d and levofloxacin 500 mg po q d for 7 days for treatment of a potential hospital acquired pneumonia as well as percocet. the patient was instructed to follow-up with dr. in weeks as well as his primary care provider weeks. discharge diagnosis: 1. hypercholesterolemia. 2. coronary artery disease, status post cabg times three performed on . , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pneumonia due to other gram-negative bacteria Pure hypercholesterolemia Tobacco use disorder

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right adrenal tumor major surgical or invasive procedure: exploratory laparotomy, right adrenalectomy and right segment 6 resection history of present illness: the patient is a 75 y/o female who presents with a right adrenal mass. the patient has been progressively feeling unwell since . after sustaining a fall, the patient started to have worsening weakness and fatigue that she needed to start using a walker to ambulate and had difficulty getting out of chairs. she also reports increased facial hair in the past six months. on imaging, the patient had a 10 x 7 cm right adrenal mass. further workup revealed that the patient had hypercortisolism. on review of systems, the patient complains of pain and increased difficulty in performing her activities of daily living. the patient denies weight loss or weight gain. although, her obesity has become more central in nature and she has had loss of hair on her scalp, while having increased facial hair. she also reports increased bruising along her extremities, some shortness of breath on exertion, thinning of her skin, and decreased energy. the patient denies fever, chills, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, constipation, or dysuria. past medical history: colon ca s/p partial colectomy and adjuvant chemo - 8y ago htn ccy adrenal mass mitral valve prolapse social history: lives alone in nj, here living with daughter while undergoes further evaluation and mgmt. denies tobacco (<100 lifetime cigarettes), social etoh, no ivdu. has 3 daughters and 2 sons family history: dm in both brothers and both parents; f - prostate and liver ca; uncle - gastric ca physical exam: t 96.3 p 66 bp 176/90 r 20 sao2 95% ra gen - no acute distress, well-appearing, upper lip hirsutism heent - facial hirsutism, no scleral icterus, moist mucous membranes lungs - clear to auscultation bilaterally heart - regular rate and rhythm abd - obese, soft, nontender, nondistended pertinent results: 08:08pm urine color-yellow appear-clear sp -1.010 08:08pm urine blood-tr nitrite-neg protein-neg glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 08:08pm urine rbc-0-2 wbc-1 bacteria-rare yeast-none epi-0-2 08:08pm urine amorph-few 05:30pm glucose-124* urea n-19 creat-0.4 sodium-142 potassium-2.9* chloride-98 total co2-33* anion gap-14 05:30pm calcium-9.2 phosphate-3.1 magnesium-1.8 05:30pm wbc-7.3 rbc-3.63* hgb-11.8* hct-33.6* mcv-93 mch-32.5* mchc-35.0 rdw-16.4* 05:30pm plt count-231 05:30pm pt-10.8 ptt-19.1* inr(pt)-0.9 brief hospital course: she was taken to the or by dr. for exploratory laparotomy, right adrenalectomy and right hepatic segment 6 resection. please see operative report for details. ebl was 3 liters. an introp u/s revealed- liver echogenicity appeared unremarkable. within the posterior segment of the right lobe of the liver, there was s a 5.5 x 3.3 cm well- circumscribed, slightly hypoechoic lesion that contained a degree of increased through transmission suggesting at least some cystic components. the relationship of this to the surrounding vasculature, particularly the posterior branch of the right portal vein was demonstrated. no other additional lesions were found.two drains were removed by postop day 5. pathology returned positive for 1. right adrenal mass, excision (a-f): malignant neoplasm most consistent with adrenal cortical carcinoma, see note. 2. liver segment six, resection (g-o): malignant neoplasm most consistent with adrenal cortical carcinoma, see note. endocrinology was to follow and the plan was to use ________ as an outpatient. postop she was in the sicu for fluid management and atn. baseline creatinine was 0.6. nephrology was consulted. creatinine trended down to 1.1 by pod 8. renal u/s was normal. stress dose steroids were given preop and postop per endocrinology. endocrinology preferred a slow 6 month steroid taper. dr. tapered prednisone after one week as she developed an incision infection necessitating opening the incision and using a wound vac. a ct of the abd was done on which demonstrated two ill-defined fluid collections post-surgical site that were extrahepatic and could represent postoperative seromas, bilomas, or less likely abscesses. multiple scattered foci of air, likely postoperative. 2. increased stranding about the head of the pancreas, possibly pancreatitis. 3. bibasilar atelectasis and small right pleural effusion. amylase and lipase were normal. lfts preop were ast 1298, alt 1308, alk phos 64 and tbili 0.7. these trended down postop with the exception of the alk phos which increased to as high as 806 on hd 20. subsequently, this has decreased some to 504 as of . she required picc line placement for iv antibiotics and tpn as her kcals were insufficient. her appetite was diminished. she appeared apathetic on many days and expressed feelings of sadness. psychiatry saw her and agreed with the team that she was experiencing intermittent delerium. there was concern that she was experiencing the effects of less cortisol. neurology recommended a ct and eeg. a head ct was done for waxing/ mental status. this was negative for bleed/mass on . an eeg was performed which demonstrated mild encephalopathy. tsh was 3.4. psychiatry did not recommend antidepressents or stimulants at the time. on ct a right pleural effusion was noted. she experienced desats and sob. pleuracentesis was performed on (hd 20)with a negative culture. a f/u cxr was improved and without pneumothorax. she developed a klebsiella uti which was treated with cipro and flagyl for the wound x 4 days. these antibiotics were switched to vanco and meropenum when a wound culture identified strep veridans, sparse yeast, klebsiella which was pan sensitive and staph coag positive resistent to levo/oxicillin/penicillin and sensitive to vanco. vanco levels were monitored. creatinine remained stable. she developed a 2nd uti,yeast which was treated with a gu ampho bladder irrigant x3 days. this was due to finish on pm. repeat u/a and cx were sent on . a repeat abd ct revealed stable appearance of hepatic fluid collections with some debris and air in the surgical bed. bibasilar atelectasis with stable right pleural effusion. stable appearance of right abdominal wall defect overlying surgical site. interval development of nonocclusive thrombus within the intrahepatic inferior vena cava. she was started on coumadin and iv heparin until she was therapeutic. inr goal was . inr on was 2.6 on after taking off the vac and reviewing the ct, drain was inserted thru the wound into a peri-hepatic collection and placed to bulb suction. water soluble contrast was administered at the bedside through this catheter. contrast was administered. contrast was seen surrounding this wound and draining along the right lateral aspect of the wound into dressing, however, no definite communication into the abdominal cavity noted. midline chevron scar and multiple clips scattered across the abdomen were seen. remainder of abdomen was gasless. small amount of oral contrast seen in the rectum. she then underwent successful drainage catheter placement in collection in the subhepatic and hepatic areas on . the plan is for her to go to rehab on tpn via a r picc with a ruq incision wound vac. she has 2 hepatic drains to gravity drainage and meropenum/vanco will continue until next week. she will follow up with dr. on and with endocrinology as an outpatient. please schedule gyn follow up of postmenopausal bleeding noted on pod #5.pelvic u/s (prelim report) - study v. limited as patient was not able to achieve proper positioning; uterus 8.0 x 4.4 x 4.5 cm; endometrium is not well visualized; ovaries not visualized. she experienced minimal spotting while hospitalized. medications on admission: hydralazine 25q8, hctz 25, kcl 40" discharge medications: 1. hydralazine 25 mg tablet sig: one (1) tablet po q8h (every 8 hours): hold for sbp <140. 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. furosemide 20 mg tablet sig: three (3) tablet po once a day. 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 4 doses. 6. insulin lispro (human) 100 unit/ml solution sig: follow sliding scale subcutaneous every six (6) hours. 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 8. bimatoprost 0.03 % drops sig: one (1) ophthalmic daily (daily). 9. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po bid (2 times a day). 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day): peri area. 12. warfarin 2 mg tablet sig: two (2) tablet po once a day: check inr twice weekly. goal . 13. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours): check vanco level twice weekly. 14. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q6h (every 6 hours). 15. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed: per picc line protocol. 16. outpatient lab work labs every monday and thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin and inr. fax to attn: , rn discharge disposition: extended care facility: for the aged - macu discharge diagnosis: r adrenal mass hepatic collections ivc thrombus malnutrition uti,yeast pleural effusion arf, resolved post menopausal bleeding discharge condition: good discharge instructions: call dr. if fevers, chills, nausea, vomiting, incision red/bleeding or draining pus, wound drain dislodges, foul smelling wound or increased wound drainage, increased shortness of breath. followup instructions: weekprovider: , md phone: date/time: 11:30 please schedule follow up with dr (endocrinology) in 1 week. attempt monday appointment gyn follow up & schedule tvu/s as outpt prior to apt. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Thoracentesis Other incision with drainage of skin and subcutaneous tissue Other genitourinary instillation Unilateral adrenalectomy Other immobilization, pressure, and attention to wound Other immobilization, pressure, and attention to wound Partial hepatectomy Diagnoses: Malignant neoplasm of adrenal gland Malignant neoplasm of liver, secondary Other corticoadrenal overactivity Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Other postoperative infection Cellulitis and abscess of trunk Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Toxic encephalopathy Unspecified essential hypertension Personal history of malignant neoplasm of gastrointestinal tract, unspecified Intestinal bypass or anastomosis status Long-term (current) use of steroids Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Other specified disorders of pancreatic internal secretion Adrenal cortical steroids causing adverse effects in therapeutic use

history of present illness: the patient is a 49 year old woman with a history of end stage liver disease secondary to hepatitis c complicated by esophageal varices as well as a history of encephalopathy and prior spontaneous bacterial peritonitis who was recently discharged from for management of her ascites. on that hospitalization multiple attempts were made to manage her fluid overload with diuretics, but she was ultimately refractory to them. she was referred for tips procedure for improved fluid management. the patient was readmitted on the day of admission on for tips. the procedure was notable for having somewhat difficult access, but no complications with an estimated blood loss of 100 cc. at the procedure she received 4 mg of versed, 600 of propofol, 150 of fentanyl. she had been hemodynamically stable for several hours post procedure, but then her blood pressure dropped from 100/40 to 70s to 80s over 30s and her heart rate remained sinus tach. at the time, although her urine output remained strong, she was transferred to the medical icu for further management. past medical history: hepatitis c genotype 1a complicated by cirrhosis, esophageal varices, encephalopathy and presumptive sbp. type 2 diabetes. obesity. hypertension. asthma. esophageal candidiasis. gastroparesis. depression. status post cholecystectomy. status post seven spur surgeries. hypothyroidism. amenorrhea. migraines. medications on admission: protonix 40 mg q.d., synthroid 100 mcg q.d., reglan 10 q.i.d., flovent two puffs b.i.d., lactulose 45 ml q.i.d., ambien 5 mg q.h.s. p.r.n., levaquin 250 mg q.d., lasix 60 mg b.i.d., spironolactone 100 mg b.i.d., morphine p.r.n., albuterol one to two puffs q.six p.r.n., serevent one puff b.i.d. social history: the patient is a prior machine operator on disability. she is not married. she lives with her son. she has a 15 pack year tobacco history, she quit in . she has a history of alcohol use, particularly heavy in the mid-. she has a history of iv drug abuse, none since the . family history: noncontributory. it does not include liver disease or bleeding disorder. physical examination: the patient's temperature was 98.5, pulse 96, bp 95/48, respiratory rate 16, sating 98 percent on 3 liters. in general, she was a pleasant, middle aged woman lying in no acute distress. head and neck exams showed normocephalic, atraumatic head with pupils equal, round, and reactive to light and accommodation. extraocular movements intact. oropharynx was slightly dry. on neck exam she had a right central venous line with mild ooze. heart was tachycardiac with regular rhythm, no murmurs. lungs were clear to auscultation bilaterally anteriorly. abdomen was soft, nondistended, nontender with active bowel sounds. she had guaiac positive stool. extremities had 2+ edema to the knees. on neuro exam she was alert and oriented times three. cranial nerves ii-xii were grossly intact. strength and sensation were grossly intact. laboratory data: white count 3.7, hematocrit 26.8, platelets 43. ptt 39.5, inr 1.5. sodium 126, potassium 4.4, chloride 94, bicarb 26, bun 31, creatinine 1.2, glucose 136. calcium 7.5, mag 1.2, phos 3.7. ast 174, alt 80, alka phos 126, t-bili 3.1, ldh 255. hospital course: 1. hypotension. the patient was admitted to the micu for hypotension. the underlying etiology was not initially clear, although the differential included excess anesthesia from the procedure, particularly given her liver disease versus hypovolemia from a hemorrhage, either around the liver into the abdomen or within the gi tract versus sepsis. she was started empirically on antibiotics with levo and flagyl. she had an abdominal ultrasound to evaluate for ascites for possible paracentesis. there was no ascites. she was maintained on antibiotic prophylaxis for several days. she was transfused one unit of packed cells and given fluids to improve her blood pressure and it responded appropriately. she was started on neo-synephrine to keep her maps greater than 55. it took several days, but this was ultimately weaned. the entire time she had excellent urine output. as cultures continued to be negative and the patient had no fever or white count, she was not maintained sbp antibiotic coverage and once she was maintained on pressors, she was able to be transferred out to the floor. she had no further evidence of hypotension while on the medicine floor. 2. hypoxia/congestive heart failure. the patient was given vigorous iv fluids hydration and blood during her micu stay. she subsequently became progressively hypoxic with diffuse wheezing and a chest film that was consistent with fluid overload. she was started with diuresis once she was on the medicine floor with rapid improvement in her hypoxia and her lung exam. once the pulmonary edema was improved, her exercise tolerance improved dramatically. 3. pulmonary. the patient does have a history of asthma and she was wheezing significantly when she hit the floor. she responded well to iv lasix and frequent nebulizer treatments. these will be continued as an outpatient per her prehospitalization regimen. 4. status post tips. the patient did not have any evidence of encephalopathy and her abdominal distention improved significantly over the course of her admission. she was between 2 and 3 liters negative per day and did not have an untoward effects with respect to her renal failure. 5. renal. the patient's creatinine slightly increased on admission to the icu. however, over the course of her admission, her creatinine went down to 1.0 by discharge which is as good, if not better, than her typical baseline. 6. infectious disease. when the patient was out on the floor, she did not show any evidence of infection. she was continued on sbp prophylaxis regimen of levaquin q.day. 7. endocrine. the patient was continued on her diabetes regimen with glargine and a sliding scale. condition on discharge: stable. discharge status: to home with vna for home safety evaluation. discharge diagnoses: 1. end stage liver disease. 2. hepatitis c. 3. anasarca. discharge medications: 1. flovent two puffs b.i.d. 2. albuterol one to two puffs q.six hours p.r.n. 3. serevent one puff b.i.d. 4. synthroid 100 mcg q.d. 5. protonix 40 mg q.d. 6. levaquin 250 mg q.d. 7. lactulose 30 ml p.o. t.i.d. 8. lasix 40 mg p.o. q.d. 9. reglan 10 mg p.o. q.i.d. 10. aldactone 25 mg p.o. b.i.d. followup: the patient will call the liver center to make an appointment with dr. in two weeks. she will contact her pcp to make an appointment within the next one to two weeks. , m.d. dictated by: medquist36 Procedure: Transfusion of packed cells Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

allergies: cyclobenzaprine attending: chief complaint: end stage liver disease major surgical or invasive procedure: none history of present illness: 49f pmh esld hep c, esophageal varices, history of sbp on daily ppx, h/o hepatic encephalopathy, s/p tips (), admitted to osh micu () with hepatic encephalopathy. with treatment for encephalopathy at osh, nh3 243 -> 11, however, worsening hyperbilirubinemia (8.1 -->16.3), xferred to for consideration of possible transplant. patient transfered to micu after development of hypotension and respiratory failure. past medical history: pmhx: hcv genotype ia refractory to ifn x 2 ascites grade i esophageal varices (egd ) h/o esophageal candidiasis s/p ccx dm ii htn asthma hypothyroid depression amenorrhea migraines echo : ef >65%, no wma, trivial tr. ett : no ischemic ekg changes, no perfusion defects at good target hr, ef ~60%, no wma. social history: h/o etoh abuse h/o ivdu quit tobacco 1 yr ago on disability physical exam: 97.9 120/50 102 22 94% 2l gen: lying in bed, jaundiced, obese heent: no jvd pulm: decreased breath sounds on right side, otherwise cta cardiac: rrr, s1, s2 abd: obese, distended, diffusely tender, no rebound ext: anasarca neuro: ao x self, hospital, thinks year is "", otherwise non-focal brief hospital course: a/p: 49f esld hcv, s/p tips for refractory ascites, admitted for rising tbili who subsequently developed respiratory failure and was transfered to the micu. 1. sepsis: upon initial admission to the icu the patient was started on a 10 day, broad spectrum course of antibx prophylactically given an episode of hypotension. the patient completed this course of antibx. however on hd 17 the patient became hypotensive with elevated wbc, and lactic acidosis to 15. she was reinitiated on broad spectrum antibx and pressors. she was initally started on levophed but her bp's continued to decrease and was then started on neosynephrine. given the patient's critically ill state at this time, the patient family was called. the family decided to withdraw support and the patient passed away peacefully several hours later. 2. respiratory failure: likely secondary to a pleural effusion which was tapped. pleural fluid analysis was consistent w/ a transudate likely from ascites/liver failure. over the course of several weeks the patient's respiratory status improved and was successfully extubated on hd 15. however, the patient was reintubated on hd 17 after she developed sepsis from which she died on hd 18. 3. esld: acute on chronic liver failure. liver (dr. and transplant were following. given the patient's critically ill state, she was not amenable to transplant during her hospital course. lactulose was continued for hepatic encephalopathy. 4) coagulopathy/thrombocytopenia - secondary to esld. the pt was transfused ffp, cryroprecipitate, platelets, and prbcs prn. 5) arf: hepatorenal syndrome versus atn (granular casts in urine). uop was poor. renal was consulted and the patient was initiated on cvvhd. 6) dm2: insulin gtt. 7) asthma: cont nebs prn. medications on admission: aldactone lactulose reglan protonix levoxyl lasix magnesium glargine discharge medications: n/a discharge disposition: expired discharge diagnosis: n/a discharge condition: deceased discharge instructions: n/a followup instructions: n/a Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Thoracentesis Pulmonary artery wedge monitoring Transfusion of packed cells Transfusion of other serum Transfusion of platelets Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Thrombocytopenia, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hepatorenal syndrome Acquired coagulation factor deficiency Other pulmonary insufficiency, not elsewhere classified Unspecified septicemia Iron deficiency anemia secondary to blood loss (chronic) Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Severe sepsis Other and unspecified alcohol dependence, in remission Portal hypertension Unspecified acquired hypothyroidism Candidiasis of other urogenital sites

allergies:cyclobnzaprine neuro: a&ox2 prior to intubation, now sedated propofol 30mcg/kg/min to 3 score, perrla x 2, r wrist restraint intact, environment secured for safety. given total of 2.5mg of mso4 iv for pain today. resp: lungs coarse to auscultation throughout anterior chest, rll and rml diminished, intubated at 1400 d/t acute desaturation when turning pt followed by audible crackles throughout. upon intubation sx'd copious amts of thin frothy bilious yellow secretions, now sx'ing scant amt of thin bilious yellow secretions, sputum cx sent, on cmv fio2 60% peep 5 tv 559 rr 14 with o2sats 99-100%, cxr showed whiteout to r lung, vent changes to be made based on this finding. cv: t 35.7-36.2, hr 65-78 sr no ectopy, a-line placed to l radial bp's 85-109/30's-50's, levophed at 0.1mcg/kg/min infusing, neosynephrine dc'd, pa line to r ij intact, site oozing bld (team aware), site sprayed with thrombin, also inr 1.6, hct 22.1 from 26, given total of 4u ffp and 1u prbc's today, to get more bld today. (+) general anasarca, 2+ pedal pulses bilat., picc line intact to r ac. fungal cx sent. echo ordered, possibly to be done tonight. see flowsheet for other vs and pa cath readings. gi: bs (+) hypoactive x 4 quad, ogt placed today, npo, abd obese, was tender to touch when pt awake, bilious brown liquid stool draining from rectal tube. gu/renal: foley cath intact, uo 175cc today icteric brown in color, renal md in to see pt, to get cvvh tomorrow d/t worsening renal status. endo: fbs 190-200's, glargine dc'd, fbs q 1hr., started on insulin gtt, insulin titrated per protocol, fbs 190-200. skin: jaundiced, sclera yellow x 2, bandaind to post chest from thoracentecis site with dry red bld, no new bldg, l radial wrist with ecchymosis at site of a-line insertion. social: son in to see pt and spoke with md, asks appropriate questions. plan: continue to monitor vs and and hemodynamics, titrate propofol for comfort, titrate levophed as ordered to maintain map's >60, fbs q 1hr and titrate insulin per protocol, poss. echo today, cvvh tomorrow, turn prn as tolerated to maintain skin integrity. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Thoracentesis Pulmonary artery wedge monitoring Transfusion of packed cells Transfusion of other serum Transfusion of platelets Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Thrombocytopenia, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hepatorenal syndrome Acquired coagulation factor deficiency Other pulmonary insufficiency, not elsewhere classified Unspecified septicemia Iron deficiency anemia secondary to blood loss (chronic) Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Severe sepsis Other and unspecified alcohol dependence, in remission Portal hypertension Unspecified acquired hypothyroidism Candidiasis of other urogenital sites

history of present illness: the patient is a 56-year-old male smoker with diabetes, and hypertension, and hepatitis c, and status post anterior myocardial infarction who presented with anterior myocardial infarction. at midnight on the day prior to admission, the patient experienced substernal chest pain while sitting at rest in his bed. the pain was radiating to his arms. it was described as not pleuritic. it was associated with shortness of breath. the patient took sublingual nitroglycerin without relief. the pain lasted 10 minutes until emergency medical service arrived. he was found to be hypertensive at 210/100. the patient was brought to emergency department. electrocardiogram showed sinus rhythm at 54, normal axis, and normal intervals. st elevations were noted to be 1 mm to 2 mm in leads v2 through v5 and avl. reciprocal st depressions of 2 mm were seen in leads ii, iii, and avf. the patient's electrocardiogram also showed poor r wave progression. the patient was taken to the catheterization laboratory. he was randomized to cool myocardial infarction protocol. on catheterization, the patient was found to have left main coronary artery without flow-limiting lesions. a 50% mid distal lesion was seen in the left anterior descending artery along with an occluded first diagonal that was stented. the left circumflex, right coronary artery, and ramus intermedius were found to be normal. pulmonary artery saturation was 75%. pulmonary artery pressure was 27/11. per the protocol, the patient was cooled to 33 degrees for five hours. he was started on aspirin, integrilin, and plavix and received a heparin bolus. he was admitted to the coronary care unit for monitoring. past medical history: 1. hypertension. 2. history of hepatitis c; on pegylated interferon and ribavirin study. the patient quit three months ago for unknown reasons. 3. dyspepsia/peptic ulcer disease. 4. diabetes; per omr but the patient denies. 5. depression; no prior suicide attempts with few years of treatment. 6. renal stones; status post renal surgery with blood transfusions in the . 7. history of angina. 8. chronic back pain; status post surgery. allergies: no known drug allergies. medications on admission: (medications on admission included) 1. atenolol 50 mg p.o. q.d. 2. prilosec 20 mg p.o. q.d. 3. quinine 325 mg p.o. q.h.s. (for leg cramps). 4. roxicet 5/325 p.o. t.i.d. as needed. 5. univasc 15 mg p.o. b.i.d. 6. hydrochlorothiazide 25 mg p.o. q.d. family history: diabetic mother. coronary artery disease. social history: the patient reports he smoked half a pack per day for 40 years for a total of a 20-pack-year smoking history. physical examination on presentation: physical examination on admission revealed heart rate was 48, blood pressure was 123/55, saturating 99% on room air. the patient was found to have dry mucous membranes. no jugular venous distention. a regular rhythm. normal first heart sound and second heart sound. no murmurs. the lungs were clear. no hematomas in the groin. extremities had bounding dorsalis pedis pulses. pertinent laboratory data on presentation: complete blood count and chemistry-7 were within normal limits as were coagulations. creatine kinase was 193. hospital course by problem: the patient was started on aspirin, and plavix (for a 30-day course), and integrilin drip (for 18 hours). the team did not start the patient on a statin as he has a history of hepatitis c. liver function tests were normal with an ast of 36, alt was 118, alkaline phosphatase was 96, total bilirubin was 0.5. a cholesterol panel was as follows: total cholesterol was 181, low-density lipoprotein was 102, high-density lipoprotein was 30, triglycerides were 231. an echocardiogram was done and revealed an ejection fraction to be normal at 55%. there was mild symmetric left ventricular hypertrophy with normal cavity size. there was mild regional left ventricular systolic dysfunction with focal hypokinesis of the apex. also of note, mild aortic sclerosis. a beta blocker and ace inhibitor were titrated to blood pressure and heart rate control. a hemoglobin a1c was found to be 5.4. therefore, the patient was determined not to be a diabetic. discharge followup: the patient was to follow up with dr. as his cardiologist and with his primary care physician (dr. . discharge diagnoses: 1. status post anterior myocardial infarction with stent to first diagonal. 2. hypertension. 3. ejection fraction of 55%. medications on discharge: 1. enteric-coated aspirin 325 mg p.o. q.d. 2. lisinopril 40 mg p.o. q.d. 3. plavix 75 mg p.o. q.d. (times 30 days). 4. atenolol 75 mg p.o. q.d. 5. sublingual nitroglycerin as needed. 6. statin not started; deferred to primary care physician. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute myocardial infarction of other anterior wall, initial episode of care

history of present illness: this is a 71-year-old gentleman with a history of peripheral vascular disease and copd with hypertension and coronary artery disease, who presented to the emergency department with 10 days of cough, shortness of breath, and chest pain. patient had been seen earlier in the week and started on zithromax for presumed respiratory infection. however, he returned on the day prior to admission with recurrent cough. cta done at that time showed a partially thrombosed pseudoaneurysm or penetrating ulcer of the aortic arch approximately 2.5 cm distal to the takeoff of the left subclavian artery with diffuse emphysematous changes, no pulmonary embolus. he was started on esmolol for blood pressure control, given an elevated pressure of 175/48 when he was admitted. he had appropriate monitoring placed including an a line and a foley catheter, and admission laboratories were significant for a hematocrit of 41.4 and a bun and creatinine of 26 and 1.4. his ekg did not show ischemic changes and his ck's and troponins were negative initially. vascular surgery and cardiothoracic surgery services were consulted and he was admitted to the intensive care unit on the vascular surgery service. past medical history: right cerebrovascular accident. coronary artery disease. hypertension. prostate cancer. history of hepatitis c. hypercholesterolemia. hypertension. asthma. past surgical history: left carotid endarterectomy in . right carotid endarterectomy in . five vessel cabg in . right upper lobectomy for lung cancer in . left vertebral artery stent in . allergies: no known drug allergies. medications: 1. albuterol. 2. . 3. lipitor 20 mg by mouth every day. 4. cartia xt 300 mg by mouth every day. 5. ecotrin 325 mg by mouth every day. 6. hydrochlorothiazide 25 mg by mouth every day. 7. protonix 40 mg by mouth every day. 8. serevent every day. social history: the patient is a former smoker. he quit in with a greater than 30 pack year history. denies ingestion of alcohol. initial physical examination: temperature 96.9, heart rate 64, blood pressure initially 131/73 down to 110/57 after institution of esmolol, 93 percent. he was alert and in no acute distress. his heart was regular with no murmurs, rubs, or gallops. his chest was clear to auscultation with diminished breath sounds in the bases. his abdomen was moderately obese with normoactive bowel sounds, soft, and nontender. extremities were warm without clubbing, cyanosis, or edema. he had palpable femoral pulses bilaterally and dopplerable popliteal, dp and pt bilaterally with monophasic dp and pt on the left. studies: cta: no pulmonary embolus. a 3 cm partially thrombosed pseudoaneurysm versus penetrating ulcer of aortic arch 2.5 cm distal to the takeoff of the left subclavian artery, diffuse emphysematous changes. chest x-ray: no new infiltrate. brief hospital course: as stated above, mr. was admitted to the icu for blood pressure control on an esmolol drip. he remained without recurrent chest pain and he had a mri/mra done of his chest to further delineate his anatomy. of note, there were two small outpouchings of contrast from the lumen of the inferior portion of the aortic arch surrounded by large thrombus component with some thickening of the aortic wall and no evidence of active bleeding or free fluid. there were additionally multiple irregularities in the aortic wall throughout the entire thoracic and abdominal aorta that was visualized. this was thought to represent an unusual appearance of a penetrating ulcer with a large thrombus component. he additionally had a cardiac catheterization to evaluate for any underlying coronary artery disease should he need operative repair. this revealed 90 percent stenosis of his right coronary artery, saphenous vein graft with patent vein grafts to the om and patent lima to the lad with diffuse disease in the distal lad. a heparin-coated stent was placed in the vein graft to the right coronary artery. other findings from his catheterization revealed an 80 percent instent stenosis of the left vertebral artery and an 80 percent right brachiocephalic ostial lesion. he tolerated the procedure well and there were no bleeding or groin complications. he returned to the intensive care unit for continued blood pressure monitoring and his esmolol drip was eventually weaned off. given the patient's multiple medical problems including his severe pulmonary disease, underlying coronary artery disease, and overall debilitated condition, the decision was made to proceed with medical management as the postoperative management of this likely penetrating ulcer. he was transitioned to oral agents. his diltiazem dose was increased and lopressor was added for additional rate control. he remained off drips for greater than 48 hours. decision was made to send him home with close followup. of note, his hematocrit remained stable. his creatinine remained within its baseline of around 1.4 and he was tolerating a regular diet and able to ambulate without difficulty. of note, because of his complaint of cough, a sputum sample was sent, which grew out pseudomonas that was , he was started on ciprofloxacin on . follow-up chest x-ray revealed bilateral lower lobe changes concerning for pneumonia. he remained afebrile with normal white count. discharge diagnoses: penetrating ulcer versus thrombosed pseudoaneurysm of the descending thoracic aorta. coronary artery disease status post right coronary artery saphenous vein graft stent with heparin-coated stent. bilateral lower lobe pneumonia. discharge medications: 1. salmeterol. 2. flovent. 3. lipitor 20 mg by mouth every day. 4. tylenol as needed. 5. aspirin 325 mg by mouth every day. 6. hydrochlorothiazide 50 mg by mouth every day. 7. diltiazem sustained release 360 mg by mouth every day. 8. lopressor 12.5 mg by mouth twice a day. 9. ciprofloxacin 500 mg by mouth every 12 hours times seven days additional. discharge instructions: patient is to have his blood pressure checked 3-4 times per week and communicate these results with dr. and his primary care doctor. he should call if his systolic blood pressure is greater than 110 or less than 90. complete a 10 day course of ciprofloxacin to take seven additional days and to call dr. should he have recurrent chest discomfort. follow up with dr. in one month with a cta of his chest, with dr. , his primary care doctor in two weeks. , Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Aortography Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Unspecified viral hepatitis C without hepatic coma Other specified disorders of arteries and arterioles Coronary atherosclerosis of autologous vein bypass graft

allergies: neurontin attending: addendum: the patient's discharge was delayed rising creatinine and concerns over oxygenation status. the patient's creatinine rose to 2.9 from 2.4. while 2.9 is near his baseline, we wanted to ensure the trend did not exceed his baseline. in regards to his oxygenation, he desated to the low 80's on ra. he states he occasionally uses home o2. chief complaint: r buttock and thigh claudication major surgical or invasive procedure: diagnostic aortic and pelvic arteriogram with left common and external iliac stents; ultrasound-guided imaging for vascular access; aortic catheterization. right common femoral endarterectomy and dacron patch angioplasty and right common and external iliac artery angioplasty and stenting and angiogram. history of present illness: 74m with c/o r buttock and thigh claudication who is followed by dr. . he had a duplex study performed in of this year that showed a patent aortoiliac system with heavily calcified and extensively diseased distal right common iliac artery, right external iliac artery, and right common femoral artery, as well as likely sfa occlusion. he has not had any tissue loss and denies rest pain. he also has some lower back issues, which he originally believed to be the source of his discomfort. he recently had a r l4, l5 and s1 transforaminal epidural and si joint steroid injection. he denies recent fevers, chills, or chest pain. baseline doe/sob due to his copd and is on home o2. he does have cri and l renal artery stenosis with an atrophied l kidney and is followed by nephrology here at . he also notes bruising and bleeding easily, despite only being on aspirin. past medical history: 1. cva x 2 s/p left vertebral artery stent in ; s/p right carotid endarterectomy and left carotid endarterectomy 2. cad s/p 5 vessel cabg s/p cath in (preop) with stent to svg-rca 3. htn 4. prostate cancer last psa 8.2, treated with watchful waiting 5. hep c vl zero in 6. hyperlipidemia 7. copd/emphysema 8. right upper lobectomy for lung ca, adenocarcinoma 9. s/p hernia repair 10. thrombosed pseudoaneurysm dxed , medically managed 11. cri baseline creatinine 1.5-2.0 12. cavitary rll abscess/pna in - treated with 4 week course of levo/flagyl. social history: lives at home with wife. retired salesman for sears. quit smoking in . 30 pack year history. no etoh use. independent in all daily activities. family history: non-contributory physical exam: general: nad. a&ox3. hent: anicteric. mmm. no carotid bruits. b/l cea scars. heart: rrr. lungs: fair aeration. diminished bases. scattered wheezes. abdomen: soft. nt. nd. no palpable pulsatile masses. extremities: feet are warm. no ulcers or fissures. no peripheral edema. pulses: c r f p dp pt r 2+ 2+ 1+ palp palp palp l 2+ 2+ 2+ 1+ palp palp pertinent results: 07:25am blood wbc-7.2 rbc-3.42* hgb-9.6* hct-29.9* mcv-88 mch-28.1 mchc-32.1 rdw-13.8 plt ct-386 06:50am blood wbc-6.8 rbc-3.18* hgb-9.4* hct-27.9* mcv-88 mch-29.4 mchc-33.6 rdw-14.1 plt ct-366 03:40pm blood wbc-7.1 rbc-3.18* hgb-9.4* hct-28.0* mcv-88 mch-29.6 mchc-33.6 rdw-14.2 plt ct-313 07:45am blood wbc-6.9 rbc-3.35* hgb-9.6* hct-29.6* mcv-88 mch-28.7 mchc-32.4 rdw-14.2 plt ct-293 01:12am blood wbc-8.0 rbc-3.34* hgb-9.7* hct-28.5* mcv-86 mch-29.2 mchc-34.1 rdw-14.5 plt ct-256 01:20pm blood wbc-10.6 rbc-3.50* hgb-10.4* hct-30.1* mcv-86 mch-29.8 mchc-34.7 rdw-14.4 plt ct-268 04:08am blood wbc-8.3 rbc-3.42* hgb-10.2*# hct-29.2* mcv-85 mch-29.9 mchc-35.0 rdw-14.4 plt ct-256 10:19pm blood hct-31.5*# 01:41pm blood wbc-6.3 rbc-2.84* hgb-8.1* hct-24.4* mcv-86 mch-28.5 mchc-33.1 rdw-14.6 plt ct-271 07:15am blood wbc-7.9 rbc-3.31* hgb-9.6* hct-29.3* mcv-88 mch-29.0 mchc-32.8 rdw-14.7 plt ct-316 07:00am blood wbc-6.1 rbc-3.20* hgb-9.0* hct-27.9* mcv-87 mch-28.0 mchc-32.2 rdw-14.9 plt ct-261 05:35am blood hct-36.3* 05:40am blood wbc-8.7 rbc-3.68* hgb-10.5* hct-31.3* mcv-85 mch-28.6 mchc-33.7 rdw-15.8* plt ct-264 09:35pm blood wbc-9.2 rbc-3.83* hgb-11.0* hct-33.7* mcv-88 mch-28.9 mchc-32.8 rdw-15.3 plt ct-266 07:25am blood plt ct-386 06:50am blood plt ct-366 03:40pm blood plt ct-313 07:45am blood plt ct-293 01:12am blood plt ct-256 01:12am blood pt-12.0 ptt-30.6 inr(pt)-1.0 01:20pm blood plt ct-268 01:20pm blood pt-11.5 ptt-28.7 inr(pt)-1.0 04:08am blood plt ct-256 01:41pm blood plt ct-271 07:15am blood plt ct-316 07:15am blood pt-11.6 ptt-27.3 inr(pt)-1.0 07:00am blood plt ct-261 06:40am blood glucose-125* urean-63* creat-3.2* na-140 k-4.2 cl-104 hco3-27 angap-13 07:25am blood glucose-87 urean-50* creat-2.7* na-140 k-4.2 cl-103 hco3-26 angap-15 06:50am blood glucose-100 urean-51* creat-2.9* na-139 k-4.3 cl-104 hco3-25 angap-14 03:40pm blood glucose-118* urean-54* creat-3.1* na-138 k-4.1 cl-102 hco3-28 angap-12 07:45am blood glucose-92 urean-53* creat-2.9* na-138 k-4.0 cl-102 hco3-26 angap-14 01:12am blood glucose-100 urean-48* creat-2.8* na-138 k-4.0 cl-101 hco3-27 angap-14 01:20pm blood glucose-113* urean-47* creat-2.8* na-139 k-4.1 cl-101 hco3-28 angap-14 04:08am blood glucose-98 urean-42* creat-2.6* na-141 k-4.0 cl-102 hco3-28 angap-15 01:41pm blood glucose-107* urean-43* creat-2.6* na-140 k-3.5 cl-102 hco3-30 angap-12 07:15am blood glucose-109* urean-44* creat-2.6* na-140 k-3.5 cl-100 hco3-30 angap-14 09:35pm blood glucose-90 urean-72* creat-3.7* na-142 k-4.7 cl-107 hco3-22 angap-18 06:50am blood ck(cpk)-39 08:50pm blood ck(cpk)-70 03:40pm blood ck(cpk)-68 09:57am blood ck(cpk)-224* 01:20pm blood ck(cpk)-383* 04:08am blood ck(cpk)-98 06:50am blood ck-mb-notdone ctropnt-0.07* 08:50pm blood ck-mb-notdone ctropnt-0.07* 03:40pm blood ck-mb-notdone ctropnt-0.07* 09:57am blood ck-mb-4 ctropnt-0.07* 01:12am blood ck-mb-5 ctropnt-0.07* 01:20pm blood ck-mb-4 ctropnt-0.09* 06:40am blood calcium-8.6 phos-3.5 mg-2.2 07:25am blood calcium-8.5 phos-3.5 mg-2.0 06:50am blood calcium-8.7 phos-3.7 mg-2.0 03:40pm blood calcium-8.7 phos-4.3 mg-2.0 07:45am blood calcium-8.5 phos-4.2 mg-2.0 01:12am blood calcium-8.5 phos-4.2 mg-1.9 01:20pm blood calcium-8.3* phos-4.5 mg-1.8 04:08am blood calcium-7.9* phos-3.3 mg-1.6 unilat lower ext veins right 8:22 am comparisons: right lower extremity ultrasound dated . findings: the bilateral common femoral, right superficial femoral and right popliteal veins are patent and compressible, without filling defect. waveforms demonstrate normal respiratory phasicity and appropriate response to valsalva and distal augmentation. the posterior tibial and peroneal veins are also patent on the right. impression: 1) no evidence of right lower extremity dvt. ecg study date of 3:03:54 pm sinus rhythm. atrial ectopy. the p-r interval is short without evidence of pre-excitation. low voltage in the limb leads. compared to the previous tracing atrial fibrillation has resolved. chest (portable ap) 4:36 pm comparison with . the lungs are hyperexpanded, consistent with copd, as before. scattered parenchymal scarring as demonstrated previously. the costophrenic sulci remain blunted. the patient is status post median sternotomy as before. the heart is normal in size, and mediastinal structures appear stable. the bony thorax is grossly intact. there is no significant interval change. ecg study date of 5:28:04 am probable atrial fibrillation with rapid ventricular response, although some sinus beats appear present. compared to the previous tracing of atrial fibrillation is present. ecg study date of 6:54:50 am sinus tachycardia slight st-t wave changes - are are nonspecific and may be within normal limits since previous tracing of , sinus tachycardia now present portable tte (complete) done at 12:33:20 pm conclusions the left atrium is elongated. 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%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic arch is mildly dilated. 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 mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , the findings are similar. brief hospital course: the patient was admitted to vascular surgery for angiogram. hd1 admitted to 5/vacular surgery dr. . routine nursing, iv access, pre-op bicarb/mucomyst, npo after mn, nephrology consult, ekg, cxr, ua, labs, consent, home meds. the patient's procedure was cancelled on secondary to concern over his creatinine. nephrology was consulted and renal ultrasound performed. with nephrology's recommendations on optimizing the patient, the patient went for his angiogram. on he underwent a diagnostic aortic and pelvic arteriogram with left common and external iliac stents, ultrasound-guided imaging for vascular access, and aortic catheterization. the patient tolerated the procedure well. for further detail of the procedure, please refer to the operative note. post operatively, the patient developed hypertension to the 180's. he was transfered to the vicu for bp management. the patient's blood pressure normalized and nephrology left recommendations on bp management. it was planned to discharge the patient to home with the medication changes and with instruction to return on wednesday for an endarterectomy. the patient's discharge was delayed rising creatinine and concerns over oxygenation status. the patient's creatinine rose to 2.9 from 2.4. while 2.9 is near his baseline, we wanted to ensure the trend did not exceed his baseline. foley was placed for failure to void and 800 cc in bladder by scan. also transfered back to vicu for monitoring secondary to persistent htn. nitro drip, norvasc and diovan started per renal recs. in regards to his oxygenation, he desated to the low 80's on ra. he states he occasionally uses home o2. foley was d/c'd, still having trouble voiding, foley re-inserted. unsteady on his feet when walking. creatinine 2.9->2.4. foley d/c'd, voiding well. still hypertensive, increasing beta blockers. creatinine ->3.2, continue to monitor. patient to floor status. creatinine ->2.9. now patient c/o l ankle pain with swelling secondary to what seems to be gout exacerbation, treated with colcichine. plan for or in am for r fem endardarectomy and stenting. pre-op, hydration, mucomyst/bicarb drip. patient c/o l ankle pain-thought to be gout excacerbation-started on colchichine. taken to or for l cia stent, pod 8 s/p r cfa ea/pa into profunda, r cia/eia stent. post-operatively did well, recovering in the pacu. transfused 2 units prbc for hct 24.4-> 31.5 post transfusion.post-op bicarb drip for 3 hours. stabilized and transferred to far 5. transferred to icu for tachycardia,low bp and desaturation. bp responded to fluid bolus for borderline low bp. renal following. on and off a-fib- given iv lopressor. hypotensive-given fluid boluses. cardiac echo-normal ef. diuresed with lasix. transferred back to 5 vicu. vicu status.vss. afbrile. continues on beta blockers.renal following- low does colchichine for gout. vicu status, still with on & off a-fib, with low grade t (tm 100.5). started diltiazem gtt started po dilt. renal fu- colchichine started, lasix hold, fluid bolus per renal.pt consult, ambulate. patient c/o r knee pain, r hip edema with erythema/l forearm edema. creatinine 3.1->2.9. afberile. rheumatology consult-start on po steroids for gout, ambulate, le and ue us. change status from vicu to floor. started prednisone taper floor status. ue & le niv. negative for dvt. foley d/c'd. cochichine changed to qd. . started on cipro for 2 wks. for klebsiella pneumoniae growth in urine.vss, afebrile. rehab screen for dispo. renal consult: stage iv ckd. continue current medications (lasix, on hold) vss, no events. cipro until . if rt knee remains swollen after steroid taper- will need injections. medications on admission: albuterol - 90 mcg aerosol - 2 puffs inhalation every 4 - 6 hours as needed allopurinol - 100 mg tablet - 1 tablet(s) by mouth every other day diltiazem hcl - 360mg capsule, sust. release 24 hr - one every day fluticasone - 50 mcg spray, suspension - sprays in each nostril once a day as needed for congestion fluticasone-salmeterol - 250 mcg-50 mcg/dose disk with device - one puff inhaler twice a day furosemide - 40 mg tablet - 1 tablet(s) by mouth daily meclizine - 25 mg tablet - 1 tablet(s) by mouth qd prn metoprolol tartrate - 50 mg tablet - 1 tablet(s) by mouth twice a day nitroglycerin - 400 mcg (1/150 gr) tablet - under the tongue as needed for chest pain oxycodone-acetaminophen - 5 mg-325 mg tablet - one tablet(s) by mouth three times a day as needed for pain protonix - 40mg tablet, delayed release (e.c.) - one every day simvastatin - 40 mg tablet - 1 tablet(s) by mouth once a day tiotropium bromide - 18 mcg capsule, w/inhalation device - one puff inhaler once a day tramadol - 50 mg tablet - 1 tablet(s) by mouth every six (6) hours as needed for pain - no substitution valsartan - 160 mg tablet - 1 tablet(s) by mouth twice a day ecotrin - 325mg tablet, delayed release (e.c.) - one every day ferrous sulfate - 325 mg (65 mg) tablet - 1 tablet(s) by mouth daily discharge medications: 1. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. tramadol 50 mg tablet sig: one (1) tablet po q12h (every 12 hours) as needed. 7. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 8. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 9. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection twice a day: until fully ambulatory. 11. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 14. colchicine 0.6 mg tablet sig: one (1) tablet po every other day (every other day). 15. diltiazem hcl 60 mg tablet sig: one (1) tablet po qid (4 times a day): hold sbp <120 . 16. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day): hold for sbp< 120, hr< 60 . 17. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours): last dose 5/26. 18. prednisone 10 mg tablet sig: one (1) tablet po daily () for 2 days: dose on and . 19. prednisone 5 mg tablet sig: one (1) tablet po daily () for 2 days: dose on and . discharge disposition: extended care facility: discharge diagnosis: primary: r buttock & thigh claudication s/p rt leg intervention hospital course complicated by increase cr (has stage iv ckd), afib and gouty knee (steroid taper) secondary: cad, s/p cva x 2, aortic arch aneurysm, htn, prostate ca, lung ca, h/o hepatitis c, hyperlipidemia, copd, stage iv ckd, chronic back pain, vitamin d deficiency, l renal artery stenosis, l kidney atrophy, prepatellar bursitis, h/o cavitary rll abscess/pna discharge condition: vss discharge instructions: division of vascular and endovascular surgery lower extremity angioplasty/stent discharge instructions medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? please note the changes we made your medications and take them as prescribed in the sheet. we discontinued your diltiazem so please make a note of this. ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home: it is normal to have slight swelling of the legs: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated ?????? it is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? drink plenty of fluids and eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? after 1 week, you may resume sexual activity ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate ?????? no driving until you are no longer taking pain medications ?????? call and schedule an appointment to be seen in weeks for post procedure check and ultrasound what to report to office: ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site sudden, severe bleeding or swelling (groin puncture site) ?????? lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call vascular office . if bleeding does not stop, call 911 for transfer to closest emergency room. followup instructions: . provider: , phone: date/time: 2:10 provider: , m.d. phone: date/time: 3:00 provider: , m.d. date/time: 10:30 provider: , md phone: date/time: 4:30 md Procedure: Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Aortography Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Repair of blood vessel with synthetic patch graft Endarterectomy, lower limb arteries Cranial or peripheral nerve graft Insertion of one vascular stent Insertion of three vascular stents Procedure on two vessels Destruction of cranial and peripheral nerves Procedure on three vessels Procedure on vessel bifurcation Diagnoses: Other iatrogenic hypotension Urinary tract infection, site not specified Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atherosclerosis of native arteries of the extremities with intermittent claudication Chronic kidney disease, Stage IV (severe) Cardiac complications, not elsewhere classified Atherosclerosis of aorta Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Personal history of malignant neoplasm of bronchus and lung Personal history of other infectious and parasitic diseases Infection with microorganisms resistant to penicillins

allergies: neurontin attending: chief complaint: rle claudication major surgical or invasive procedure: diagnostic aortic and pelvic arteriogram with left common and external iliac stents; ultrasound-guided imaging for access; aortic catheterization. history of present illness: 74m with c/o r buttock and thigh claudication who is followed by dr. . he had a duplex study performed in of this year that showed a patent aortoiliac system with heavily calcified and extensively diseased distal right common iliac artery, right external iliac artery, and right common femoral artery, as well as likely sfa occlusion. he has not had any tissue loss and denies rest pain. he also has some lower back issues, which he originally believed to be the source of his discomfort. he recently had a r l4, l5 and s1 transforaminal epidural and si joint steroid injection. he denies recent fevers, chills, or chest pain. baseline doe/sob due to his copd and is on home o2. he does have cri and l renal artery stenosis with an atrophied l kidney and is followed by nephrology here at . he also notes bruising and bleeding easily, despite only being on aspirin. past medical history: 1. cva x 2 s/p left vertebral artery stent in ; s/p right carotid endarterectomy and left carotid endarterectomy 2. cad s/p 5 vessel cabg s/p cath in (preop) with stent to svg-rca 3. htn 4. prostate cancer last psa 8.2, treated with watchful waiting 5. hep c vl zero in 6. hyperlipidemia 7. copd/emphysema 8. right upper lobectomy for lung ca, adenocarcinoma 9. s/p hernia repair 10. thrombosed pseudoaneurysm dxed , medically managed 11. cri baseline creatinine 1.5-2.0 12. cavitary rll abscess/pna in - treated with 4 week course of levo/flagyl. social history: lives at home with wife. retired salesman for sears. quit smoking in . 30 pack year history. no etoh use. independent in all daily activities. family history: non-contributory physical exam: nad. a&ox3. anicteric. mmm. no carotid bruits. b cea scars. rrr. fair aeration. diminished bases. scattered wheezes. soft. nt. nd. no palpable pulsatile masses. feet are warm. no ulcers or fissures. no peripheral edema. c r f p dp pt r 2+ 2+ 1+ dop dop dop l 2+ 2+ 2+ 1+ dop dop pertinent results: labs: \11.0/ 9.2 ---- 266 /33.7\ pt: 11.8 ptt: 26.0 inr: 1.0 142 107 72 / ------------- 90 4.7 22 3.7 \ estgfr: 16/20 (click for details) ca: 9.1 mg: 2.3 p: 4.2 renal u/s 5/7/8 conclusion: atrophic left kidney with further shrinkage compared to a prior study in . normal size right kidney with mildly elevated ri's but otherwise excellent flow. no hydronephrosis. multiple simple cysts bilaterally. brief hospital course: the patient was admitted to surgery for angiogram. the patient's procedure was cancelled on secondary to concern over his creatinine. nephrology was consulted and renal ultrasound performed. with nephrology's recommendations on optimizing the patient, the patient went for his angiogram on . he underwent a diagnostic aortic and pelvic arteriogram with left common and external iliac stents, ultrasound-guided imaging for access, and aortic catheterization. the patient tolerated the procedure well. for further detail of the procedure, please refer to the operative note. post operatively, the patient developed hypertension to the 180's. he was transfered to the vicu for bp management. the patient's blood pressure normalized and nephrology left recommendations on bp management. the patient is discharged home with the medication changes and with instruction to return on wednesday for an endarterectomy. upon discharge, the patient is afebrile with all vitals stable, with stable blood pressure, tolerating po feeds, ambulating, and with pain controlled on po pain medication. medications on admission: albuterol 2 puffs q4-6h prn, allopurinol 100 qod, diltiazem sr 360', advair 250/50 one puff", lasix 40', meclizine 25' prn, lopressor 50", ntg sl prn, percocet prn, protonix ec 40', simvastatin 40', spiriva with handihaler 18mcg one puff', ultram 50 q6h prn, valsartan 160", ecotrin 325', feso4 325' discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 2. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 5. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed). 6. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 7. valsartan 80 mg tablet sig: one (1) tablet po bid (2 times a day). 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 10. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 11. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 12. tramadol 50 mg tablet sig: one (1) tablet po q12h (every 12 hours) as needed. 13. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 14. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 15. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* discharge disposition: extended care facility: discharge diagnosis: primary: r buttock & thigh claudication . secondary: cad, s/p cva x 2, aortic arch aneurysm, htn, prostate ca, lung ca, h/o hepatitis c, hyperlipidemia, copd, stage iv ckd, chronic back pain, vitamin d deficiency, l renal artery stenosis, l kidney atrophy, prepatellar bursitis, h/o cavitary rll abscess/pna discharge condition: afebrile, vital signs stable, tolerating regular diet, ambulating, pain well controlled on po medication. discharge instructions: division of and endovascular surgery lower extremity angioplasty/stent discharge instructions medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? please note the changes we made your medications and take them as prescribed in the sheet. we discontinued your diltiazem so please make a note of this. ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home: it is normal to have slight swelling of the legs: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated ?????? it is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? drink plenty of fluids and eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? after 1 week, you may resume sexual activity ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate ?????? no driving until you are no longer taking pain medications ?????? call and schedule an appointment to be seen in weeks for post procedure check and ultrasound what to report to office: ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site sudden, severe bleeding or swelling (groin puncture site) ?????? lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call office . if bleeding does not stop, call 911 for transfer to closest emergency room. followup instructions: please return on wednesday to the surgery check-in for your angiogram. . provider: , phone: date/time: 2:10 provider: , m.d. phone: date/time: 3:00 provider: , m.d. date/time: 10:30 Procedure: Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Aortography Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Repair of blood vessel with synthetic patch graft Endarterectomy, lower limb arteries Cranial or peripheral nerve graft Insertion of one vascular stent Insertion of three vascular stents Procedure on two vessels Destruction of cranial and peripheral nerves Procedure on three vessels Procedure on vessel bifurcation Diagnoses: Other iatrogenic hypotension Urinary tract infection, site not specified Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atherosclerosis of native arteries of the extremities with intermittent claudication Chronic kidney disease, Stage IV (severe) Cardiac complications, not elsewhere classified Atherosclerosis of aorta Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Personal history of malignant neoplasm of bronchus and lung Personal history of other infectious and parasitic diseases Infection with microorganisms resistant to penicillins

history of present illness: this 69-year-old man was transferred from on the to . he has a history of coronary artery disease, hypertension, hyperlipidemia, prostate and lung cancer with severe carotid stenosis and transient ischemic attacks who is referred now with the abrupt onset of speech difficulty and right-sided weakness. the patient had been hospitalized briefly in with speech difficulty and right-sided weakness. his studies back in showed severe bilateral carotid stenosis and there was thought to be a critical stenosis on the right, a marked stenosis on the left. ct scan was normal and the patient had been on aspirin and was then started on plavix. he was referred to and he was scheduled for a carotid endarterectomy a week prior to his admission. on the day of admission aspirin and plavix had been stopped in anticipation of this upcoming surgery, however, while at home patient fell asleep, complained to his wife of not feeling well and found him a few hours later slumped over in the bed and felt that his speech was slurred and not very comprehensible. he complained of double vision at the time. paramedics reported that he was moving his extremities, however, developed right-sided weakness when he arrived at . medications prior to admission: lipitor, cardia, hydrochlorothiazide, bronchodilators. past medical history: coronary artery bypass graft in . social history: he had been a smoker for the majority of his life though only smoking a few cigarettes a day. he quit in . physical examination: he was awake and fairly alert with fluent speech. no dysarthria. he repeats well and there is no anomia. he follows commands. cranial nerves: pupils were small and reactive to light. fundi were not seen. he had a fairly pronounced vertical gaze palsy. there was suggestion of slight lateral rectus weakness. visual fields were full to confrontation testing. there was mild right central facial weakness. the other cranial nerves were intact. motor examination showed no drift and normal strength to confrontation. fine finger movements were intact but finger-to-nose testing was ataxic, especially on the right. the patient's findings were remarkable for a vertical gaze palsy, maybe a right vi nerve palsy which relates to his complaint of double vision. the patient was transferred to where he was admitted to the hospital, was started on anticoagulation and carotid duplex was performed. he was admitted to the vascular service there and a stroke consult was done. laboratory on admission: white count 13.7, hematocrit 34.6, platelet count 209,000, pt 12.8, ptt 36.4, inr 1.1. sodium 137, potassium 4.0, bun 24, creatinine 1.4. hospital course: the stroke team recommended stopping heparin on his admission day and just continuing on aspirin and plavix with their considering recent strokes. the mri showed acute stroke in the paramedian thalamus and left of the midbrain. he also had small areas of stroke in the cerebellum. they recommended a four vessel angiogram and a carotid endarterectomy on the right carotid and once again the patient was now on the 11th started on heparin. the patient was monitored on the floor where he did continue with double vision and he was prepped for the carotid artery endarterectomy. his repeat carotid ultrasound was completed which shows a narrowing of 80-99% bilaterally of the tardive rppca suggest proximal disease. on the 12th the patient continued with double vision. his blood pressure was in the 140's to 180's and no other distress. the patient was made known to the neurosurgery service where he was to have an angiogram done. on the he had an angiogram which showed greater than 85% left vertebral artery stenosis, an occluded right vertebral artery. he had greater than 85% of the right common carotid bifurcation stenosis, 75% innominate origin stenosis. it was noted that patient had a left groin hematoma after the angiogram where he was monitored closely post-angiogram. he was also on telemetry during this time. he did end up having an ultrasound of the groin to rule out pseudo-aneurysm. the stroke team, the neurology team and the vascular team decided that the patient should have a right carotid endarterectomy and then have a stenting of his left vertebral artery. on the 13th he did have the ultrasound of his left groin which showed no pseudo-aneurysm. the patient was kept on heparin during this time. on the the patient had a right carotid endarterectomy done. he tolerated the procedure well. on postoperative day one he was awake, alert and oriented. incision was clean, dry and intact. he was reevaluated by the stroke service the same day. his blood pressure was 140/46, heart rate 74, respirations 14, temperature 97.8. at that point he was transferred back to neurology service. the patient did receive one unit of red blood cells on the 18th. it was noted on the 19th that he had slight swelling of the surgical scar, otherwise the patient was okay. on the 19th it was noted that that scar had serous fluid. no pus or edema. the site was monitored by the vascular service. the patient's pain was under control with percocet. a follow-up ultrasound on the 20th showed a patent right carotid, small right neck hematoma, no evidence of pseudo-aneurysm. his left groin hematoma was small, however, improving. the patient remained awake, alert and oriented. his neurological status was unchanged. during the postoperative period the patient was on aspirin and plavix. his staples were removed from the surgical neck site on the 21st. the site was dry and intact. he continued to be followed by neurology and neurosurgery. labs on the 23rd showed white count of 7.5, hematocrit of 39.2, 297,000 for platelets. on the 25th patient did have a left vertebroangioplasty and stent. estimated blood loss was minimal. the patient did well with the procedure. he woke up awake, alert and oriented. he had no drift. grasp was bilaterally. lower extremities were full. he remained on heparin post stenting at 800 units an hour and continued on aspirin and plavix. the patient was monitored in the trauma intensive care unit postoperatively. he was kept on a nipride drip to keep his blood pressure less than 140. a rheumatology consult was asked for on the 26th because of right-sided knee swelling. there was no erythema, however, there was increase in warmth. patient was thought to have heterotopic ossification. it was thought not to be an infectious process. patient was already on aspirin. they recommended topical aspirin cream. the patient was monitored in the intensive care unit. on the 27th he continued to need nipride to keep his blood pressure less than 140. he remained neurologically intact. case management was following him at this time. he was moved out of the unit on the 28th. his groin incision was noted to be intact with no infectious process noted. no further hematoma. he remained neurologically intact. his blood pressure was well controlled on oral antihypertensives. physical therapy and occupational therapy were involved in the patient's care and they recommended home physical therapy and also for nursing to follow up with the patient to check blood pressure. rheumatology's final recommendations were prednisone taper, nsaids and some local therapy to his right knee. patient was treated for methicillin-resistant staphylococcus aureus urinary tract infection diagnosed on the . he was started on intravenous vancomycin. infectious disease recommended that he start on dicloxacillin for one week after discharge. discharge medications: include: 1. atorvastatin 20 mg one tablet q. day. 2. __________ 110 mcg two puffs b.i.d. 3. albuterol 90 one to two puffs every q. 4-6h. 4. oxycodone one to two tablets q. 4-6h. 5. aspirin 325 one tablet q. day. 6. plavix 75 mg one tablet q. day. 7. cardizem 240 mg sa one tablet q. day. 8. salmeterol 50 mcg one diskus inhalation q. 12h. 9. lopressor 50 mg twice a day. 10. hydrochlorothiazide 1.5 tabs q. day. 11. doxycycline 100 mg q. 12h. 12. rheumatology recommended a prednisone taper which was given to the patient. 13. motrin 600 mg p.o. t.i.d. was given for the patient's inflammatory process of his right knee. discharge instructions: patient is to follow up with dr. in five weeks. follow up with dr. in one month. he will have home visits from vna nurses to check his blood pressure and a home safety evaluation with physical therapy. , m.d. dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Endarterectomy, other vessels of head and neck Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Aortocoronary bypass status Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction Hematoma complicating a procedure Acute, but ill-defined, cerebrovascular disease Occlusion and stenosis of vertebral artery without mention of cerebral infarction Asthma, unspecified type, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: redo aortic valve replacemetn (mechanical) on history of present illness: 50 yr old female with h/o rheumatic heart disease/mitral stenosis/aortic insufficiency s/p mitral valve replacement (mechanical) and aortic valve replacement (mechanical) who has been c/o increasingly worsening dyspnea on exertion. an echo revealed severe pulmonary hypertension with an increased trans-aortic gradient with a peak gradient of 85mmhg and a mean gradient of 49mmhg (aortic stenosis). she then underwent a cardiac cath which showed clean coronary arteries and similar disease with the prosthetic mechanical aortic valve. she was then seen for redo-aortic valve replacement. past medical history: redo-aortic valve replacement (mechanical) h/o rheumatic heart disease/mitral stenosis/aortic insufficiency s/p mitral valve replacement (mechanical) and aortic valve replacement (mechanical) pulmonary hypertension atrial fibrillation aortic insufficiency s/p mitral commissurotomy hypothyroid urinary retention h/o atrial fibrillation uterine fibroids s/p left oophorectomy, partial left salpingectomy social history: lives with husband. alcohol or tobacco use. family history: no diabetes, hypertension, or coronary artery disease physical exam: neuro: a&o x 3, non-focal heart: rrr 4/6 sem lungs: ctab -w/r/r abd: soft, nt/nd +bs ext: warm, trace edema pertinent results: carotid u/s : no evidence of carotid stenosis in the right or left carotid arteries echo : pre bypass: the left atrium is markedly dilated. the right atrium is moderately dilated. overall left ventricular systolic function is normal (lvef>55%). a mechanical aortic valve prosthesis is present. motion of the aortic prosthesis leaflets/discs is abnormal. only one leaflet seen to move normally. the transaortic gradient is higher than expected for this type of prosthesis. there is at least moderate to severe aortic valve stenosis ( 0.8, mean gradient 27). mild (1+) aortic regurgitation is seen. a mechanical mitral valve prosthesis is present. the prosthetic mitral leaflets appear normal. mild (1+) mitral regurgitation is seen. significant pulmonic regurgitation is seen. post bypass: preserved biventricular function lvef > 55%. mechanical 21 prosthesis well seated in aortic position without perivavluar leak. no ai. aortic valve area 1.7-1.9 by continuity, peak gradient 58, mean 29 mm hg initally post bypass, subsuqently peak gradient 52, mean 16 mm hg. mitral valve prosthesis remains unchanged. tr and pi unchanged. 10:30pm blood wbc-4.4 rbc-3.53* hgb-11.8* hct-34.4* mcv-97 mch-33.4* mchc-34.3 rdw-13.0 plt ct-136* 02:40pm blood wbc-11.9* rbc-3.48*# hgb-10.9*# hct-31.0*# mcv-89 mch-31.5 mchc-35.3* rdw-16.3* plt ct-86* 05:45am blood wbc-10.3 rbc-3.07* hgb-9.4* hct-28.5* mcv-93 mch-30.8 mchc-33.1 rdw-15.5 plt ct-189# 10:30pm blood pt-14.0* ptt-27.4 inr(pt)-1.2* 05:30am blood pt-20.1* ptt-97.5* inr(pt)-1.9* 05:45am blood pt-24.7* inr(pt)-2.5* 10:30pm blood glucose-101 urean-25* creat-0.8 na-143 k-4.4 cl-106 hco3-29 angap-12 05:45am blood urean-25* creat-1.0 na-138 k-4.7 cl-99 hco3-28 angap-16 05:30am blood mg-1.9 03:57am blood freeca-1.14 11:25pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-1 ph-6.5 leuks-neg brief hospital course: patient was admitted prior to her surgery secondary to being on coumadin for her current prosthetic mechanical valves. her coumadin was stopped and she was started on heparin. she had her pre-operative work-up done along with a carotid u/s. on her inr was at a safe level for surgery and she was brought to the operating room where she underwent a redo aortic valve replacement with a mehanical valve. please see op note for surgical details. she was then brought to the csru in stable condition. later on op day patient was weaned from sedation and awoke neurologically intact and was then extubated. she was weaned from all inotropes by post op day one and was started on b blockers and diuretics. she was gently diuresed throughout her hospital course towards her pre-operative weight. on post-op day two she was transferred to the cardiac surgery step-down unit. chest tubes and epicardial pacing wires were removed on post-op day two. coumadin was restarted on this day as well. physical therapy worked with patient during entire post-op course for strength and mobility. she appeared to be progressing well although on post-op day four she had some abdmonial pain, but abdmonial x-ray was negative. by post-op day five she was ambulating well and cleared level 5. her inr was therapeutic and she was discharged home with vna services and the appropriate follow-up appointments. medications on admission: atenolol 25mg qd, aldactone 50mg qd, lasix 40mg , coumdin, digoxin 0.125mg qd, levoxyl 100mcg qd discharge medications: 1. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours) for 7 days. disp:*14 packet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. pravastatin 20 mg tablet sig: four (4) tablet po daily (daily). disp:*120 tablet(s)* refills:*2* 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 10. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 11. warfarin 5 mg tablet sig: one (1) tablet po once a day for 1 days: then vna to draw inr and call results to dr. for continued dosing. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: redo-aortic valve replacement (mechanical) h/o rheumatic heart disease/mitral stenosis/aortic insufficiency s/p mitral valve replacement (mechanical) and aortic valve replacement (mechanical) pulmonary hypertension atrial fibrillation hypothyroid discharge condition: good discharge instructions: may shower, no bathing or swimming for 1 month no driving for 1 month no lifting > 10# for 10 weeks followup instructions: with dr. in weeks with dr. in weeks with dr. ( in 4 weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Unspecified acquired hypothyroidism Atrial fibrillation Other complications due to heart valve prosthesis Aortic valve disorders Other chronic pulmonary heart diseases

history of present illness: the patient is a 48 year old female with a history of metastatic breast cancer status post lumpectomy and radiation with a history of two recent admissions in and , for bilateral malignant pleural effusions and bilateral pleurodesis requiring home o2 and bi-pap, now presenting with one week of progressive worsening shortness of breath. the patient noted, starting approximately one week ago, progressively worsening shortness of breath at rest with increasing home o2 requirements. two days prior to admission, the patient presented to the emergency department complaining of shortness of breath, increased heart rate, decreased o2 saturations in the low 90s. the patient was evaluated for pulmonary embolism by ct angiogram which was negative with only slight increase in the right pleural effusion and atelectatic changes. the patient was discharged home with home o2 to follow-up with her pulmonologist, dr. . on the morning of admission, the patient saw dr. , reporting worsening shortness of breath, increased o2 requirements from 1.5 to 4 liters, decreased o2 saturations from the mid-90s to the low 90s and increased heart rate above 100. an echocardiogram of the lungs was done showing no change in pleural effusions and the patient was referred to the for transthoracic echocardiogram. the echocardiogram revealed a moderate to large sized pericardial effusion with a right atrial collapse and a right ventricular diastolic collapse, consistent with impaired filling and tamponade. past medical history: 1. metastatic breast cancer diagnosed in : infiltrating ductal carcinoma status post lumpectomy and radiation with axillary node dissection, recurrence ; admission and for bilateral pleural effusions, bilateral pleurodesis requiring home o2. 2. cerebrovascular accident in : small hemorrhagic cerebrovascular accident from a cavernous hemangioma. 3. seasonal allergies. 4. right low anterior rib fracture. medications on admission: 1. xeloda 150 mg p.o. twice a day. 2. claritin q. day. 3. protonix 40 mg p.o. q. day. 4. ativan 0.4 to 1 mg p.o. q. six p.r.n. 5. motrin p.r.n. for rib pain. 6. home o2. allergies: no known drug allergies. social history: the patient has been an intensive care unit nurse here at the for 28 years. drinks alcohol socially. she has a 20 pack year history of tobacco and quit in . family history: the patient has an aunt and great-aunt with breast cancer. her mother died of mixed connective tissue disorder. her father died of hairy cell leukemia. physical examination: vital signs upon admission, temperature maximum of 97.7 f.; heart rate of 104 to 109; blood pressure of 121/89, nap of 102; respiratory rate of 30; pulses 16, 128/112. the patient's o2 saturation is 92 to 97 on four liters. generally, the patient is a thin female, notably short of breath while speaking. heent examination: no scleral icterus. extraocular muscles are intact. pupils are equal, round, and reactive to light and accommodation. mucous membranes were moist. neck examination: at 30 degrees with jugular venous distention approximately 10 centimeters. no carotid bruits noted. lung examination with decreased breath sounds bilaterally at the bases, right greater than left, crackles half way up the right side and a third of the way up the left side. dullness to percussion bilaterally, right greater than left; no wheezes. cardiovascular examination with increased heart rate; normal s1, split s2. no murmurs, rubs or gallops. pulsus paradoxus with radial pulse decreasing with inspiration. pulses at 16. her abdominal examination with normoactive bowel sounds. abdomen was nondistended, nontender. spleen tip was palpable. extremities were warm with normal dorsalis pedis pulses bilaterally. no peripheral edema, clubbing or cyanosis. neurologic examination: the patient is awake, alert and oriented times three with no gross lesions. laboratory data: on , white blood cell count 6.9, hematocrit of 39.2, platelets of 353. sodium 136, potassium 3.9, chloride 99, carbon dioxide 25, bun 15, creatinine 0.4, glucose 104, calcium 9.1. alkaline phosphatase 91, ast 24, alt 14, albumin 3.4, fsh 91. blood cultures negative. ca antigen and . ct angiogram in the emergency , showed no evidence of pulmonary embolus, slight interval increase in right pleural effusion with left loculated atelectatic changes. a lung ultrasound showing no change in pleural effusion. transthoracic echocardiogram showing left ventricular systolic function, mildly decreased septal hypokinesis, moderate to large pericardial effusion, right atrial collapse, right ventricular diastolic collapse consistent with impaired filling or tamponade. on , white blood cell count 5.7, hematocrit 37.5, platelets 329, potasium 4.1. hospital course: in brief, the patient is a 48 year old female with a history of metastatic breast cancer status post two recent admissions for bilateral malignant pleural effusions, bilateral pleurodesis requiring home o2 and bi-pap, now presenting with progressively worsening shortness of breath times one week and transthoracic echocardiogram consistent with pericardial effusion. 1. cardiovascular: the patient with an echocardiogram consistent with pericardial effusion. the patient was taken to the catheterization laboratory on , where the effusion was tapped and drained for 250 cc. of serosanguinous fluid. right ventricular pressure of 33/15, p- a pressure of 35/17, wedge of 21. cardiac output 5.3, cardiac index 3.2. the drain was subsequently pulled on . miss had an ekg upon admission which showed no evidence of electrical alternans and ekg upon discharge which also showed no evidence of electrical alternans. the house officer was called to see the patient in the evening of , for chest pain with inspiration. a pericardial rub was heard. an ekg showed some elevation in pr interval in avr. throughout her hospital course, the patient remained tachycardic, in the low 100s to 110. a follow-up echocardiogram was done revealing normal ejection fraction 45 to 50% and no evidence of pericardial effusion. 2. pulmonary: the patient has a history of malignant pleural effusions likely contributing to her symptoms of shortness of breath. dr. was made aware and recommended no further intervention at this point. the patient was saturating well in the low 90s to 95 range on four liters of nasal cannula which was decreased to two liters prior to discharge. the patient reported subjectively that her shortness of breath had improved somewhat following the tap. she will return home on home o2 and bi-pap. 3. hematology/oncology: the patient has a history of metastatic breast cancer and malignant bilateral pleural effusions, now with a new pericardial effusion which is exudative. cytology has been sent to evaluate if this is, in fact, a malignant pericardial effusion. dr. was made aware that the patient was hospitalized and involved in her care during her inpatient stay. she is scheduled to follow-up with him on tuesday, . she will continue on xeloda and pain control with morphine, percocet, toradol and motrin p.r.n. the patient was discharged home on , with the following medications, discharge diagnoses and instructions. discharge diagnoses: 1. new pericardial effusion, cytology pending. 2. metastatic breast carcinoma with a history of malignant pleural effusions. 3. cerebrovascular accident in . 4. seasonal allergies. 5. history of rib fracture. medications upon discharge: 1. xeloda 1650 mg twice a day. 2. protonix 40 mg p.o. q. day. 3. 60 mg p.o. q. day. discharge instructions: 1. an appointment has been made for miss to follow-up with dr. in hematology/oncology on tuesday, , at 02:30 p.m. 2. it is recommended that the patient have a follow-up echocardiogram to evaluate any further re-accumulation of pericardial fluid. 3. the patient is to call if she has worsening symptoms or shortness of breath, palpitations, chest pain. 4. the patient is to resume all prior medications. no new medications have been added upon this admission. , m.d. dictated by: medquist36 d: 14:56 t: 15:13 job#: Procedure: Pericardiocentesis Right heart cardiac catheterization Diagnoses: Secondary malignant neoplasm of other specified sites Secondary malignant neoplasm of pleura Personal history of malignant neoplasm of breast

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: confusion; multiple intraparenchymal intracranial hemorrhages on osh ct scan major surgical or invasive procedure: mri mra brain tee under general anaesthesia history of present illness: 36 year old with no known prior medical history presented to ed with confusion. the outside notes do not detail the confusion or any decline; however, ed physicians state that when they spoke to the physicians there, he was apparently alert enough to give his own history. laboratory workup was unremarkable. head ct showed multifocal parenchymal hemorrhages throughout the cerbral hemispheres, primarily at the grey-whit ejunction aidn the largest at the right temporal lobe. he was loaded with dilantin 1 gram and then subsequently transferred to ed. on arrival, the ed physicians have noted that he will respond to vigorous stimulation but seemed to be worse than reported from ed past medical history: episode of head requiring hospitalisation 5 years ago social history: lives with an uncle named . wife and 3 children resident in . employed recently in screw production factory and fish factory. patient denies any iv drug use, any recent recreational drug use, unprotected sex, or alcohol use. family history: nil significant reported physical exam: physical exam: vitals: t 99.8 hr 81 bp 115/60 hr 16 97% on ra general: warm to touch but in no acute distress heent: op clear, no lymphadenopathy heart: rrr no murmurs pulm: clear bilaterally, good areation extremities: warm and well perfused, no rashes over body ms: arouses to gentle sternal rub and then quickly falls back asleep. answering only yes or no to questions. not following any commands - squeeze hand, show thumb, stick out tongue. cn: pupils 2mm bilaterally and reactive, blinks to threat bilaterally, corneals intact, facial movements symmetric, gag intact. motor: moves all extremities equally, symmetrically, and purposefully. normal bulk and tone. sensation: withdraws to pain in all extremities reflexes: 2+/4 bilaterally, no clonus, no grasp reflex, toes upgoing bilaterally. gait deferred pertinent results: labs on admission: cbc 12.1/14.4/41.5/182 inr 1.3 pt 14.3 ptt 27.3 lytes 145/3.6/110/26/10/0.7/111 ca 8.7 mg 2.1 phos 2.9 ast 29 alt 36 amylase 33, ap 84, tb 0.5 lithium 0.3 troponin negative uds and sds negative ekg with nsr dilantin 7.4 csf: wcc 71 rcc * prot 41 gluc 71 negative for gram stain, bacterial culture, malignant cells, cryptococcus, fungal and viral cultures, acid fast bacilli to date neurocysticercosis/toxo pnd eeg: this is an abnormal eeg in the waking and drowsy states due to the infrequent right frontocentral slowing. this suggests a right frontocentral region of subcortical dysfunction. no epileptiform features were noted. mra/mrv of head findings: there are diffuse areas of intraparenchymal hemorrhage, the largest lesions involving the right anterior temporal lobe and right inferior frontal lobe with smaller hemorrhagic lesions noted scattered through the right frontal, right parietal, right occipital lobe, and left parietal, temporal, and frontal lobes. additional lesions are noted within the left corpus callosum and right basal ganglia. many of these lesions display mild surrounding edema; however, no areas of abnormal enhancement are noted throughout the brain parenchyma. there is no shift of normally midline structures or minor or major vascular territorial infarct apparent. mild mucosal thickening is noted within the maxillary sinuses bilaterally with surrounding osseous structures appearing unremarkable. there is a probable small left parietal subgaleal hematoma. mra of the circle of the major tributaries of the circle of are patent with no areas of significant stenosis or aneurysmal dilatation. within the limits of coverage of study, no sign of an av malformation is apparent. caliber of the vessel lumens appears smooth and within normal limits with no irregular stenotic areas identified. mrv of the brain demonstrates no venous sinus thrombosis. impression: 1. bilateral intraparenchymal hemorrhages many of which are at the grey white junction with additional lesions noted within the left corpus callosum and right basal ganglia. no abnormal areas of enchancement to suggest underlying focal masses identified. mostly unremarkable mra. differential includes vasculitis and septic emboli including fungal etiologies. less likely would be coagulopathy, hemorrhages from underlying trauma, or diffuse metastatic disease. tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. overall left ventricular systolic function is normal (lvef>55%). the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. no vegetation/mass is seen on the pulmonic valve. testicular uss: bilateral simple epididymal cysts and small left-sided hydrocele with no evidence of focal testicular lesion. brief hospital course: 36 year old with previous episode of head trauma (details unknown) who presents with confusion and multiple intraparenchymal hemorrhages. the etiology of lesions remains unclear. the initial differential included drugs such as cocaine, cns vasculitis, hypertensive crisis, sinus thrombosis, or multiple mass lesions with hemorrhage. mri demonstrated l scalp hematoma, suggestive of trauma. we suspect he may have had a seizure followed by fall. thus traumatic precipitant likely but possible other underlying predisposition for bleeding. the patient was initially monitored in the neurology icu and transferred to the floor on . the patient was intially treated with antibiotics but ceased after cultures were negative. the patient was treated with dilantin and doses increased for low level. please check dilantin level. eeg showed mild right frontal slowing. the patient remained difficult to rouse for the first several days. the patient became increasingly responsive but remained with clear cognitive impairment including poor recall for events despite repeated explanation. he was abulic, needing significant prompting to participate in therapy. no other focal deficits present at discharge. formal testing of power difficult due to variable effort but appears full. pt ot provided. review of imaging studies revealed no concensus regarding etiology of lesions. cavernous angiomas a possibility but felt unlikely explanatory of all lesions. mrv was negative for venous sinus thrombosis. drug toxicology screens were negative, but note possible substances not captured on screening. echocardiogram to look for signs of endocarditis/septic emboli was performed under ga (due to failure to obtain without sedation) and demonstrated no source of septic emboli. lp was performed and negative for cryptococcus, toxoplasmosi, neurocysticercosis. inflammatory markers were elevated on admission and trended down. question of possible bleeding metastatic lesions explored with testicular ultrasound which was normal aside from epipidymal cysts. ct abdomen demonstrated hypodensity in the liver likely due to early fatty infiltration. ct chest suggested small rll pe. he was asymptomatic and no further action taken in view of intracranial bleeding. there was an episode of urethral bleeding occurred on likely associated with recent catheterisation, then settled. the social work team were involved early on to assist to communicating with friends and family and patient. medical team discussed progress with wife in and obtained phone consent for procedures (tee). follow up with neurology and pcp has been initiated. required further social work support to pursue free care options and arrange pcp. medications on admission: nil discharge medications: 1. phenytoin sodium extended 30 mg capsule sig: one (1) capsule po three times a day: take with 200mg tablet tid. 2. phenytoin sodium extended 200 mg capsule sig: one (1) capsule po three times a day: take with 30mg tablet tid. discharge disposition: extended care facility: - discharge diagnosis: multiple intracranial hemorrhages discharge condition: stable. remains abulic requiring encouragement to participate in therapy. discharge instructions: please keep all follow up appointments and seek further medical assistance for new symptoms of confusion, weakness, abnormal sensations or speech problems. please keep all follow up appointments and seek further medical assistance for new symptoms of confusion, weakness, abnormal sensations or speech problems. you have been started on a medication to prevent seizures called dilantin. please have levels checked in the next couple of days and at intervals thereafter as advised by your doctor. followup instructions: need dilantin levels followed at rehab please call for assistance with free care and to arrange pcp follow up. mri wednesday 10am with interpreter dr neurology 2.30pm please call to confirm the appointment; with spanish interpreter. md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Diagnostic ultrasound of heart Insertion of endotracheal tube Diagnoses: Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Other convulsions Unspecified fall

history of present illness: father is a 61-year-old man, with known cad, status post coronary artery bypass graft on with a lima to the lad, saphenous vein graft to om1, saphenous vein graft to d1, and saphenous vein graft to pda. the patient was discharged home on , and returns on the day of admission complaining of sternal drainage x several days with increasing amounts on the day of admission. the patient denies fever, chills, nausea, vomiting, or malaise. past medical history: cad, status post cabg with an ef of 20 percent. diabetes mellitus, currently insulin dependent. hypercholesterolemia. gerd. allergies: none. meds on admission: 1. colace 100 mg . 2. aspirin 81 mg once daily. 3. plavix 75 mg once daily. 4. carvedilol 6.25 mg . 5. simvastatin 40 mg once daily. 6. lasix 40 mg . 7. lantus insulin 45 units q pm. 8. percocet 5/325, 1-2 tabs q 4 h prn. labs on admission: white count 18.6, hematocrit 33.9, platelets 893, pt 17.5, ptt 24, inr 1.1, sodium 139, potassium 4.2, chloride 101, co2 25, bun 14, creatinine 0.9, glucose 246. chest x-ray shows cardiomegaly with left-sided effusion with atelectasis, multiple displaced wires. ekg: sinus rhythm with a rate of 100, q's in iii and avf, nonspecific st changes with poor r wave progression. physical exam: temperature 103, heart rate 116--sinus tachycardia, blood pressure 100/47, respiratory rate 30, o2 sat 97 percent on 2 liters nasal prongs. neuro: alert and oriented x 3, moves all extremities, follows commands, nonfocal exam. respiratory: clear to auscultation with a sucking chest wound. cardiovascular: regular rate and rhythm. sternum with surrounding erythema of about 10 cm, with a positive click. small draining hole in midincision with milky serous drainage. staples remain in place. abdomen is soft, nontender, nondistended with normoactive bowel sounds. extremities are warm and well-perfused with no edema. right calf with a healing wound and minimal erythema. left knee with an endoscopic site that is healing, open to air, clean and dry. hospital course: the patient was admitted to the cardiothoracic intensive care unit. he was begun on vancomycin 1 gm q 12 h, as well as levofloxacin 500 mg once daily. he was typed and screened and kept npo for mediastinal exploration plus/minus a flap closure. on hospital day 2, the patient was brought to the operating room. please see the or report for full details. in summary, the patient had a sternal exploration and debridement. he tolerated the operation well and was returned to the cardiothoracic intensive care unit intubated and sedated with an open chest wound. plastic surgery was also following the patient. the patient did well in the immediate postoperative period. his anesthesia was reversed. he was weaned from the ventilator and successfully extubated. several hours following extubation, the patient was found to be in acute respiratory distress and was emergently reintubated. from that point forward, he was kept sedated and ventilated awaiting plastics follow-up for flap closure. on the , the patient returned to the operating room. please see the or report for full details. in summary, the patient was brought to the operating room by the plastic surgery service for pectoral advancement with an omentum flap. he tolerated the operation well and was returned to the cardiothoracic intensive care unit. the patient remained intubated following his surgery. however, his sedation was minimized to allow the patient to overbreathe the ventilator. during that period, the patient had several episodes of coughing which led to a dehiscence of his abdominal incision, and on the the patient again returned to the operating room for re-exploration and closure of the fascia of his abdominal wound. he tolerated this surgery well also and following that returned to the cardiothoracic intensive care unit, again ventilated and sedated. the patient remained ventilated and sedated for the next several days in an attempt to give the wound a chance to heal. ultimately, the patient was successfully extubated on the . however, he stayed in the cardiothoracic intensive care unit following extubation for close pulmonary monitoring. it should be noted that during the patient's icu course, he had several intermittent episodes of atrial fibrillation for which he was begun on amiodarone, as well as heparin and ultimately coumadin for anticoagulation. the patient did well over the next several days, and ultimately was transferred to the floor on , hospital day 15, postoperative day 13. at that point, a picc line was placed for long-term antibiotic coverage. over the next several days, the patient's activity level was increased with the assistance of the nursing and the physical therapy staff. his antibiotic coverage was continued. his anticoagulation was transitioned from intravenous to oral. finally, on the , the patient's final - drain was removed from his chest, and it was decided that he was stable and ready to be transferred to rehabilitation for long-term antibiotic coverage, as well as glucose control. at that time, the patient's physical exam was as follows: vital signs: temperature 98.4, heart rate 82--sinus rhythm, blood pressure 113/66, respiratory rate 18, o2 sat 95 percent on room air, weight day of dictation 106.6 kg, preoperatively 100 kg. lab data: pt 17.1, inr 1.9, sodium 139, potassium 3.7, chloride 100, bicarb 27, bun 11, creatinine 0.9, glucose 149, white count 9.1, hematocrit 28.4, platelets 830. physical exam - neurologically: alert and oriented x 3, nonfocal exam. pulmonary: clear to auscultation bilaterally. cardiac: regular rate and rhythm, s1, s2. sternum: incision with staples, clean and dry. no erythema or drainage. abdomen was soft, nontender, nondistended with normoactive bowel sounds. abdominal incision with staples, also clean and dry. extremities were warm with no edema. right saphenous vein graft harvest site was healing well, open to air, clean and dry. condition on discharge: good. discharge diagnoses: coronary artery disease, status post coronary artery bypass grafting complicated by sternal infection requiring sternal debridement and flap closure. diabetes mellitus. hypercholesterolemia. gastroesophageal reflux disease. follow up: follow-up with dr. with plastic surgery service in 1 week. he is to call for an appointment at . he is also to have follow-up with dr. in 4 weeks. the patient is also to call for that appointment; the number is . discharge medications: 1. ranitidine 150 mg . 2. simvastatin 40 mg once daily. 3. ferrous sulfate 325 mg once daily. 4. ascorbic acid 500 mg . 5. zinc sulfate 220 mg once daily. 6. aspirin 81 mg once daily. 7. erythromycin ophthalmic ointment . 8. colace 100 mg . 9. metoprolol xl 100 mg once daily. 10.glargine 24 units q at bedtime. 11.humalog insulin sliding scale q ac and at bedtime. 12.lasix 20 mg once daily. 13.potassium chloride 20 meq once daily. 14.amiodarone 400 mg x 1 week, then 400 mg once daily x 1 week, then 200 mg once daily. 15.oxacillin 2 grams q 4 h through . 16.warfarin as directed to maintain a target inr of 2 to 2.5. the patient's warfarin doses starting with 4 days ago - 3 mg, 5 mg, 5 mg, 5 mg. the patient is to receive 4 mg on the .albuterol 2 puffs qid prn. disposition: the patient is to be discharged to rehabilitation. , dictated by: medquist36 d: 13:31:57 t: 14:15:12 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other repair of chest wall Graft of muscle or fascia Other repair or plastic operations on bone, scapula, clavicle, and thorax [ribs and sternum] Excisional debridement of wound, infection, or burn Other partial ostectomy, scapula, clavicle, and thorax [ribs and sternum] Excision or destruction of lesion or tissue of mediastinum Diagnoses: Esophageal reflux Other postoperative infection Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation Disruption of internal operation (surgical) wound Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Unspecified osteomyelitis, other specified sites

history of present illness: the patient is a 61-year-old male with a history of diabetes type 2 x5 years complicated by peripheral neuropathy, hyperlipidemia, and gerd, who presented to the emergency department on with a chief complaint of epigastric pain and burning. the patient had exerted himself and had felt fatigued and lightheaded. at that point in time, he was also short of breath and slightly diaphoretic. he had an elevation of his st elevations and old q waves inferiorly on his ekg at that point in time. the patient was then cardiac catheterized, at which time he had a cardiac output of 5.15 with an index of 2.26. assessment was severe lmca three-vessel coronary artery disease with recent thrombotic occlusion distal rca, severe left ventricular diastolic heart failure, and he had a balloon pump inserted. it was decided that the patient could undergo cabg by dr. . he underwent a cabg x4, lima to lad with a jump graft, ramus, and he was diagnosed with a pda. he had ef preoperatively of 30 percent. past medical history: his past medical history included diabetes with peripheral neuropathy, hyperlipidemia, coronary artery disease, and gerd. medications at home: his medications at home included zocor, humulin insulin, aspirin 325 mg, and lopressor b.i.d. social history: the patient is educator, who has difficulty ambulating at times and uses a cane to walk with assistance. he smokes cigars once a week. he drinks an occasional glass of wine or scotch every evening. hospital course: the patient, in the postoperative period, did quite well within the unit for a brief period of time and was discharged to the floor when he met criteria. he tolerated the procedure quite well, and so he was weaned off of his neo immediately postoperatively. he was on the insulin drip, and he was started on aspirin and plavix, and given lasix for diuresis. was called, who helped consult to help manage his diabetes. the patient had good pain control. he had some shortness of breath in the postoperative period. however, he was evaluated by physical therapy, and once again, he was ambulating and was able to recruit and do quite well from a pulmonary perspective, and by the end of discharge, he was able to ambulate independently, was able to do stairs, and had his blood sugar under control. condition on discharge: the patient was discharged in stable condition. discharge/follow-up instructions: he was given instructions. he is to follow up in three to four weeks with dr. . he was given instructions to see his cardiologist within one week. he was given instructions to see his primary care physician in one week and go over the medications and review all medications that the patient was currently taking. the patient is with an off-pump bypass and therefore should be on plavix for three months. major diagnoses: coronary artery disease, status post myocardial infarction, with a recent thrombotic occlusion, status post coronary artery bypass graft of four vessels, diabetes, hyperlipidemia, and blood loss anemia. , dictated by: medquist36 d: 15:29:08 t: 02:04:44 job#: Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Implant of pulsation balloon Transfusion of packed cells Other skeletal x-ray of pelvis and hip Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes

history of present illness: the patient is a 56-year-old right handed lady who presents to the for sudden onset of frontal occipital headache and brief one to three minute episode of generalized tonoclonic seizure. ct scan was consistent with subarachnoid hemorrhage. the morning of admission at 11:30 while working in her office talking on the phone, she put her head down followed by shaking of bilateral upper extremities as per colleagues. her eyes were open and she was looking straight ahead. she did not respond to any stimuli. no tongue biting, no vomiting. she did not have any urinary of fecal incontinence. ems was activated. after approximately two to three minutes she was back to her baseline. past medical history: 1. anemia 2. appendectomy allergies: penicillin causes a rash. demerol causes hypersensitivity. medications: the patient is on no medications on admission. family history: stroke, father died of stroke. social history: she is widowed, lives with sister. heavy , one pack per day for 20 years. alcohol use, one bottle of beer per day. physical examination on admission: temperature 96.3??????, respiratory rate 20, pulse 76, blood pressure 170/87. in general, she is a 56-year-old lady in no acute distress. she had an o2 nonrebreather mask, appeared tired, alert, awake and oriented to time, place and person. followed commands. speech was fluent. no paraphasic events. repetition and naming were intact. she was attentive. pupils bilaterally 2 mm to 1.5 mm. pupils equal, round and reactive to light. extraocular muscles were intact. face was symmetric, bilateral, equal and intact facial sensation. uvula and tongue were midline. sternocleidomastoid and trapezius intact. neck supple. normal tone and bulk. power and strength was in all four extremities and muscle groups. reflexes were 2+ throughout. toes were downgoing. coordination - finger nose finger was slow. gait was deferred. hospital course: while in the emergency department, the patient became more somnolent, still was arousable, but became sleepier. the patient was admitted to the neurosurgery service on . she had an angiogram which demonstrated an anterior communicating artery aneurysm which was clipped. the patient received triple h therapy and decadron while in the surgical intensive care unit. she was observed for vasospasms, no evidence of occurred and her intravenous fluids were slowly weaned. her steroids were weaned off. the patient, at this time, has a neurological exam consisting of mental status - the patient is alert. she is oriented in that she knows what hospital she is in. she is oriented to person. she states that the date is which has been an improvement. the patient has slight evidence of pronator drift. she is still mildly ataxic. the patient is being discharged to rehabilitation on . discharge diagnosis: 1. subarachnoid hemorrhage secondary to anterior communicating artery aneurysm discharge medications: 1. nimodipine 60 mg po q4 until 2. heparin 5000 units subcutaneous 3. dilantin 200 mg po tid 4. zantac 150 mg po bid follow up: the patient will follow up with dr. in three to four weeks. discharge condition: stable , md dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Clipping of aneurysm Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Diagnoses: Tobacco use disorder Hyposmolality and/or hyponatremia Other convulsions Subarachnoid hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: intermittent chest pain for 1-2 months, but worse in last few days prior to admission with associated arm pain major surgical or invasive procedure: cabg x3 history of present illness: 77 yo male with 1-2 months , but worsening in past few days. also has associated arm pain. admitted to med ctr. in ri . ruled in for nstemi by exzymes. cath performed there revealed ef 70%, 90% lad, cx 90-95%, 90% pda. he has significant copd with reported hx of fev1 0.6/ fvc 1.2l. transferred here for cabg with dr. . past medical history: cad copd htn gout depression pvd s/p right cea social history: smoked 1 ppd for 55 years, quit 1 year ago uses alcohol, but none in 2 months wife died last year family history: no family hx of cad or cva physical exam: 5'6" 58.2 kg 99.3 125/91 sr 83 92% on 2l nad at/nc no jvd, lymphadenopathy, or bruits bilat. healed right cea scar. distant heart sounds rrr no murmur distant breath sounds without wheezes abd. soft, nt, nd extrems. without c/c/e, bilat erythema over medial malleoli, + ttp pulses: 2+ bil. carotid, radial; pops. not palpable 1+ bilat. femoral, dp and pt pertinent results: 06:35am blood wbc-18.0* rbc-3.79* hgb-11.4* hct-34.4* mcv-91 mch-30.0 mchc-33.1 rdw-12.6 plt ct-295 06:35am blood wbc-18.0* rbc-3.79* hgb-11.4* hct-34.4* mcv-91 mch-30.0 mchc-33.1 rdw-12.6 plt ct-295 06:35am blood wbc-18.0* rbc-3.79* hgb-11.4* hct-34.4* mcv-91 mch-30.0 mchc-33.1 rdw-12.6 plt ct-295 06:35am blood wbc-18.0* rbc-3.79* hgb-11.4* hct-34.4* mcv-91 mch-30.0 mchc-33.1 rdw-12.6 plt ct-295 06:35am blood wbc-18.0* rbc-3.79* hgb-11.4* hct-34.4* mcv-91 mch-30.0 mchc-33.1 rdw-12.6 plt ct-295 08:55pm blood wbc-7.0 rbc-3.65* hgb-11.6* hct-33.7* mcv-92 mch-31.7 mchc-34.3 rdw-12.2 plt ct-199 06:35am blood neuts-89.6* lymphs-5.3* monos-4.4 eos-0.6 baso-0.1 06:35am blood plt ct-295 08:55pm blood pt-12.1 ptt-40.9* inr(pt)-1.0 10:30am blood glucose-110* urean-17 creat-1.0 na-134 k-4.2 cl-92* hco3-31* angap-15 08:55pm blood alt-13 ast-21 ld(ldh)-183 alkphos-77 totbili-0.4 02:30am blood calcium-8.4 phos-3.3 mg-1.9 08:55pm blood %hba1c-5.6 -done -done 12:24pm blood cortsol-29.0* brief hospital course: carotid u/s done pre-op showed no signif. stenoses. underwent cabg x3 on with dr. . plaque was found in thoracic aorta during intraop tee. transferred to csru on titrated neosynephrine and propofol drips. remained on neo on pod #1 on ventilator for weaning. vascular surgery () consulted about plaque and cta of chest was negative for dissection. hemodynamically stable on neo 0.3. extubated on pod #2 and chest tubes removed. transferred back to csru after one hour on the floor. not reintubated, but moitored carefully for respiratory issues/copd. transferred back to floor on pod #4. seen and eval. by pt. beta blockade and lasix diuresis started. had some confusion and wheezing. treated with haldol and restarted on pulmonary toilet. anxiety and confusion has resolved. betablockade was increased on pod #7. he continued to increase his ambulation. uti diagnosed on with rising wbc to 20. wbc decreased to 18 today on day 2 of a 7 day course of cipro. afebrile today, vs 98.5 67 sr 166/63 rr 20 92% on 2l , 55.5 kg today ( down from pre-op weight 2.5 kg). alert and oriented, wounds healing well. patient is on 2l o2 via nc at home. will require o2 therapy. transferred to rehab on pod # 9. medications on admission: combivent 2 puffs qid heparin iv 800 u /he tiotropium 1 puff qd ecasa 81 mg qd advair 50/100 1 puff flomax 0.4 mg qd ntg paste prn bisoprolol 2.5 mg qd lipitor 10 mg qd lexapro 10 mg qd atenolol 50 mg qd discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. 2. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 5 days. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain for 1 months. 6. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). 7. albuterol sulfate 0.083 % solution sig: one (1) nebulizer ih inhalation q4wa (). 8. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 9. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: disk with devices inhalation (2 times a day). 10. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 11. escitalopram oxalate 10 mg tablet sig: one (1) tablet po daily (daily). 12. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 13. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 14. formoterol fumarate 12 mcg capsule, w/inhalation device sig: one (1) capsule, w/inhalation device inhalation (2 times a day). 15. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. discharge disposition: home with service facility: skilled nursing discharge diagnosis: s/p cabg x3 cad copd elev. chol htn uti gout depression mi pvd s/p right cea discharge condition: stable discharge instructions: may shower over wounds; pat dry no powders, creams or lotions on incisions may not drive for one month no lifting greater than 10 pounds for 10 weeks followup instructions: follow up with pcp weeks post discharge follow up with dr. for postop visit in 4 weeks Procedure: (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Transfusion of packed cells Transfusion of other serum Continuous intra-arterial blood gas monitoring Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atherosclerosis of aorta Gout, unspecified Unspecified transient mental disorder in conditions classified elsewhere Peripheral vascular disease, unspecified Personal history of tobacco use

history of present illness: this is an 80-year-old male who reports episodes of severe fatigue in that resolved spontaneously. diagnosed with cardiomyopathy and mitral insufficiency. he also reports an episode of chest pressure earlier in that resolved with rest, with a recent increase in episodes of fatigue recently. therefore, referred for cardiac catheterization in . cardiac catheterization revealed an ejection fraction of 56 percent, a 100 percent rca occlusion, a 100 percent om occlusion, a 70 percent ramus occlusion, a 90 percent lad occlusion, an 80 percent first diagonal occlusion, with 2 plus mitral regurgitation; for which he was referred for evaluation for coronary artery bypass grafting and mitral valve repair or replacement. past medical history: peripheral vascular disease, abdominal aortic aneurysm, silent myocardial infarction, transient ischemic attacks, hypothyroidism, gastroesophageal reflux disease, psoriasis, glaucoma, hypertension, left lower extremity varicosities, and a sodium abnormality (on steroid treatment). past surgical history: includes a left carotid endarterectomy in and bilateral cataract removal. preoperative medications: hydrocortisone 10 mg in the morning and 5 mg in the evening, aspirin 325 mg once daily, lisinopril 5 mg once daily, crestor 10 mg once daily, lasix 40 mg every other day, testosterone 200-mg injection every three to four weeks, levoxyl (unknown dose), atenolol (unknown dose), and xalatan eye drops (unknown dose). allergies: intravenous dye. physical examination on presentation: height was 6 feet 2 inches tall, weight was 186 pounds, the heart rate was 44, the blood pressure on the right was 143/68 and on the left 131/61. in general, a tall solid elderly male. skin revealed no obvious disease. heent examination revealed the pupils were equal, round, and reactive to light and accommodation. the extraocular movements were intact. the eyes were anicteric. the neck revealed a healed left carotid endarterectomy scar. negative jugular venous distention. no bruits appreciated. chest was clear to auscultation. right crackles at the left base. heart revealed a regular rate and rhythm. s1 and s2. no appreciated murmur. the abdomen was soft, nontender, and nondistended. there was positive bowel sounds. negative costovertebral angle tenderness. the extremities were warm and well perfused. there was 1 plus edema on the left leg. varicosities were present in the left lower extremity with venous stasis changes. neurologically, cranial nerves ii through xii were grossly intact; nonfocal. good strength in all four extremities. discharge status: home with visiting nurse. discharge diagnoses: 1. coronary artery disease and mitral regurgitation. 2. status post coronary artery bypass grafting times four and mitral valve repair. 3. peripheral vascular disease. 4. osteoarthritis. 5. abdominal aortic aneurysm. 6. panhypopituitary. 7. gastroesophageal reflux disease. 8. psoriasis. 9. glaucoma. 10. hypertension. 11. status post left carotid endarterectomy. medications on discharge: 1. colace 100 mg p.o. twice daily. 2. percocet 5/325 one to two tablets p.o. q.4h. as needed (for pain). 3. lipitor 20 mg p.o. once daily. 4. latanoprost 0.005 percent drops 1 drop both eyes at bedtime. 5. brimonidine tartrate 0.2 percent drops 1 drop both eyes q.8h. 6. aspirin 81 mg p.o. once daily. 7. lasix 20 mg p.o. once daily (for seven days). 8. potassium chloride 20 meq p.o. once daily (for seven days). 9. hydrocortisone 20 mg in the morning and 10 mg in the evening (until otherwise instructed by dr. . 10. levoxyl 88 mcg p.o. once daily. 11. crestor 10 mg p.o. once daily. die follow-up plans: 1. the patient was to follow up with dr. in one to two weeks; with dr. in one week; with dr. in three to four weeks; and with dr. in one to two weeks. , m.d. dictated by: medquist36 d: 15:39:55 t: 16:41:29 job#: Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Annuloplasty Continuous intra-arterial blood gas monitoring Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Unspecified acquired hypothyroidism Peripheral vascular disease, unspecified Mitral valve insufficiency and aortic valve insufficiency Unspecified glaucoma

history of present illness: patient is a 50-year-old male with history of neurosarcoidosis and epidural lipomatosis secondary to prednisone. patient's sarcoidosis was diagnosed in beginning with myelopathy secondary to epidural lipomatosis and chronic steroid use. patient was evaluated and felt would benefit from a t4-t8 laminectomy. past medical history: hypertension. diabetes. gerd. obesity. on physical exam, he is in no acute distress. his lungs are clear to auscultation. he does have some inspiratory stridor. he has been on chronic steroid use since /. his cardiovascular system: regular, rate, and rhythm, no murmurs, rubs, or gallops. abdomen is obese. he has very full neck and chin secondary to chronic steroid use. his motor strength is decreased throughout. the patient has been walking with a walker since . he had worsening myelopathy. he is admitted status post t4-t8 laminectomy without intraoperative complications. postoperatively, his vital signs are stable. he was afebrile. he was following commands x4, moving all extremities with 4 plus strength. his lungs were clear. his abdomen was soft and nontender. his eoms were full. grasp was three. his at, , and gastrocs were bilaterally. his dressing was clean, dry, and intact. on postoperative day number one, he was awake, alert, and oriented times three. his strength on the right ip is 5, 4 plus on the left. quads 4 plus on the right and 5 on the left. at 5 on the right and 4 plus on the left. gastrocs 4 plus bilaterally. he had decreased proprioception at the ankles and decreased sensation of the lower extremities by 20 percent. he has decreased plantar reflexes. his vital signs were stable. he was transferred to the regular floor. his dressing was clean, dry, and intact. he had a mri with gadolinium of the thoracic spine, which showed good removal of lipomatosis. he was in stable condition, and was discharged to home on with follow up with dr. in one month. he will follow up in 10 days for staple removal. medications on discharge: 1. baclofen 60 p.o. q.d. 2. citalopram hydrobromide 60 p.o. q.d. 3. pantoprazole 40 p.o. q.d. 4. metoprolol 100 p.o. q.d. 5. trazodone 50 p.o. q.h.s. 6. primidone 150 p.o. q.d. 7. fentanyl patch 75 mcg topically q.72h. 8. multivitamin one p.o. q.d. 9. glipizide 5 p.o. q.d. 10. hydrochlorothiazide 25 p.o. q.d. 11. mirtazepine 30 mg p.o. q.h.s. 12. alendronate sodium 70 mg p.o. q monday. discharge condition: his condition was stable at the time of discharge. , Procedure: Other exploration and decompression of spinal canal Diagnoses: Esophageal reflux Unspecified essential hypertension Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Sarcoidosis Spondylosis with myelopathy, thoracic region Lipoma of other specified sites Spinal stenosis, thoracic region

history of present illness: the patient is a 51-year-old male with a history of bilateral supraclinoid carotid artery occlusion (moyamoya-variant) who presented to for elective surgery. past medical history: 1. hypertension. 2. hypercholesterolemia. 3. depression. 4. history of stroke 13 years ago. 5. history of heart murmur. past surgical history: 1. hernia repair. 2. tonsillectomy and adenoidectomy as a child. allergies: the patient has no known drug allergies. medications at home: 1. vasotec. 2. wellbutrin. 3. pravachol. 4. hydrochlorothiazide. 5. coumadin 8 mg q.d. 6. diltiazem. hospital course: the patient underwent a pial synangiosis. the patient tolerated the procedure well. the patient was started on diet postoperatively, and was advanced gradually. the patient was able to get out of bed and ambulate. his foley catheter was discontinued. the patient was transported from the intensive care unit to the floor. the patient's neurological examination was stable postoperatively. the patient was discharged on in stable condition. discharge status: to home. condition on discharge: stable. discharge medications: 1. aspirin 81 mg p.o. q.d. 2. wellbutrin 150 p.o. q.d. 3. percocet for pain as needed. 4. hydrochlorothiazide 25 p.o. q.d. 5. pravachol 20 mg p.o. q.d. 6. diltiazem 60 mg p.o. q.i.d. 7. vasotec 5 mg p.o. q.d. 8. dilantin 100 mg p.o. q. 8 hours. follow up: the patient should of with dr. , please call dr. office for a follow-up appointment. , m.d. dictated by: medquist36 Procedure: Extracranial-intracranial (EC-IC) vascular bypass Diagnoses: Pneumonia, organism unspecified Pure hypercholesterolemia Unspecified essential hypertension Moyamoya disease

allergies: penicillins / coumadin attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass graft x 3 (lima to lad, svg to diag, svg to om) history of present illness: 74 y/o male with 1 year of dyspnea on exertion which has been worsening over the past couple of months. underwent cardiac cath at osh which revealed 50% lmca and 3 vessel disease. he was then tranasferred to for surgical intervention. past medical history: cornary artery disease s/p ptca/stent , atrial fibrillation, hyperthyroidism, diabetes mellitus, hyperchoelsterolemia, s/p hernia repair, eczema, neuropathy, ?tia social history: retired. quit smoking after 12yrs x 1ppd. denies etoh. family history: non-contributory physical exam: general: nad skin: bilat. soles with eczema. neck with 1" scar secondary to cyst removal lungs: ctab -w/r/r heart: irreg. rate and rhythm -murmur abd: soft, nt/nd, +bs ext: brown discoloration b/l le, -varicosities neuro: non-focal, mae, a&o x 3 pertinent results: vein mapping : duplex evaluation was performed of bilateral lower extremity veins. greater saphenous vein is patent bilaterally from the groin to the ankle. on the right, vein diameters range from .24-.46 cm. on the left, vein diameters range from .20-.5 cm to .62 cm. echo : pre-bypass: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular systolic function is normal. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. mild(1+) mitral regurgitation is seen. there is no mitral valve prolapse. the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. there are simple atheroma in the descending thoracic aorta. no thoracic aortic dissection is seen. post-bypass: preserved -ventricular systolic function. no evidence of aortic dissection post decannulation. the mitral regurgitation may have been slightly improved. cxr : 04:44pm blood wbc-9.5 rbc-4.32* hgb-12.8* hct-36.7* mcv-85 mch-29.7 mchc-35.0 rdw-14.8 plt ct-250 01:57am blood wbc-17.4*# rbc-3.77* hgb-10.7* hct-32.6* mcv-86 mch-28.4 mchc-32.9 rdw-15.3 plt ct-205 02:44am blood wbc-13.6* rbc-3.53* hgb-10.5* hct-30.0* mcv-85 mch-29.8 mchc-35.0 rdw-15.3 plt ct-363 04:44pm blood pt-12.2 ptt-24.7 inr(pt)-1.0 06:45am blood pt-16.1* ptt-28.4 inr(pt)-1.5* 04:44pm blood glucose-349* urean-13 creat-1.1 na-133 k-5.1 cl-96 hco3-29 angap-13 06:45am blood glucose-114* urean-34* creat-1.4* na-137 k-4.6 cl-97 hco3-29 angap-16 06:45am blood calcium-8.7 phos-3.2 mg-2.4 05:09pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg brief hospital course: as mentioned in the hpi, mr. was transferred from osh to for surgical care. upon admission he underwent all pre-operative work-up, including vein mapping and carotid ultrasound. he remained medically managed, including heparin gtt, for several days awaiting plavix load from cardiac cath to washout. on he was brought to the operating room where he underwent a coronary artery bypass graft x 3. please see operative report for surgical details. he tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition. he remained intubated until post-op day one, when he was weaned from sedation, awoke neurologically intact and was extubated. on this day attempted cardioversion was performed d/t atrial fibrillation and was then paced at 90. but later he then converted back to afib. of note, he was in afib prior to surgery d/t hyperthyroidism. on post-op day two beta blockers and diuretics were started. he was gently diuresed towards his pre-op weight. chest tubes were removed and he was transferred to the sdu on post-op day two. although later on this day he was transferred back to the csru d/t respiratory distress for aggressive pulmonary toileting. on post-op day five his epicardial pacing wires were removed and he was started on coumadin for afib. on post-op day six he was transferred to the sdu for continued post-op care. physical therapy followed patient during entire post-op course for strength and mobility. he was discharged home on post-op day 9 with vna and the appropriate follow-up appointments. first blood draw tomorrow with results to be called to dr. . medications on admission: lisinopril, plavix, aspirin, atenolol, tapazole, glucophage, lipitor, humalog, amitryptiline, cymbalta discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*1* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 4. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*1* 5. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*1* 6. methimazole 5 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* 7. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*1* 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 9. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days. disp:*4 tablet(s)* refills:*1* 10. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 10 days. disp:*20 capsule, sustained release(s)* refills:*0* 11. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day) for 10 days. disp:*10 tablet(s)* refills:*0* 12. propoxyphene n-acetaminophen 100-650 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 13. humalog 75/25 58 units qam 42 units qpm as prior to surgery . coumadin 1 mg tablet sig: 0.5 tablet po once a day for 2 days: no coumadin tonight, , check inr . disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: cornary artery disease s/p coronary artery bypass graft x 3 pmh: s/p ptca/stent , atrial fibrillation, hyperthyroidism, diabetes mellitus, hyperchoelsterolemia, s/p hernia repair, eczema, neuropathy, ?tia discharge condition: good discharge instructions: take shower. wash incisions and pat dry. do not take bath. do not apply lotions, creams or ointments to incisions do not drive for 1 month. do not lift more than 10 pounds for 2 months. if you develop a fever, notice redness or drainage from incision, please contact office immediately. call to schedule all follow-up appointments. followup instructions: dr. in 4 weeks dr. weeks dr. on monday at 10:15 am Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Atrial cardioversion Transfusion of packed cells Continuous intra-arterial blood gas monitoring Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Personal history of tobacco use Atrial flutter Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status

allergies: heparin agents attending: chief complaint: kidney mass major surgical or invasive procedure: left radical nephrectomy and adrenalectomy, regional lymphadenectomy. history of present illness: mr is a 50-year-old male, with a long history of multiple medical problems which include aortic valve replacement with a mechanical valve in on chronic coumadin therapy, heparin-induced thrombocytopenia from intravenous heparin given in , coronary disease status post myocardial infarction at age 35, dilated cardiomyopathy with ejection fraction of 25 percent, who was found to have bilateral renal masses in . six weeks ago, he underwent right partial nephrectomy in preparation for today's left radical nephrectomy. he has a previous biopsy of the left renal mass that was done at an outside hospital, which was confirmatory of renal cell carcinoma. he presents now for surgical therapy. past medical history: cad s/p mi dilated cardiomyopathy c chf (ef 25%) and global hypokinesis aicd (prophylactic for ef, no h/o arrythmias) avr s/p mechanical heart valve 00' osa social history: tob: 1 ppd x 35y until quit 3m ago. married, lives with wife, 1 son. etoh, no drugs. retired employee. family history: father had kidney cancer and prostate cancer. mother had breast cancer. physical exam: gen: nad. wd, wn. heent: ncat, eomi neck: no cervical, occipital, clavicular, axillary, or inguinal lad. cv: rrr 3/6 sem at rusb, mechanical click pulmo: ctab abd: obese, soft, nt, nd, no cva tenderness. no palpable masses. r sided subcostal incision well-healed. ext: warm, no c/c/e, 2+ dp/pt. gu: phallus nl. pertinent results: 11:58pm wbc-10.4 rbc-4.08* hgb-12.0* hct-35.8* mcv-88 mch-29.3 mchc-33.4 rdw-13.5 11:58pm plt count-187 04:48pm pt-18.5* ptt-37.4* inr(pt)-2.2 04:48pm glucose-155* urea n-14 creat-1.1 sodium-138 potassium-4.7 chloride-109* total co2-25 anion gap-9 04:48pm calcium-7.6* magnesium-1.7 brief hospital course: patient tolerated procedure well and was transferred to nsicu d/t cardiac history. post-op course was unremarkable. patient remained in nsicu for 2 days and was eventually transferred to 12reisman. pain was controlled with dilaudid through hospitalization. on pod1, chest tube was removed. on pod2, ngt was removed. on pod3, patient was transferred out of nsicu to 12r on pod4, patient began regular diet after onset of flatus. on pod5, patient was provided toradol for pain. ct scan of thorax was performed to rule out any source for pain; scan revealed no hematoma/bleeding/fluid collection. on pod6, patient was deemed stable and suitable for discharge. on discharge patient remained therapeutic (inr 2.5-3.5) on warfarin. medications on admission: toprol xl 50 qd lasix 40 lipitor 40 mavik 4 coumadin 5/7.5 discharge medications: 1. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 3. hydromorphone hcl 4 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. disp:*40 tablet(s)* refills:*0* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). tablet, delayed release (e.c.)(s) 5. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* 7. warfarin sodium 5 mg tablet sig: one (1) tablet po once (once) for 1 doses: alternate 5mg and 7.5mg qod. 8. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: left renal cancer discharge condition: good. discharge instructions: go to an emergency room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 f), chills, or shortness of breath. proceed to the er/ew/ed if your wound becomes red, swollen, warm, or produces pus. you may remove your dressings 2 days after your surgery if they were not removed in the hospital. leave the steri strips on until they begin to peel, then you may remove them. staples and stitches will remain until your follow-up appointment. if you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. no heavy lifting or exertion for at least 6 weeks. no driving while taking pain medications. narcotics can cause constipation. please take an over the counter stool softener such as colace or a gentle laxative such as milk of magnesia if you experience constipation. you may resume your regular diet as tolerated. you may take showers (no baths) after your dressings have been removed from your wounds. continue taking your home medications unless otherwise contraindicated and follow up with pcp. restarting mavik. recheck inr tomorrow. followup instructions: f/u with . please call for appt. f/u with pcp. restarting mavik. Procedure: Venous catheterization, not elsewhere classified Nephroureterectomy Division or crushing of other cranial and peripheral nerves Regional lymph node excision Unilateral adrenalectomy Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Malignant neoplasm of kidney, except pelvis Heart valve replaced by other means Old myocardial infarction Long-term (current) use of anticoagulants Automatic implantable cardiac defibrillator in situ

history of present illness: the patient is a 48-year-old male with prior cardiac history significant for coronary artery disease, history of myocardial infarction, history of congestive heart failure, cardiomyopathy and aortic regurgitation. the patient's aortic insufficiency has progressed from moderate to severe over the last several years. the patient claimed that he had a few symptoms. however, his wife stated that he has had more dyspnea on exertion and fatigue recently. the patient smokes approximately one pack a day. he is overweight. the patient denies any chest pain. the patient also has a history of sleep apnea. a recently performed echocardiogram showed moderate severe aortic insufficiency with ejection fraction of approximately 25%. a repeat cardiac catheterization performed on showed one vessel branch coronary artery disease, moderate to severe aortic regurgitation, severe global left ventricular systolic dysfunction, mild biventricular systolic dysfunction and mild pulmonary arterial diastolic hypertension. at the time, the left ventricular ejection fraction was estimated to be 29%. given the patient's worsening symptoms, the decision was made to proceed with an aortic valve replacement as a long term solution. past medical history: 1. echocardiogram with ejection fraction of 20% to 25% with multiple wall motion abnormalities including apical akinesis, anteroseptal hypokinesis/akinesis, inferior hypokinesis/akinesis as well as lateral hypokinesis/akinesis. 2. congestive heart failure with ejection fraction of 20% to 29%. history of myocardial infarction. 3. aortic insufficiency 4. cardiomyopathy 5. coronary artery disease 6. sleep apnea past surgical history: no known surgical history. medications: 1. coumadin 5 mg po q day 2. lipitor 20 mg po q day 3. mavik 4 mg po q day 4. lasix 40 mg po q day 5. toprol xl 25 mg po q day allergies: no known drug allergies. physical examination: vital signs: afebrile, heart rate 70 and sinus rhythm, blood pressure 130/81. general: alert and oriented in no apparent distress, obese white male. head, ears, eyes, nose and throat: within normal limits. no evidence of jugular venous distention. no evidence of bruits. pulmonary: clear to auscultation bilaterally. cardiac: sinus rhythm, 2/6 systolic murmur and diastolic murmur. abdomen: obese, soft, nontender. extremities: no edema, pulses present and are palpable bilaterally. laboratory studies on admission: hematocrit 30.5, white blood cell count 10.2, platelets 122. ptt 35.2, pt 12.2, inr 1.0. glucose 119, bun 14, creatinine 0.9. sodium 136, potassium 4.7. imaging: preoperative chest x-ray was within normal limits. summary of hospital course: the patient was admitted to cardiac surgery service. given symptomatic aortic insufficiency and also history of congestive heart failure, it was decided that a surgical intervention would be appropriate. on , the patient underwent aortic valve replacement with a 23 mm carbomedics mechanical valve. the procedure was without any complications. the patient tolerated the procedure well. please see the full operative note for details. the patient remained intubated and was transferred to the intensive care unit for further management in stable condition. the patient was extubated on the same day. his oxygenation remained good. he was making adequate urine. postoperatively, the patient's arterial blood gas was ph 7.38, pco2 of 34, po2 of 110. his hematocrit was stable at 30.5. the patient was further diuresed. he was transferred to the regular floor on postoperative day 1 in good condition. the patient continued to have excellent oxygenation on minimal supplemental oxygen. physical therapy was consulted which followed the patient throughout his hospitalization and then officially cleared him to go home. anticoagulation with coumadin was restarted. given the presence of a mechanical valve, an inr of 2.5 to 3 was set as the goal. the patient remained afebrile. he remained in sinus rhythm. his lungs were clear to auscultation bilaterally. his pacing wires were removed on postoperative day 3. his urine catheter was removed on postoperative day 2. the patient was also started on intravenous heparin on postoperative day 3 given slow rise in the nr level. the patient was ambulating without assistance. the patient was continued to be diuresed with lasix. he had 1+ lower extremity edema bilaterally. his incision was clean, dry and intact throughout this hospitalization course. on the date of discharge, his inr was 1.9. the patient was discharged to home on postoperative day 6. discharge condition: stable discharge disposition: home discharge diagnoses: 1. severe aortic insufficiency, status post aortic valve replacement with a 23 mm carbomedics mechanical valve. 2. congestive heart failure 3. cardiomyopathy 4. sleep apnea discharge medications; 1. lasix 20 mg po bid x14 days 2. lipitor 20 mg po q day 3. lopressor 50 mg po bid 4. coumadin 7.5 mg on and 7.5 mg on (to follow up at the clinic for further dosing). 5. potassium chloride 20 milliequivalents po bid x14 days 6. colace 100 mg po bid 7. percocet 1 to 2 tablets po q 4 to 6 hours prn pain discharge instructions: 1. the patient is to follow up with his surgeon, dr. , in approximately for weeks. 2. the patient is to follow up with dr. grape, who is his primary care physician and cardiologist, in approximately one week. 3. the patient is to follow up at the clinic in two days to have his inr levels drawn and his coumadin levels adjusted. dr., 02-229 dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Aortic valve disorders Other chronic pulmonary heart diseases Unspecified sleep apnea Old myocardial infarction

allergies: heparin agents attending: chief complaint: bl renal masses major surgical or invasive procedure: right partial nephrectomy . history of present illness: 50yo m h/o cad, dilated cardiomyopathy, chf, avr s/p mechanical heart valve, presented to c/o l flank pain x1d. abdominal ct showed bilateral renal masses: left kidney mass 7 cm, exocytic, lower pole and right kidney mass 2.6 cm, w/ infarcted tissue in upper mid left kidney. a renal ultrasound showed a solid 2.6 cm mass on right, and a complex cystic 7 cm mass on the left. an urinalysis showed microscopic hematuria. pt underwent a core biopsy of left renal mass x2. his pain was controlled with a morphine pca and then dilaudid iv and his anticoagulation was switched from coumadin to heparin in the context of his renal biopsy. he is now transferred to for continuation of care. past medical history: cad s/p mi dilated cardiomyopathy c chf (ef 25%) and global hypokinesis aicd (prophylactic for ef, no h/o arrythmias) avr s/p mechanical heart valve 00' osa social history: tob: 1 ppd x 35y until quit 3m ago. married, lives with wife, 1 son. etoh, no drugs. retired employee. family history: father had kidney cancer and prostate cancer. mother had breast cancer. physical exam: gen: lying in bed, nad. wd, wn. heent: ncat, eomi, perrl. no cervical, occipital, clavicular, axillary, or inguinal lad. cv: rrr 3/6 sem at rusb, mechanical click pulmo: ctab abd: obese, soft, nt, nd, no cva tenderness. no palpable masses ext: warm, no c/c/e, 2+ dp/pt. gu: phallus nl. pertinent results: 04:30am blood hct-28.4* 04:31am blood pt-15.2* inr(pt)-1.5 04:31am blood creat-1.1 k-4.2 06:20am blood hbsag-negative hbsab-negative hav ab-positive 06:00am blood igm hav-negative 06:20am blood hcv ab-negative 01:00pm blood heparin dependent antibodies- 10:57pm urine color-straw appear-clear sp -1.030 10:57pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 10:57pm urine rbc-0 wbc-0 bacteri-none yeast-none epi-0 06:25am blood wbc-8.9 rbc-4.19*# hgb-12.8*# hct-37.1* mcv-89 mch-30.5 mchc-34.5 rdw-13.0 plt ct-96*# 06:25am blood plt ct-96*# 06:25am blood pt-12.9 ptt-52.2* inr(pt)-1.1 06:25am blood glucose-114* urean-16 creat-0.9 na-135 k-3.9 cl-98 hco3-29 angap-12 06:25am blood alt-109* ast-82* ld(ldh)-604* alkphos-81 totbili-0.4 06:25am blood albumin-3.3* calcium-8.8 phos-3.8 mg-2.0 brief hospital course: 50yo m admitted initially to the medicine service for work-up of his newly-dx'd bl renal masses, concerning for malignancy. his platelet count dropped during the time of his transfer, presumably from hit although the one assay performed here was negative. for this reason his anticoagulation was switched to argatroban and carefully titrated to effectively anticoagulate for his mechanical valve; his platelet count normalized. he remained as an inpatient during this complicated work-up period. the pathology report from revealed renal cell carcinoma. a metastatic work-up with head ct, chest ct, abd-pelvic ct, and bone scan was negative except for an adrenal mass whose density was not consistent with benign adenoma. (mri could not be performed due to his aicd). dr. from urology planned a two-stage resection; first a right-partial and then a left-total. cardiac clearance was obtained with a combination of studies from and ; an echo here showed ef 20-30% and he was maintained on beta-blocker. he did develop lue swelling but u/s and ct were negative for dvt. he was maintained on therapeutic argatroban and transitioned successfully to coumadin. ep-cardiology was contact regarding deactivating his aicd. he underwent a bowel prep on the day prior to surgery. a right partial nephrectomy was performed on while on coumadin. see operative report for details. he was placed in the icu post-operatively for close hemodynamic monitoring in light of his complicated cardiac history; he remained intubated with a swan-ganz catheter, chest tube, jp drain, ng tube, and foley catheter. he was extubated without complication on pod 1. on pod 2 the chest tube was removed, cxr showed minimal ptx. the ng tube was removed on pod 3. he was transfused 1 unit prbcs for anemia (hct 27). he remained in the icu for observation related to mobilizing fluid and concern for volume overload given his compromised cardiac output. it was noted that he developed a contact dermatitis, presumably from the tape during surgical positioning; this resolved after several days with topical cream for comfort. he remained stable and was transferred to the regular floor on pod 4 after the swan-ganz was changed over a wire to a triple-lumen catheter. at this time he was passing regular flatus and given a regular (cardiac) diet. his pain control was transitioned to po dilaudid. his hct remained low and he received a 2nd unit of prbcs. the jp drain was removed on pod 5. his inr was closely checked throughout his post-operative course with dosage decreased during immediate post-op period (inr 2.8-3.2); it rose to 3.8 and 3.9 with dosage decreased. after beginning po intake, the inr dropped significantly to 3.4 then 2.1 over 12 hours and then 1.5. his dose meanwhile had been increased to 7.5 qhs. he was resumed on his usual home medications. the foley was removed on pod 6 and the triple-lumen catheter on pod 7. at the time of discharge he was urinating independently, tolerating po diet and pain moderately controlled on po meds. medications on admission: lasix 40 mg po qd toprol xl 50 mg po qd mavik 4 mg po qd lipitor 40 mg po qd colace 100 mg po bid dilaudid 2-4 mg iv q4h heparin 1100 units/hr discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. tablet(s) 2. hydromorphone hcl 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. disp:*30 tablet(s)* refills:*0* 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): while taking dilaudid to prevent constipation. disp:*30 capsule(s)* refills:*1* 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 7. trandolapril 4 mg tablet sig: one (1) tablet po daily (daily). 8. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 9. warfarin sodium 7.5 mg tablet sig: one (1) tablet po hs (at bedtime) for 1 doses. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: renal cell cancer heparin-induced thrombocytopenia lue cellulitis dilated cardiomyopathy avr, mechanical valve contact dermatitis discharge condition: stable. discharge instructions: see "nephrectomy" instruction sheet. no baths or soaks or swimming. shower, pat wound dry. do not drive or drink alcohol while taking dilaudid. md if develop fever, or if incision develops redness, swelling, drains pus. heart-healthy diet. followup instructions: follow-up with dr. as previously arranged. call for time and date for staple removal and post-op check, and to discuss/schedule the l nephrectomy. follow-up with primary care physician 2 days to discuss inr and coumadin dosing. have inr checked twice daily until coumadin dose is settled with your pcp. Procedure: Diagnostic ultrasound of heart Pulmonary artery wedge monitoring Transfusion of packed cells Partial nephrectomy Artificial pacemaker rate check Diagnoses: Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Malignant neoplasm of kidney, except pelvis Systolic heart failure, unspecified Other specified forms of chronic ischemic heart disease Heart valve replaced by other means Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Unspecified sleep apnea Cellulitis and abscess of upper arm and forearm Automatic implantable cardiac defibrillator in situ Anticoagulants causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gi bleeding. major surgical or invasive procedure: endoscopy. history of present illness: 53m with hx of hepc, hepatitis c, thrombocytopenia, and cad s/p cabg, with cardiac cath with stenting 1 week ago at which time he was started on plavix. tx'd from osh for 2 episodes each of black stool/brbpr and cola colored emesis. no abd pain. . in the ed patient was noted to have frankly bloody guiaic with 300cc ng aspirate of cola fluid and coffee grounds; lavage was clear, hd stable. hct was noted to have dropped 36 to 26 over past 8 days. past medical history: cad s/p cabg with subsequent bell's palsy, cath w stent hypertension hx of hepatitis c. patient's primary care provider states that the patient underwent treatment approximately 10 years ago, and then additional "incomplete" treatment several years ago. unclear re: specifics. thrombocytopenia. have been running 60's-80's. gout hx of binge drinking appendectomy social history: single, works construction. lives with son, age 21. has sister in area, (# .) patient smoked 2-3 packs a day for approximately 30 years, quitting in . family history: mother with an enlarged heart. physical exam: physical exam: vs: temp: af bp: 118/57 hr: 90 rr: 20 o2sat: 100% 2 lpm gen: middle-aged man in nad, pale appearing heent: eomi, perrl resp: non labored and clear anteriorly cv: rrr no mrg abd: soft, nd, nt, pos bs ext: no edema skin: no rash pertinent results: labwork on admission: 06:00am wbc-5.6 rbc-2.48*# hgb-8.9*# hct-26.4*# mcv-106*# mch-35.7* mchc-33.6 rdw-13.8 06:00am plt count-86* 06:00am neuts-71.7* lymphs-21.8 monos-6.0 eos-0.2 basos-0.3 06:00am pt-14.5* ptt-31.5 inr(pt)-1.3* 06:00am glucose-154* urea n-23* creat-0.7 sodium-139 potassium-4.5 chloride-111* total co2-21* anion gap-12 . 06:00am blood ctropnt-<0.01 06:00am blood ck-mb-4 . 12:44pm blood heparin dependent antibodies-negative . echo: lvef 60% with mild lvh. mild mr, tr. . ett (): 5 minutes 15 seconds protocol, 54% max phr. + chest pain and ekg changes with exercise (st elevation). imaging: mild inferior scar with mild inferior and inferolateral ischemia. lvef 68%. final diagnosis: 1. severe native 3 vessel coronary artery disease. 2. moderate systemic arterial hypertension. 3. patent lima-lad and radial artery-diagonal grafts. 4. svg-rpda with 80% stenosis; svg-om with 30% stenosis. 5. successful stenting of the svg (to rpda) (drug eluting) . ecg sinus rhythm. normal ecg. compared to the previous tracing of no change. . egd impression: normal mucosa in the duodenum ulcers in the antrum and stomach body - tear . labwork on discharge: 04:10am blood wbc-4.7 rbc-3.45* hgb-11.2* hct-32.7* mcv-95 mch-32.4* mchc-34.3 rdw-16.9* plt ct-67* 04:10am blood glucose-116* urean-15 creat-0.8 na-138 k-4.3 cl-107 hco3-24 angap-11 04:10am blood calcium-8.6 phos-3.8 mg-2.1 brief hospital course: a/p: 53 y/o man with cad s/p recent stent (), history of hepatitis c, etoh abuse who presented from osh with melena, coffee ground emesis; found to have hematocrit drop from 36 to 26 over past 8 days prior to admissin. admitted to micu for monitoring prior to endoscopy. . 1. gi bleed. the patient was transfused three units packed red blood cells with appropriate bump in hematocrit. the hematocrit remained stabled after transfusion with hematocrit in low 30s hospital days . the patient had two episodes of melena the night of hospital day one; no further episodes of hematemesis or melena during hospitalization. hematocrit 32.7 on discharge. aspirin and plavix were initially held but were restarted the second day of admission per gi recommendations. patient was initially treated with protonix 40 mg iv bid; this was changed to po prior to discharge. egd with results as above; no further treatment as tear and ulcer were no longer actively bleeding. h. pylori serum antigen was negative. the patient was taking high-dose indomethacin for one week prior to admission for gout. the patient is scheduled to have a repeat endoscopy in 4 weeks as below to assess for healing of the ulcers. . 2. cad. remained asymptomatic throughout hospitalization. aspirin and plavix were initially held but were restarted the second day of admission per gi recommendations. antihypertensives were restarted the second day of admission. patient to make follow-up appointment with cardiology. . 3. hepatitis c. no varices seen on endoscopy. further work-up and management deferred to the primary care doctor. . 4. etoh use/abuse. patient evaluated with ciwa scale but showed no signs of withdrawal. . 5. thrombocytopenia. stable, chronic. heparin products held as primary care doctor have dropped in the past in response to heparin. hit ab negative. in 60s on discharge. medications on admission: aspirin 81mg daily every morning lisinopril 40mg daily every morning folic acid 1mg daily every morning norvasc 5mg daily every morning atenolol 100mg daily every morning plavix discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 4. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). 5. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. pantoprazole 40 mg iv q12h 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: 1. upper gi bleed, - tear on endoscopy 2. ulcers in stomach body and antrum . secondary: 1. cad s/p cabg with subsequent bell's palsy, cath w stent 2. hypertension 3. hepatitis c 4. thrombocytopenia- have been running 60's-80's 5. gout 6. hx of binge drinking 7. s/p appendectomy discharge condition: afebrile, vital signs stable. hematocrit stable. discharge instructions: please contact a physician if you vomit blood, experience black stools, bloody stools, chest pain, shortness of breath, or any other concerning symptoms. . please take your medications as prescribed. take protonix 40 mg twice a day for the rest of your life. . please keep your follow-up appointments as below. followup instructions: follow-up endoscopy: provider: , md phone: date/time: 9:00 provider: suite gi rooms date/time: 9:00 . please call your primary care doctor and arrange follow-up within the next two weeks. . please make a follow-up appointment with your cardiologist. Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Gout, unspecified Aortocoronary bypass status Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Gastroesophageal laceration-hemorrhage syndrome

history of present illness: this is an 80 year old male with a history of dementia and psychosis, nursing home resident, status post fall this morning, found at 5:45 a.m. on the day of admission. the patient was down for approximately 1.5 hours as noted by records from the nursing home. the patient was noted to have a laceration at the back of his head, on the left, with a fair amount of bleeding. per the nursing home, the patient was alert and oriented when found. initially with oxygen saturation of 87% on two liters when sent by ems. on arrival to the emergency room, the patient was disoriented, unable to give name. the patient did not have a cervical collar in place. the laceration on the left forehead was noted. laboratory studies revealed a blood sugar in the 300's with an anion gap of 24, with ketones in the urine. the patient was treated with insulin 10 cc intravenous, followed by five units per hour drip. he received one liter of normal saline, 200 cc an hour, with 40 of kcl of intravenous fluids. the patient received 500 mg of levaquin for a urinary tract infection that was noted on urinalysis. head ct was performed and showed a left temporal hemorrhage and a left subarachnoid hemorrhage. the patient was initially seen by neurosurgery in the emergency department and was thought not to be operable. they recommended keeping svp's less than 140, correcting coagulopathy with platelets and limiting intravenous fluids. the patient also had cervical spine films, after his laceration was repaired, but was noted to be unused. the patient was transferred to the medical intensive care unit for management of the dka with a soft collar in place. repeat finger sticks in the emergency department was 230. the patient also received 1 mg of intravenous haldol times two in the emergency room. past medical history: 1.) dementia. 2.) psychosis. 3.) syndrome of inappropriate adh secretion (siadh). 4.) benign prostatic hypertrophy. 5.) hypertension. 6.) diabetes mellitus. 7.) status post lung abscess. 8.) status post rib resection. 9.) history of intravenous drug use. 10.) urinary retention. 11.) history of methicillin resistant staphylococcus aureus. 12.) history of alcohol use. 13.) question of hepatitis b. 14.) prior cerebrovascular accident. 15.) pulmonary embolus, procedure in . physical examination: vital signs: the patient had a temperature of 95.2; heart rate of 106; blood pressure 100p/44; saturation 96% on two liters. generally, agitated in a c collar. head, eyes, ears, nose and throat: pupils two mms, reactive; dry blood on lips; head lags to the posterior left. neck: c collar in place. lungs: coarse breath sounds throughout. decreased breath sounds at the bases. coronary: tachycardiac, irregular, no mitral regurgitation. abdomen: soft, distended, positive bowel sounds, nontender. extremities: venous stasis changes, cool feet. trace distal pulses. abrasions on toes. neurologic: agitated, not responding to commands; moving all extremities. laboratory data: pertinent white count of 15.6; hematocrit of 30.5; platelets of 150 with a differential on the hematocrit of 53% polys, 7 bands, 23 lymphs, 1 eosinophil, 2 metamyelocytes. potassium of 3.4; bicarbonate of 15; creatinine 1.6; sugar of 393. ck of 2,135; mb of 16; troponin of .05; mb index of .7. arterial blood gases: lactate of 15.3. coagulations: inr of 1.9. urinalysis: trace ketones; greater than 300 protein; white blood cell count 6 to 10. chest x-ray was limited by motion; prominent upper mediastinum; ill defined opacity in the right lung base; left retrocardiac subtle opacity; multiple rib fractures in right ribs four, five and six. head ct revealed left temporal lobe hemorrhage; left frontal small subarachnoid hemorrhage; no mass effect; no shift. cervical spine films: limited by motion; no fracture, no dislocation. left femoral line in place. electrocardiogram: sinus rhythm with premature ventricular contractions, 85, normal axis; normal intervals; peak t waves to v2 to 3. no st or t wave changes. hospital course: 1.) given the concern for cerebral hemorrhage, the patient had neurosurgery continuing to consult on this patient and they recommended maintaining sbp of 140, correcting inr, neurologic checks and repeating a ct. repeat ct on hospital day number two showed a stable bleed with a new basilar skull fracture. neurosurgery continued to follow and recommended getting a magnetic resonance scan when stable. the patient had every one hour neurologic checks and correction of his inr coagulopathy, and assessment of his baseline mental status. on hospital day number three, given the concern that the patient had changes in his neurologic examination and a dilated fixed right pupil, a repeat head ct was performed. this actually showed a left grossly enlarged parietal infarct, around the area of the initial bleed that was noted. neurologic medicine was consulted and they recommended that the patient be started on mannitol, though they recognized that the patient had a grim prognosis, given his basilar skull fracture, as well as the questionable cervical spine fracture. dka: the patient presented with elevations of finger sticks in the 400's, with an anion gap of 25 and ketones in the urine; all consistent with diabetic ketoacidosis. the patient was initially hydrated and had his electrolytes repleted. he was started on an insulin drip, with closure of his anion gap within the first 24 hours of admission here. the patient also presented with a severe lactic acidosis that we continued to follow and, with hydration, his lactic acidosis eventually resolved. this was likely on top of acute renal failure. the patient likely had the lactic acidosis secondary to metformin, which he was taking prior to admission. the patient was maintained on the drip and then subsequently transferred to the regular insulin on a sliding scale. acute renal failure: the patient presented with elevations of his creatinine, in a setting of diabetic ketoacidosis, lactic acidosis, infection and also appearing dry on examination. his creatinine subsequently returned to on the day of discharge, with improvement in his hydration status. hemodynamics: the patient was maintained with sbp of 120 to 140 per neurosurgery to maintain cerebral perfusion. the patient was maintained with minimal intravenous fluids. pancytopenia: on hospital day number two, the patient presented with severe pancytopenia with a drop in his white count from 10 to 0.7. hematology/oncology was consulted regarding this and it was thought that this was a multi-factorial event, likely due to a dilutional component since the platelet line and hematocrit were also down, but likely felt that this was due to drug offenders, namely the h2 blocker and ppi. he was initially placed on prophylaxis; these were discontinued and subsequently, on repeat checks of his white blood cell count, this actually bumped to appropriate levels, to 3.8. the patient was also transfused for his hematocrit as well as transfused with platelets. infection: the patient had a urinary tract infection and was placed on levofloxacin for a ten day course. cultures showed no growth to date. pneumonia: the patient had a left retrocardiac opacity, likely pneumonia, which could have contributed to his current condition. the patient was on levaquin and started on clindamycin for possible aspiration coverage. rhabdomyalysis: the patient's elevation of ck and creatinine, in the setting of a fall, troponins were flat. likely, rhabdo contributing to acute renal failure. the patient was aggressively hydrated. c spine collar: patient status post fall and multiple films showed questionable dense fracture. magnetic resonance scan was performed as per neurosurgery. this was unrevealing, unable to rule out dense fracture. the patient was maintained on a hard/soft collar. pain control: the patient was maintained on morphine prn as his blood pressure allowed. code status: the patient's legal guardian, as well as grand niece were contact regarding the patient's poor prognosis after his initial insult with the basilar skull fracture, possible dense fracture and subarachnoid hemorrhage and the patient was initially made "do not resuscitate" by the family. after repeat head ct showed evolution of his infarct, and neurology forecasting a grim prognosis for this gentleman, family meeting was called and the attending of record, this intern, and the guardian as well as the primary care physician, meeting. the patient's grand niece and family agreed that the most appropriate care was comfort measures only for this patient and the patient was made comfort measures only, with withdraw of his endotracheal tube and placed on morphine drip with withdraw of all his medications on the day of discharge. the patient expired on at 8:36 p.m. disposition: deceased. , m.d. dictated by: medquist36 d: 10:09 t: 04:15 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closure of skin and subcutaneous tissue of other sites Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified fall Open wound of forehead, without mention of complication Acute respiratory failure Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled Encounter for palliative care Cerebral artery occlusion, unspecified with cerebral infarction Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness

history of present illness: this is a 47-year-old woman with known mitral regurgitation followed by electrocardiogram. cardiac catheterization done showed 3 to 4+ mitral regurgitation with normal coronaries and an ejection fraction of 67%. cardiac echocardiogram done in of this year showed an ejection fraction of 60% with mildly enlarged left atrium. no aortic insufficiency. there was 3+ mitral regurgitation. past medical history: 1. mitral valve prolapse. 2. hypothyroidism. 3. varicosities of the lower extremities (left greater than right). past surgical history: no past surgical history. medications on admission: levoxyl 50 mcg by mouth once per day. allergies: the patient states no known drug allergies. social history: she lives with her husband and two children. occupation as a writer. she denies tobacco use. occasional alcohol use. denies any other drug use. family history: her mother is alive. her father is alive, status post mitral valve repair. physical examination on presentation: her height was 5 feet 3.5 inches, her weight was 130 pounds. in general, she was well-appearing and in no acute distress. the skin was unremarkable. head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. the extraocular movements were intact. the sclerae were anicteric. the neck was supple with no lymphadenopathy. there was no jugular venous distention. there were no bruits. the chest was clear to auscultation bilaterally. heart was regular in rate and rhythm. first heart sounds and second heart sounds. there was a 3/6 systolic ejection murmur that radiated throughout the precordium. the abdomen was soft, nontender, and nondistended. there were positive bowel sounds. there was no hepatosplenomegaly or costovertebral angle tenderness. the extremities were warm and well perfused. there was no clubbing, cyanosis, or edema. varicosities bilaterally (left greater than right). neurologically, cranial nerves ii through xii were grossly intact. a nonfocal examination. the pulses revealed 2+ femoral bilaterally, 2+ dorsalis pedis pulses bilaterally, and 2+ posterior tibialis pulses bilaterally, and 2+ radial pulses bilaterally. pertinent laboratory values on presentation: white blood cell count was 5.7, her hematocrit was 33.2, and her platelets were 199. her inr was 1.1. sodium was 136, potassium was 3.5, chloride was 100, bicarbonate was 25, blood urea nitrogen was 8, creatinine was 0.5, and blood glucose was 92. liver function tests were within normal limits. urinalysis was negative. pertinent radiology/imaging: electrocardiogram showed sinus bradycardia at a rate of 57 beats per minute. a chest x-ray showed no active cardiopulmonary processes. summary of hospital course: as stated previously, the patient was a direct admission to the operating room on where she underwent minimally invasive mitral valve repair via a right mid axillary mini-anterior thoracotomy with a 28-mm angioplasty. please see the operative report for full details. in summary, the patient had a minimally invasive mitral valve repair. her bypass time was 130 minutes with a cross-clamp time of 110 minutes. she tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient's mean arterial pressure was 74 with a central venous pressure of 6. she was in a sinus rhythm at 89 beats per minute. she had a levophed infusion at 0.3 mcg/kg per minute and propofol at 20 mcg/kg per minute. the patient did well in the immediate postoperative period. her anesthesia was reversed. she was weaned from the ventilator and successfully extubated. she had no other events on operative day. on postoperative day one, the patient continued to require a levophed infusion for blood pressure support which was titrated as tolerated. her swan-ganz catheter was removed on postoperative day two. the patient had weaned to off the levophed infusion, and she was transferred to the floor for continued postoperative care and cardiac rehabilitation. additionally, on postoperative day two, the drain was removed. over the next several days, the patient had an uneventful hospitalization. once on the floor, with the assistance of the nursing staff and the physical therapy staff, the patient's activity level was advanced. she remained hemodynamically stable throughout her hospitalization. on postoperative day four, it was decided that the patient was stable and ready to be discharged to home. at that time, the patient's physical examination was as follows. vital signs revealed her temperature was 99, her heart rate was 92 (sinus rhythm), her blood pressure was 104/68, her respiratory rate was 20, and her oxygen saturation was 97% on room air. her weight preoperatively was 59 kilograms, at discharge was 66.7 kilograms. laboratory data revealed a white blood cell count of 7.7, her hematocrit was 23.1, and her platelets were 129. sodium was 137, potassium was 3.7, chloride was 100, bicarbonate was 31, blood urea nitrogen was 8, creatinine was 0.5, and her blood glucose was 99. physical examination revealed she was alert and oriented times three. she moved all extremities. she followed commands. respiratory examination revealed the lungs were clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm. first heart sounds and second heart sounds. the abdomen was soft, nontender, and nondistended with normal active bowel sounds. the extremities were warm and well perfused with no clubbing, cyanosis, or edema. right thoracotomy incision with steri-strips, opened to air, clean and dry. medications on discharge: 1. enteric-coated aspirin 325 mg every day. 2. niferex 150 mg mouth once per day. 3. vitamin c 500 mg twice per day. 4. toprol-xl 12.5 mg once per day. 5. levoxyl 50 mcg by mouth once per day. 6. colace 100 mg twice per day. 7. lasix 20 mg once per day (times two weeks). 8. potassium chloride 20 meq once per day (times two weeks). 9. dilaudid 2 mg to 4 mg q.4-6h. as needed. discharge diagnoses: 1. status post minimally invasive mitral valve repair via a right thoracotomy. 2. hypothyroidism. condition at discharge: good. discharge disposition: the patient was to be discharged home with . die instructions/followup: 1. the patient was instructed to have followup on the clinic in two weeks. 2. the patient was instructed to follow up with dr. in three weeks. 3. the patient was instructed to follow up with dr. in four weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of mitral valve without replacement Diagnoses: Mitral valve disorders Unspecified acquired hypothyroidism

history of present illness: the patient is a 51 year old male with hepatitis c virus cirrhosis, right lobe hepatocellular carcinoma, status post radiofrequency ablation on who presents preop for a liver transplant in a.m. he reports loose stools x10 per 24 hours associated with chronic abdominal pain, no fever or chills, no nausea or vomiting, no cough, no urinary frequency, or symptoms of uti. does admit to feeling hungry and has baseline shortness of breath. past medical history: 1. significant for hepatocellular carcinoma status post radiofrequency ablation. 2. hepatitis c virus. 3. cirrhosis. 4. hypertension. 5. nephrolithiasis. 6. djd. allergies: patient is allergic penicillin. medications at home: 1. lactulose 30 cc b.i.d. 2. atavan 1 mg p.r.n. 3. protonix 40 mg p.o. q. d. 4. aldactone 100 mg p.o. b.i.d. 5. lasix 40 mg p.o. q. d. 6. fluoxitene 20 mg p.o. q. d. 7. nadolol 20 mg p.o. q. d. 8. bupropion 100 mg p.o. b.i.d. 9. glotrimizole troche 1 five times a day. 10. multivitamin one tab q. d. 11. methadone 145 mg q. d. clinic is discovery, phone number . social history: lives in . habits: history of alcohol abuse. denies any cigarette smoking. physical examination: on admission, temperature 98.1, heart rate 65, blood pressure 122/84 with a respiratory rate of 18, 98% on room air. he was alert and oriented, no acute distress. lungs clear to auscultation bilaterally. heart regular rate and rhythm. abdomen soft, obese, positive bowel sounds, nonfocal abdomen, tender, negative rebound, negative hemorrhoids, positive umbilical hernia. rectal, guaiac negative, no hemorrhoids. extremities, positive venous changes and no edema. laboratory data: on admission, the patient had a chest x-ray that showed no acute process, no suspicious nodules. ekg on , sinus bradycardia, rate 49, inferior lateral flat t-waves. on , ct of the thorax was stable, no lesions. hospital course: the patient was admitted to the transplant service. he was made npo after midnight. iv fluid was started. lab work was sent off to use preop for the or. labs preop: white count 3.7, hematocrit 38, platelet count 38, fibrinogen 135. coags: pt 17, ptt 37, inr 1.6. creatinine 1, bun 19, sodium 139, potassium 3.9, chloride 105, co2 26. the ua was negative. he was taken to the or on for orthotopic liver transplant. surgeon was dr. , co-surgeon was dr. . ebl was 2 liters. he was replaced with 5 liters of crystalloid, 6 units of ffp, 6 units of packed red blood cells, 3 bags of platelets and 1 bag of cryoglobulin. please see operative report for details. the patient was intubated and taken to the surgical intensive care unit in critical, but stable condition. he was given induction immunosuppression of 500 mg of solu- medrol, 1 gram of cellcept intraop. in the sicu, his hematocrits were followed closely. he was replaced with iv fluid. hematocrit was 30.6. he was weaned and extubated. his lfts trended down. properatively, his ast was 1463, alt 1116, alkaline phos 55, total bilirubin 3.9, and an amylase of 279. on postoperative day 2, his ast was 476, alt 746, alkaline phos 56, and a total bilirubin of 1.2. a duplex ultrasound of the liver demonstrated perihepatic ascites. portal veins and hepatic veins were visualized with normal direction of flow, poorly dopplered hepatic artery waveforms were noted, likely secondary to technical limitations. a repeat ultrasound was done on postoperative day 2. this demonstrated appropriate waveforms and directionality of flow within the portal veins, hepatic veins, and hepatic arteries. his lfts continued to trend down. vital signs were stable. his preop weight was 113. on postoperative day 1, his weight was 130.5. he began on iv lasix and his weight trended down and achieved a weight of 116.7 no postoperative day 14. his hematocrit trended down to 23.5 on postoperative day 9. he received 3 units of packed red blood cells. a repeat hematocrit was 26.9. he received another unit of packed red blood cells as well as 1 unit of platelets for a platelet count of 74. post-platelet transfusion was 114 and a post- hematocrit was 32.1. his hematocrit remained in the range of 28 to 29 for the remainder of his hospital course. he did undergo abdominal ct with and without contrast to evaluate for any bleeding. the ct demonstrated no cause for drop in hematocrit. there was moderate hepatic artery stenosis noted. there was narrowing of the portal vein at the area of the anastomosis as well as mild stenosis at the origin of the right renal artery. a small amount of ascites and perihepatic fluid was noted. there were multiple low attenuation areas in the transplanted liver likely representing simple cysts. when the patient was in the sicu, as he awakened, he complained of pain control. patient was on methadone 145 mg p.o. q. d. at home and he had not been on this as of postoperative day 2. dilaudid 2 mg iv q. 1 hour was ineffective in relieving the patient's pain, so the dilaudid was increased to 4 mg iv q. 1 to 2 hours. methadone was restarted. the patient was started on clear liquids. he tolerated this without incident. his blood sugars were elevated and consult was obtained. he was placed on an insulin sliding scale to achieve normalization of blood glucoses. he was hypertensive while in the sicu. he was given hydralazine and lopressor. blood pressure improved and ranged between 130s to 140s down to 90 to 100 systolic. lopressor was changed to p.o. his solu-medrol was tapered per protocol and he was started on 20 mg on postoperative day 7 of prednisone and he remained on cellcept 1 gram b.i.d. throughout this hospital course. prograf was started on postoperative day 2 at 2 mg p.o. b.i.d. prograf was adjusted and titrated to levels. prograf level increased to 18.9 on postoperative day 8. his dose was decreased and he was stabilized on 2 mg p.o. b.i.d. with a prograf level of 9 to 14 on 2 mg twice a day. he was transferred to the medical/surgical unit where he continued to recover slowly. pain control continued to be an issue. consult was obtained. recommendations included continuation of methadone 145 mg q. a.m. and adjusting dilaudid p.o. to 8 to 16 mg p.o. q. 2 hours p.r.n. for the remainder of this hospital course, his pain continued to be monitored. he complained primarily of right upper quadrant discomfort. towards the end of his hospital stay, his pain was lessened and he was receiving 4 mg p.o. approximately 4 times a day. a physical therapy consult was obtained. pt worked with him to ambulate. given his deconditioning, it was recommended that he continue home pt. he has 2 - drains; #1 was discontinued on postoperative day 5 and #2 jp drain continued to drain approximately 290 cc of serosanguineous fluid. on postoperative day 7, he was started on iv vancomycin for some erythema around the incision at the left lower quadrant. this erythema resolved towards the end of the hospital course and vancomycin was stopped. his white blood cell count remained in the 4.7 to 6.6 range. the second jp was removed. his lfts continued to decrease. he was tolerating a regular diet and needed a lot of encouragement to ambulate. on postoperative day 9, patient complained of right neck discomfort. his right ij site appeared mildly edematous. a carotid ultrasound was done. this demonstrated no pseudoaneurysm. there was also noted of a right ij partially occlusive clot. he was not started on heparin or coumadin. the consult was obtained. he was maintained on a sliding scale insulin regimen for moderately elevated blood sugars. he required a minimal amount of regular insulin and this was tapered off towards the end of the hospital stay. he was discharged home on postoperative day 15 in stable condition. his lfts had trended down with an ast of 49, alt 217, alkaline phos 102, total bilirubin 0.6, albumin of 3.1. his creatinine was 1.1, bun 21, white blood cell count 6.6 and a hematocrit of 29.4. he was urinating independently without any difficulty. he was tolerating p.o. well. blood pressure ranged between 118/72 to 135/78. he was afebrile. he was out of bed ambulating independently. visiting nurse services were set up for medication management, acucheks and wound assessment. the plan was for him to return to the clinic on monday, , for assessment for continuation of methadone maintenance. clinic was the discovery house clinic. that telephone number was 1-. he was discharged home in stable condition. discharge medications: 1. fluconazole 400 mg p.o. q. d. 2. prednisone 20 mg p.o. q. d. 3. protonix 40 mg p.o. q. d. 4. bactrim single strength 1 p.o. q. d. 5. cellcept 1 gram p.o. b.i.d. 6. methadone 145 mg p.o. q. a.m. for maintenance. 7. fluoxitene 20 mg p.o. q. d. 8. bupropion 100 mg sustained release tab, 1 tab p.o. b.i.d. 9. colace 100 mg p.o. b.i.d. 10. dilaudid 2 mg tabs, 1 to 2 tabs p.o. p.r.n. q. 4 to 6 hours. 11. balcyte 900 mg p.o. q. d. 12. lasix 20 mg p.o. q. d. he was scheduled to follow up with dr. on at 9 a.m. discharge condition: stable. discharge diagnosis: end-stage liver disease secondary to hepatocellular carcinoma and hepatitis c virus. secondary diagnoses: 1. chronic pain, chronic back pain. 2. methadone maintenance. 3. anemia. 4. hypertension. 5. history of alcohol and iv drug abuse. , Procedure: Venous catheterization, not elsewhere classified Other transplant of liver Transfusion of packed cells Transfusion of other serum Other operations on lacrimal gland Transplant from cadaver Diagnoses: Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Acute posthemorrhagic anemia Other chronic pulmonary heart diseases Opioid type dependence, continuous Calculus of gallbladder with other cholecystitis, without mention of obstruction Malignant neoplasm of liver, primary Other and unspecified alcohol dependence, unspecified Calculus of kidney

final diagnoses: right subdural hematoma status post surgical evacuation of right subdural hematoma. he also has a cervical spine subluxation with neck flexion. he is recommended to followup. he is to get repeat cervical spine flexion and extension x-rays in 2 weeks. he is to follow up with dr. in 2 weeks, , at 9 a.m. to be preceded by flexion and extension x-rays of his cervical spine at 8 a.m. major surgical procedure while in the hospital: surgical evacuation of right subdural hematoma. discharge condition: his discharge condition is improved though still with some gait unsteadiness requiring supervision. discharge medications: 1. oxycodone and acetaminophen 5/325 mg tablet, 1-2 tablets p.o. q.4-6h. as needed. he is dispensed 40 tablets with 0 refills. 2. he is also prescribed lopressor 50 mg tablet. he is to take 0.5 tablets p.o. b.i.d. he is to hold if his heart rate is less than 60 or his blood pressure is less than 100. he is dispensed 30 tablets with 2 refills. discharge condition: the patient's condition at the time of discharge is stable. , m.d. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Incision of cerebral meninges Insertion of endotracheal tube Diagnoses: Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Closed dislocation, cervical vertebra, unspecified Accidental fall from ladder

history of present illness/hospital course: the patient is a 54 year old gentleman with a history of a 5 feet with no loss of consciousness, complained of headache on , and went to hospital. computerized tomography scan of the head showed large right subdural hematoma, longitudinally covering the whole hemisphere with about 2 cm plus substantial midline shift and complete effacement of the right lateral ventricle. the patient was sedated and intubated and sent to for further management. on arrival the patient's pupils were less than 2 mm and nonreactive. the right was 5 mm and nonreactive. the patient was taken emergently to the operating room for evacuation of acute subdural hematoma. the patient was taken to the operating room and underwent evacuation of a right frontal subdural hematoma without intraoperative complications. postoperatively the patient was intubated off of propofol and attempted to open his eyes to voice, moving all four extremities spontaneously. after attempts to localize the noxious stimuli, lower extremities withdraw to pain. his blood pressure was kept less than 120 with nipride. he continued on propofol. his pco2 was kept in the 30 to 35 range. he had his thoracolumbosacral spine cleared. his cervical spine was unable to be cleared at that time and he has remained in a hard collar. on , he had a repeat head computerized tomography scan which showed post surgical changes and a small amount of subdural hematoma still visible. his cervical spine showed degenerative changes and spinal stenosis. he was extubated also on . he was following commands. he had right drift in the upper extremity, but moving all his other extremities spontaneously. on , the patient had another repeat head computerized tomography scan which showed stable appearance of the remaining subdural hematoma. the patient was withdrawing all four extremities, less on the right lower extremity, somewhat sleepy. the patient was transferred to the regular floor on and remained in stable condition. he had a swallow evaluation which he passed, feeding tube was removed and he was able to start taking p.o. intake. he had flexion extension films done of the cervical spine which were inadequate and needed to be repeated. results of that are pending. he has been followed by physical therapy and occupational therapy and found to require acute rehabilitation. he is awake, alert and following commands, moving all extremities. discharge medications: 1. metoprolol 25 mg p.o. t.i.d., hold for heart rate less than 60, blood pressure less than 110. 2. nystatin oral suspension 5 cc p.o. q.i.d. 3. heparin 5000 units subcutaneously q. 12 hours. 4. famotidine 20 mg p.o. b.i.d. 5. folic acid 1 mg p.o. q. day. 6. thiamine 100 mg p.o. q. day. 7. clonidine patch one patch q. day, q. monday. condition on discharge: stable. vital signs were stable at the time of discharge. follow up: he will follow up with dr. in one month with a repeat head computerized tomography scan. , Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Incision of cerebral meninges Insertion of endotracheal tube Diagnoses: Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Closed dislocation, cervical vertebra, unspecified Accidental fall from ladder

no known allergies. unknown meds or past medical history. according to pt's brother-pt is a drug and alcohol abuser. tox screen positive for cocaine. pt slowly awakened. moves all extremities, follows commands, perla 3mm. remains on propofol @ 30mcg/kg. cervical collar on. dressing on head dry and intact. pt receiving dilantin. nsr. brief period on nipride to maintain sbp< 120. ca repleted. hct stable. pneumoboots on. ivf@ 100cc/hr. vent changes to obtain pco2 30-35. breath sounds clear. o2 sat 100%. suctioned x1 for sm. amt. blood tinged sputum. ogt to suction, draining bile. abd. soft. pt on protonix. urine output adequate. skin intact. wife spoke via phone to neurosurg team; brother visited. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Incision of cerebral meninges Insertion of endotracheal tube Diagnoses: Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Closed dislocation, cervical vertebra, unspecified Accidental fall from ladder

allergies: penicillins / heparin agents attending: chief complaint: fever major surgical or invasive procedure: left subclavian central line - removed picc line - placed history of present illness: 55 y/o f w/ complicated pmhx w/ known type ii aortic dissection c/b sma occlusion s/p bowel resections c/b short gut syndrome (now on chronic tpn), s/p recent arf, s/p recent open chole, recent mrsa bacteremia on a long course of vancomycin, chronic stage 4 sacral decub, now is transferred from osh ed with fevers to 103 at home. the pt was recently hospitalized for arf felt to be due to atn, and she was treated with vanc/zosyn for fever and a stage iv decub. since she was discharged from off of therapy for her stage iv decubitus ulcer, she did well until when she developed fever to 101.9. she was restarted on zosyn and vancomycin that day. blood cultures were drawn at that time. 2/4 bottles from grew mrsa. of note, her picc line through which she receives tpn was changed on , so it was felt less likely that this was the source. she was complaining of low back and hip pain, and dr. recommended mri of the pelvis to reassess the si joint and sacral decubitus ulcer and possibly an echocardiogram. pt states she thinks this was done and did not reveal a source. omr notes indicate that repeat blood cultures were drawn on x1 and x2 and as of these were negative. she recently returned home with vna from rehab facility on and has been doing well until the day pta when she developed the fevers. in the ed at osh, pts blood cx are growing gnr in bottles. the pt denies sob, abdominal pain, dysuria, diarrhea, headache. she admits to a chronic cough nonproductive of sputum and 3 minutes of l sided sharp chest pain on arrival to , not associated with sob, nausea, or radiation. she currently feels chills. . in the ed, the pts bp was initially 145/77. however, the pts sbp was noted to drop to 77/41 with pulse 99, requiring a 3 ns and then levophed gtt. she was also noted to be febrile to 103 with wbc 11.9, lactate up to 2.4 (resolving to 1.2 s/p fluids), and cxr was negative for acute process. in ed she was seen by both vascular and transplant surgery who felt abd was stable and were concerned fevers were likely line infection and recommmended removing picc line vs. following blood cultures before removing. the pt was seen by id wo recommended obtaining records of pts recent mri, starting meropenem/levoflox, obtaining ab imaging to eval for intrab collection, and d/c of picc line. she received vancomycin 1 gm iv, zosyn, and levofloxacin 500 mg ivx1. past medical history: 1. descending aortic dissection , s/p repair, c/b bowel ischemia and resection. briefly: . -: fenestration and sma stent - -- pt underwent stenting of both renal arteries as the aortic dissection had spread and had stenosed both renal arteries. - -- abdominal aorta and bilateral pelvic runoff, aortic dissection and fenestration, removal and replacement of right renal stent. - -- pts. bowel ischemia worsened, went to the or for exploratory laparotomy, ascending aorta to superior mesenteric artery bypass, resection of distal ileum, right colon, and transverse colon, ileostomy, and subtotal colectomy and small bowel resection. over the next week the pt underwent several laparotomies/washouts and revisions of her ileostomy. finally, a gj tube was placed for enteral feeding. - -- pt underwent a ct angiogram which demonstrated a widely patent sma graft, and a stable aortic dissection. 2. open cholecystectomy . 3. stage iv sacral decub (mrsa/vre) 4. short gut syndrome, on tpn 5. bilateral pneumothorax 6. h/o of g/j tube now removed 7. anxiety 8. depression 9. htn 10. h/o hepatitis 11. h/o pancreatitis 12. klebsiella bacteremia/pneumonia --complicating pts cholecystitis 13. mrcp : 1. status post cholecystectomy. normal biliary system. no evidence for retained stones. no explanation for abnormal liver enzymes by mri examination. 14. recent hospitalization for sacral decub: "dedicated hip and sacrum mri, which showed the sacral ulcer, infectious changes tracking up into the si joint and fluid around the sciatic notch. in addition, it noted avn of the left femoral head. no abscess was seen. the patient was continued on vancomycin and started on zosyn per id service recommendations. per id recs, the patient will remain on vanc and zosyn indefinitely, and will be followed in clinic."--per d/c summary. mri : 1. edema or minimal fluid within the left sacroiliac joint, and edema within the adjacent soft tissues, extending through the sciatic notch. findings concerning for underlying infectious etiology. no abcess is identified. minimal marrow edema within the left sacrum may be reactive; while, osteomyelitis cannot be entirely excluded, it is thought less likely. 15. h/o hit ab 16. admssion /05 for mrsa line infection social history: 40 pack year history but quit , occ etoh, no illicit drug use, on disability family history: mother: cad physical exam: vs: t 97.7 bp 141/78 p 127, r29 sat 98%ra cvp 11, svo2 80 gen - overweight female, having rigors heent - op clear, mm very dry, poor dentition neck - supple, no lad, no jvd, no bruits cor - rrr, hsm at lusb chest - ctab, sternal scar well healed abd - midline abdominal scar well healed. illeostomy bag with liquid output. +ttp in middle of abdomen to upper left of colostomy bag, nabs ext- warm, well-perfused, no c/c/e back - sacral decub (stage iv) with slight erythema surrounding, ttp. no prurulence or fluctuance. neuro: a&ox3. pertinent results: 11:54pm glucose-102 urea n-29* creat-1.4* sodium-139 potassium-3.4 chloride-106 total co2-21* anion gap-15 11:54pm calcium-8.1* phosphate-2.2* magnesium-1.8 11:54pm cortisol-43.0* 11:54pm wbc-12.2* rbc-3.54* hgb-10.5* hct-30.6* mcv-86 mch-29.6 mchc-34.3 rdw-14.8 11:54pm neuts-90.7* lymphs-5.6* monos-3.4 eos-0.1 basos-0.2 11:54pm plt count-211 11:53pm urine osmolal-263 11:21pm cortisol-23.1* 10:14pm type-mix 10:14pm hgb-11.2* calchct-34 o2 sat-95 06:21pm lactate-1.2 05:15pm glucose-92 urea n-38* creat-1.6* sodium-132* potassium-3.5 chloride-97 total co2-23 anion gap-16 05:15pm lipase-16 05:15pm tot prot-6.0* calcium-9.4 phosphate-2.4* magnesium-2.1 05:15pm cortisol-43.4* 05:15pm crp-103.8* 05:15pm wbc-11.9* rbc-3.86* hgb-11.6* hct-33.2* mcv-86 mch-30.1 mchc-34.9 rdw-15.3 05:15pm neuts-64 bands-27* lymphs-0 monos-6 eos-1 basos-0 atyps-1* metas-1* myelos-0 05:15pm plt count-232 03:17pm lactate-2.4*. . cxr: no acute cardiopulm process ekg: nsr, no st changes, nl axis 06:43am urine color-yellow appear-clear sp -1.013 06:43am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 12:50am glucose-81 urea n-46* creat-1.5*# sodium-135 potassium-3.7 chloride-100 total co2-23 anion gap-16 12:50am alt(sgpt)-67* ast(sgot)-57* ld(ldh)-116 alk phos-309* amylase-45 tot bili-1.1 12:50am albumin-3.7 calcium-9.3 phosphate-3.5 magnesium-1.5* 12:50am neuts-84.9* bands-0 lymphs-7.6* monos-4.5 eos-2.5 basos-0.6 12:50am hypochrom-normal anisocyt-normal poikilocy-1+ macrocyt-normal microcyt-normal polychrom-normal ovalocyt-occasional teardrop-occasional 12:50am plt count-283 12:50am pt-13.4* ptt-31.3 inr(pt)-1.2* 12:49am comments-green top 12:49am lactate-1.3 brief hospital course: briefly, this is a 55 yo f with mmp including stage iv sacral decub, picc for chronic tpn, avascular necrosis with fluid in l sacroiliac joint, recent mrsa bacteremia, and gnr in blood from osh, admitted with sepsis. pt was found to have positive blood cx for klebsiella, now afebrile on vanc and levoflox. . # sepsis/id: likely klebsiella line infection. pt was hypotensive and febrile on admission to sbp 70s, requiring pressors in the icu. her wbc was 11.9 with 27% bands on admission. the pt has a h/o mrsa bacteremia from and now gnr in blood (now +for klebsiella) from ed on . cxr was negative for acute cardiopulm process and ua was somewhat dirty but not grossly positive. the pt responded appropriately to stim test. given it was the most likely source of infection, the pts picc line was pulled on admission. repeat ruq us was wnl. tte on was negative for vegetations. levophed was weaned off and pts bp has been holding. meropenem was d/c'd after blood cx from showed klebsiella s to levoflox. id was and has been following the pt. the patient was transferred to the medical floor once stable. it was decided to continue the levoflox for treatment of the klebsiella line infection and vancomycin for h/o mrsa until she saw id in clinic for further f/u. . # sacral decub: stage iv. wound vac was discontinued pta due to pain. per one of pts prior hospitalizations, plastic surgery was considering a flap. plastic surgery was and states decub appears to be healing well. wound care was regarding decub care. the pt has been receiving pain meds with oxycodone and dilaudid prn. . #hyponatremia: na 132 on admission, with baseline 136-140. likely hypovolemic in etiology. na improved after fluids. . #uri sxs: --r/o with influenza dfa; droplet precautions . # elevated lfts: ast, alt and alk phos are all down compared to discharge. these elevations have been present since prior to dissection. she had an open cholecystectomy in for cholecystitis. previous workup has included: negative hepatitis b and c serologies x 2, nml hida scan , mrcp showed s/p cholecystectomy: normal biliary system, no evidence for retained stones, mri with no explanation for abnormal liver enzymes, negative ama, negative hiv. abd pain is currently at baseline. repeat ruq us on was negative . # short gut syndrome: the pt is on chronic tpn. abd exam seems stable. per pcp pt has been on tpn since and is followed by surgery. it is unclear if the pt still needs tpn, so a trial without tpn had been initiated. however, per nutrition, the patient needs tpn due to poor absorption given her short gut syndrome. tpm was re-initiated and the patient had another picc line placed for both tpn and her antibiotics. . # anemia: hct was 32 on admission, was previously 30 on discharge. the pt has been on epo as outpt started during last hospitalization for arf, but unclear if pt still needs it. her epo has been discontinued this admission. . # h/o arf: on last admission was felt atn in setting of hypotension. cr now 1.5, down from 2.6 on last discharge. . # avascular necrosis with fluid within the l sacroiliac joint: - repeat mri here showed persistent fluid in left sacroiliac joint. on vancomycin. to f/u with id re: duration of vancomycin. . # htn: the pts hydral and metoprolol were held in the setting of sepsis. her bp was normotensive without the medications, so she was not discharged on either hydral or metoprolol. . # fen: replete prn . # ppx: pneumoboots given h/o hit, no bowel regimen given short gut syndrome, ppi . # full code , #communication: hcp . medications on admission: -zoloft 50mg po qd -metoprolol 25mg po bid -hydralazine 150mg po tid -multivitamin po qd -vitamin d 800 units po qam -epogen 10,000 units inj qmon -metoclopramide 5mg po qid -protonix 40mg po qd -prochlorperzine 10mg po tid prn -clonazepam 1mg po bid prn -benefiber qam -vancomycin 1g iv q72 -hydromorphone 2mg po tid to q4 hours prn -oxycodone 5mg po q6hours prn -acetominophen 650mg prn -trazodone 50mg po qhs prn -ambien 5mg po qhs prn discharge medications: 1. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp<100 and hr<55. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. disp:*40 tablet(s)* refills:*0* 6. clonazepam 1 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 7. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. disp:*1 bottle* refills:*0* 8. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 9. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 10. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 11. hydromorphone 2 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 12. levofloxacin in d5w 500 mg/100 ml piggyback sig: one (1) dose intravenous q24h (every 24 hours): continue until you see dr. on . disp:*35 doses* refills:*0* 13. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) dose intravenous q 24h (every 24 hours). disp:*35 doses* refills:*0* 14. iv care infusion pump and tubing 15. picc line picc line care per protocol 16. outpatient lab work needs weekly cbc, chem 10, lfts, vancomycin trough starting drawn - results to be faxed to dr. at . discharge disposition: home with service facility: discharge diagnosis: primary - klebsiella bacteremia, sacro-iliac joint enhancement secondary - mesenteric ischemia s/p aortic dissection; on tpn; stage iv sacral decub, depression, htn, h/o hepatitis, h/o mrsa line infection discharge condition: stable, tolerating tpn, afebrile, walking with pt discharge instructions: -continue with medications as prescribed -please follow-up with your pcp weeks -continue with vancomycin and levofloxacin until you see dr. on -please see dr. on as scheduled below - it is very important! -please come back to the ed if you have any fevers, dizziness/lightheadedness, shortness of breath, nausea/vomiting, or any other concerning symptoms followup instructions: provider: care id phone: date/time: 2:00 provider: , md phone: date/time: 10:00 () please see your pcp weeks for follow-up - call to make an appointment Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Unspecified essential hypertension Hyposmolality and/or hyponatremia Aortocoronary bypass status Sepsis Chronic kidney disease, unspecified Pressure ulcer, lower back Other septicemia due to gram-negative organisms Infection and inflammatory reaction due to other vascular device, implant, and graft Other and unspecified postsurgical nonabsorption Sacroiliitis, not elsewhere classified Aseptic necrosis of head and neck of femur Ileostomy status

indication: 55-year-old female with complicated past medical history, left femoral head avascular necrosis, and fluid within the left sacroiliac joint on prior exam. the patient with sacral decubitus ulcer, status post antibiotic therapy. followup examination. technique: coronal t1 and stir, as well as axial stir, and axial fame pre- and post-gadolinium images with subtraction images were obtained through the pelvis. additional coronal t1 fame post-gadolinium images through the pelvis were obtained. of note, axial t1-weighted images not obtained due to patient's discomfort and inability to remain in the magnet. findings: direct comparison with prior study dated . as before, there remains small amount of fluid within the left sacroiliac joint, with evidence of edema and enhancement within adjacent iliac and sacral bones. this has not significantly changed since the prior exam. the previously identified fluid signal traversing the left sacroiliac notch is not identified on this study. there has also been interval resolution of previously seen edema and enhancement deep to the left iliacus muscle and deep to the left gluteal muscles. signal abnormality within the left femoral head compatible with avascular necrosis is again identified. there has been no interval collapse or increase in distribution of signal abnormality. there is no hip joint effusion on the left. femoral head articular surface is smooth. again seen is a large sacral decubitus ulcer, just to the right of the midline, with evidence of marginal soft tissue enhancement. no discrete edema or enhancement within the subjacent sacrum or coccyx. no soft tissue or bone abscess identified. evaluation of the right hip is grossly unremarkable. there is no hip joint effusion, or avascular necrosis. there has been interval placement of a right lower quadrant ostomy since the prior exam. (over) 3:02 pm mr hip w&w/o contrast bilat; mr contrast gadolin clip # reason: eval for presence of fluid, evidence of osteomyelitis, absce admitting diagnosis: fever contrast: magnevist amt: 18 ______________________________________________________________________________ final report (cont) incidental note is made of diffuse erythropoietic marrow. impression: 1. right sacral decubitus ulcer as described, with marginal soft tissue enhancement. no bone or soft tissue abscess. 2. persistent fluid within the left sacroiliac joint, and adjacent edema/enhancement within the sacrum and iliac bone. the extent and distribution has not significantly changed since the prior exam. persistent infection, while unlikely, is not entirely excluded. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Unspecified essential hypertension Hyposmolality and/or hyponatremia Aortocoronary bypass status Sepsis Chronic kidney disease, unspecified Pressure ulcer, lower back Other septicemia due to gram-negative organisms Infection and inflammatory reaction due to other vascular device, implant, and graft Other and unspecified postsurgical nonabsorption Sacroiliitis, not elsewhere classified Aseptic necrosis of head and neck of femur Ileostomy status

allergies: pcn neuro: arrived sedated. propofol started shortly after arrival. cisatricurium initiated->unable to get baseline ma ? d/t excessive edema. md aware. to evaluate clinically. midazolam also added. perrl. no response to requests but ? awake at times d/t increased bp noted occasionally w/ turns. cv: arrived hypotensive. treated w/ colloid and pressors (see flowsheet). episodes of a fib with rates in 140's causing hypotension->dc cardioverted w/ 300 joules, lytes repleted. initial hct 21->received total 4units prbc's. ffp for coagulopathy. ci < 2.0 at mn->2 ffp with good effect. tachy initially->hr currently in 80's. weaning neo to keep map's 60 or greater. amicar started as ordered. plt 35 this am. mediastinal cts initally w/ large o/p which is decreasing. abdominal jp's to wall suction w/ large o/p, also decreasing. skin warm, dry. resp: arrived on pcv. abg's with poor pao2's and mixed acidosis. peep increased. rate increased. bicarb x 3. left pleural effusion noted on cxr->left pleural tube inserted w/ return of mod amt clear fluid. improved pao2 and o2 sats post ct insertion. ett also adjusted by respiratory. currently fio2 down to 80%, peep 15, vt's ~ 480cc w/ balanced ph and adequate fio2. suctioned for thick tan/yellow secretions. gi: ngt w/ large amts thick dk red dng. md's aware. protonix started. abd open with serousang dng throughout dsg and leaking from dsg edges. ileostomy stoma difficult to assess d/t bag placement->adjusted by md. stoma dark in color->sometimes appearing reddish-black other times dk red. functional for serousang dng. jp's as above. gu: adequate u/o. cr 1.0 this am. id: very cold upon arrival->took a while to warm w/ bair huggar. abx as ordered for gi coverage and pneumonia. endo: insulin gtt as per protocol. skin: sternal dsg with serousang dng in large amts. abd dsg as above. no breakdown noted on buttocks/back/heels. considerable generalized edema. comfort: sedation as ordered. fentanyl for comfort. social: no calls overnight. a: hypotensions improving. acidosis improved. slightly improved oxygenation. large o/p's from various drains. adequate u/o. Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Other partial resection of small intestine Other partial resection of small intestine Left heart cardiac catheterization Enteral infusion of concentrated nutritional substances Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other and unspecified partial excision of large intestine Temporary ileostomy Temporary tracheostomy Other gastroenterostomy without gastrectomy Aortography Revision of stoma of small intestine Open and other right hemicolectomy Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Open and other resection of transverse colon Other intra-abdominal vascular shunt or bypass Injection or infusion of oxazolidinone class of antibiotics Re-entry operation (aorta) Re-entry operation (aorta) Diagnoses: Other postoperative infection Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Atrial fibrillation Atherosclerosis of renal artery Other complications due to other vascular device, implant, and graft Pressure ulcer, lower back Anticoagulants causing adverse effects in therapeutic use Acute vascular insufficiency of intestine Cholangitis Other and unspecified postsurgical nonabsorption Dissection of aorta, thoracic Mechanical complication of colostomy and enterostomy Chronic vascular insufficiency of intestine

allergies: penicillins / heparin agents attending: addendum: discharge dx: thromocytopenia, sma agraft thrombosis d/c instructions: patient should never recieve hepain. discharge disposition: extended care facility: nursing & rehabilitation center - md Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Other partial resection of small intestine Other partial resection of small intestine Left heart cardiac catheterization Enteral infusion of concentrated nutritional substances Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other and unspecified partial excision of large intestine Temporary ileostomy Temporary tracheostomy Other gastroenterostomy without gastrectomy Aortography Revision of stoma of small intestine Open and other right hemicolectomy Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Open and other resection of transverse colon Other intra-abdominal vascular shunt or bypass Injection or infusion of oxazolidinone class of antibiotics Re-entry operation (aorta) Re-entry operation (aorta) Diagnoses: Other postoperative infection Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Atrial fibrillation Atherosclerosis of renal artery Other complications due to other vascular device, implant, and graft Pressure ulcer, lower back Anticoagulants causing adverse effects in therapeutic use Acute vascular insufficiency of intestine Cholangitis Other and unspecified postsurgical nonabsorption Dissection of aorta, thoracic Mechanical complication of colostomy and enterostomy Chronic vascular insufficiency of intestine

allergies: penicillins / heparin agents attending: chief complaint: nausea/vomiting major surgical or invasive procedure: abdominal aorta and bilateral pelvic run-off, aortic dissection fenestration including transluminal balloon angioplasty, superior mesenteric artery angiography and stenting and intervascular ultrasound of aorta and iliac arteries. bilateral renal artery stent. abdominal aorta and bilateral pelvic runoff, aortic dissection and fenestration, removal and replacement of right renal stent, intravascular ultrasound of aorta. exploratory laparotomy, ascending aorta to superior mesenteric artery bypass, resection of distal ileum, right colon, and transverse colon, ileostomy. subtotal colectomy and small bowel resection. reexploration of abdomen with distal colon resection and distal small-bowel resection and temporary abdominal closure. exploratory laparotomy with abdominal washout and temporary closure. exploratory laparotomy, small bowel resection with end-to-end small bowel anastomosis, revision of ileostomy, gastrojejunostomy tube placement and abdominal closure. tracheostomy hickman catheter placemant, hit positive postoperative sacral decubitus postoperative fevers ?? etology history of present illness: the patient is a 54 year old female with a history of hypertension and recent discharge from hospital 14 days ago with a type b aortic dissection treated medically who presented to hospital on with persistent nausea and vomiting and intensified back pain radiating down her spine. at , a ct-a was performed which showed no pe and a dissection extending below the diaphragm. the patient was transferred to for further management. the patient's symptoms began 3 weeks ago with band-like chest pain radiating to her back with diaphoresis. she was found at to have a type b dissection (unknown extension) and was admitted to the icu and discharged 14 days ago on po labetalol, nifedipine, protonix and clonidine (doses unknown). since her discharge, the patient has been feeling increasingly weak with intermittent nausea and bilious vomiting and has been unable to tolerate a po diet at home. she also noted hematemesis within the past few days. she denies any blood in her stool recently but notes green diarrhea x 14 days with a history of blood in her stool at . the patient states that she has been compliant with all her medications at home. she states her back pain recently intensified as well. at , the patient was having bilious emesis with specks of blood with a blood pressure of 160 systolic. she was placed on a labetalol drip at 1 mg but then developed sinus bradycardia to the 50s. as a result, nipride was started and was at 0.1 on exam. the blood pressure in her left arm was 100/58 and in the right, 160/68 with a hr of 79 on nipride alone. the patient was pain-free on exam. a repeat ct chest and a/p was performed that showed a large, well-perfused false lumen extending distal to the left subclavian with the left renal artery and inferior mesenteric artery branching from the false lumen. the superior mesenteric artery did extend from the true lumen, however, is partially occluded by the intimal flap. there was no bowel wall thickening. the dissection extends inferiorly into the bilateral external iliacs into the groin. vascular and cardiac surgery was consulted. vascular surgery decided to monitor medically for now. past medical history: hypertension hepatitis ?unknown type s/p appendectomy h/o right shoulder surgery social history: the patient works as a manager for fried kitchen. she admits to smoking 1 ppd x 38 years but has not smoked since her admission to 3 weeks ago. she admits to a history of heavy alcohol use in the past x 1 year with 4-5 beer/hard liquor 4 x a week. she denies any history of illicit drug use. the patient is not married and has four children and lives alone. family history: no family history of aortic dissection/marfan's. physical exam: a/o x 3,nad ncat, perrl, eomi neg lesions nares, oral pharnyx, auditory supple, farom, neg lymphandopathy, supraclavicular nodes cta b/l rrr without murmers soft, nttp, neg cva, pos bs palp dp/pt b/l pertinent results: echo findings: left atrium: normal la size. no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. right atrium/interatrial septum: normal ra size. left ventricle: symmetric lvh. mild regional lv systolic dysfunction. right ventricle: normal rv chamber size and free wall motion. aorta: normal ascending aorta diameter. simple atheroma in ascending aorta. normal aortic arch diameter. simple atheroma in aortic arch. moderately dilated descending aorta descending aorta intimal flap/aortic dissection. flow in false lumen. aortic valve: normal aortic valve leaflets (3). trace ar. mitral valve: normal mitral valve leaflets with trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. the patient was sedated for the tee. medications and dosages are listed above (see test information section). local anesthesia was provided by benzocaine topical spray. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. conclusions: the left atrium is normal in size. no spontaneous echo contrast orthrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. there is symmetric left ventricular hypertrophy. lv systolic function appears mildly depressed with inferior/infero-lateral hypokinesis. there are simple atheroma in the ascending aorta and aortic arch without evidence of aortic dissection. the descending thoracic aorta is moderately dilated. a mobile density is seen in descending aorta consistent with an intimal flap/aortic dissection. there is flow in the large false lumen. there is a fenestration/communication between the true/false lumen at approx. 35 cm from the incisors that may represent the point of initial intimal tear. the dissection extends proximally and ends at the takeoff of the left subclavian artery without compromising subclavian flow. there is partial thombosis of the false lumen just distal to the left subclavian artery. the dissection extends distally to abdominal aorta and extends beyond what was visualized (50 cm from the incisors).the true lumen is significantly narrowed at times but distal flow is not clearly compromised. both coronary artery ostia were visualized in their appropriate orientation with normal color doppler signal (pulse wave doppler was not performed).the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. impression: thoracic aortic dissection limited to the descending aorta (type b). large false lumen that is partially thrombosed proximally. there is no clear evidence of distal flow compromise but clinical correlation is suggested. renal u.s. reason: aortic dissection, assess renal flow medical condition: 54 year old woman with extensive descending dissection to external iliacs bilaterally with left renal off of false lumen now with decreased urine output reason for this examination:please assess renal flow indication: assess renal vascular flow, s/p aortic dissection. renal ultrasound: the right kidney measures 10.3 cm. the left kidney measures 10.3 cm. no hydronephrosis or stones. no perinephric fluid collection identified. duplex ultrasound: color doppler son was performed of the renal vasculature. normal flow is demonstrated in the right and left renal arteries. normal waveforms are identified within the left and right main renal arteries. impression: normal renal ultrasound. normal flow and waveforms are demonstrated in the main renal arteries bilaterally. cta chest w&w/o c & recons medical condition: 54 year old woman with type b aortic dissection by ct from osh but scan did not find distal extent. reason for this examination: eval extent of dissection indication: type b aortic dissection by ct from outside hospital but scan did not find distal extent. evaluate dissection. technique: contiguous axial images through the chest were obtained without contrast. subsequently, following the administration of 150 cc of optiray contrast, contiguous axial images through the chest, abdomen, and pelvis were obtained during opacification of the aorta and its branches. multiplanar reconstructions were obtained. cta of the chest: there is a type b aortic dissection present. the dissection begins just distal to the left subclavian artery origin of the aorta. there is a large false lumen seen to the left and a smaller true lumen. there is a fenestration in the intimal flap seen on series 3, image 18. thus, the true and false lumens communicate. the celiac axis arises from the true lumen, though the intimal flap is abutting the origin of the celiac axis. the dissection extends into the celiac axis. the sma similarly arises from the true lumen, though the intimal flap is protruding into the ostium of the origin of the sma. the dissection extends into the sma and the sma is quite small. the right renal artery arises from the true lumen, and the intimal flap extends slightly into the ostium of the right renal artery. this is best seen on series 4, image 295. the left renal artery arises from the false lumen. more inferiorly, the arises from the false lumen. the dissection extends into both common iliac arteries. the dissection extends into the common external and iliac arteries on the right side. the dissection also extends into the external and internal iliac arteries on the left side. the intimal flap extends through the right external iliac artery and is seen clearly to about the level of the acetabulum. beyond this point, it is difficult to assess. the intimal flap is no longer seen definitely in the mid portion of the left external iliac artery. there is low-density material fill to the origin of the left subclavian artery. the dissection does not clearly extend into the left subclavian artery. ct of the chest without and with contrast: there is atelectasis within the lungs dependently. no consolidations. there are very small pleural effusions at the bases posteriorly. no pericardial effusion. ct of the abdomen with contrast: the liver, gallbladder, spleen, pancreas, and adrenals are normal. the kidneys enhance symmetrically and excrete normally, despite the left renal artery arising from the false lumen. no free air or free fluid within the abdomen. the noncontrast opacified loops of bowel are containing some fluid but are otherwise unremarkable. ct of the pelvis with contrast: the bladder, uterus, rectum, and sigmoid are unremarkable. within the cecum, there is a rounded enhancing structure of unclear etiology. no pathologically enlarged lymph nodes within the pelvis. bone windows: there are no suspicious osteolytic or sclerotic lesions. multiplanar reformatted images were essential in delineating the anatomy and pathology in this case. impression: extensive type b aortic dissection. the dissection arises distal to the left subclavian artery. there is a fenestration between the true and false lumen. the celiac and sma arise from the true lumen, though the dissection extends into these vessels. the residual sma is quite small. the right renal artery arises from the true lumen and the left renal artery from the false. the arises from the false lumen. the dissection extends into the external and internal iliac arteries bilaterally. brief hospital course: the patient is a 54 year old female with a history of htn, type b descending dissection who presents with persistent nausea/vomiting with possible left renal and superior mesenteric artery involvement. 1. type b dissection - appreciate vascular and cardiac surgery input. the patient is at higher risk for bowel ischemia given the nature of the near occlusion of the sma by the intimal flap. in addition, there is potential renal involvement of the left renal artery as it already extends from a large false lumen. at this time, the patient will be medically managed with a nipride drip with a goal sbp 100-120. labetalol gtt was attempted in the er without success and was limited by sinus bradycardia to the 50s. - we will continue to monitor for signs of renal failure or bowel ischemia. - on , the patient's urine output dropped to 15-20 cc/hr from 60-70. a stat renal ultrasound with doppler flow was obtained to evalaute renal perfusion in the setting of a left renal artery previously seen to be coming from the false lumen. in addition, her lactate was checked tid which rose from 0.7 to 1.1 on . vascular and cardiac surgery were called and made aware. then the patient developed severe left arm pain and concern was that her dissection was extending proximally. - on the pt went to the angiography suite and underwent successful fenestration of her abdominal aortic false lumen, and fenestration and stenting of her sma. - -- pt underwent stenting of both renal arteries as the aortic dissection had spread and had stenosed both renal arteries. -- abdominal aorta and bilateral pelvic runoff, aortic dissection and fenestration, removal and replacement of right renal stent, intravascular ultrasound of aorta. -- pts. bowel ischemia worsened, went to the or for exploratory laparotomy, ascending aorta to superior mesenteric artery bypass, resection of distal ileum, right colon, and transverse colon, ileostomy, and subtotal colectomy and small bowel resection. over the next week the pt underwent several laparotomies/washouts and revisions of her ileostomy. finally, a gj tube was placed for enteral feeding. -- pt underwent a ct angiogram which demonstrated a widely patent sma graft, and a stable aortic dissection. 2. chf, ef unknown - the patient has 10 cm jvp on exam with no known ef. meanwhile, we will keep the patient euvolemic. an echo was perfomed on which showed an inferior wall that was hypokinetic and there was concern that her right coronary artery was being affected by a dissection. as a result, a tee was to be performed on and cardiac surgery was made aware. 3. transaminitis - the patient reports a history of hepatitis that was contracted from eating food in a hospital during her delivery in . we will recheck a hepatitis panel and trend her lfts. we do not know her baseline. if her lfts continue to climb, we may consider a ruq ultrasound with concern for ischemia with known celiac involvement. 4. coffee-ground emesis - the patient will remain npo for now with iv protonix . the patient is hemodynamically stable at present. we will check her hct tid for now. patient icu to vicu/floor after prolonged complicated postoperative course and trach removal -. patient remined on tpn for nutritional support because of short bowel syndrome.viedo swallow exams negative for aspiration. pt/ot continued to work with patient.await medicade application approval for final dipos planning to rehabiltitaion. id consulted for persistant fevers.patient delined and line and blood cultures sent.finalization of cultrues negative. placement of hickman catheter and repositioning of gj tube. tpn was restarted and cycling of tube feeds began. patient continued to progress. to rehabilitation for continued care stable. medications on admission: protonix qd, labetalol 2 tablets , nifedipine 1 tablet po bid, clonidine 1 tablet tid discharge medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic qhs (once a day (at bedtime)). 2. insulin regular human 100 unit/ml solution sig: as directed injection asdir (as directed). 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. clonidine 0.1 mg tablet sig: one (1) tablet po bid (2 times a day). 5. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed. 6. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). 7. acetaminophen 160 mg/5 ml elixir sig: po q4-6h (every 4 to 6 hours) as needed. 8. epoetin alfa 3,000 unit/ml solution sig: 3000 (3000) units injection qmowefr (monday -wednesday-friday). 9. albuterol 90 mcg/actuation aerosol sig: four (4) puff inhalation q6h (every 6 hours) as needed. 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 11. scopolamine base 1.5 mg patch 72hr sig: one (1) patch 72hr transdermal q3days (). 12. opium 10 % tincture sig: twenty (20) drop po asdir (). 13. levocarnitine 330 mg tablet sig: 1.5 tablets po q500cc tubefeeds (). 14. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 15. papain-urea 830,000-10 unit-% spray, non-aerosol sig: one (1) appl topical daily (daily). 16. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for agitation. 17. metoclopramide 10 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 18. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 19. dolasetron mesylate 12.5 mg iv q8h:prn nausea 20. insulin regular human 100 unit/ml solution sig: as directed injection every four (4) hours: glucose <60 amp d50% glucoses 61-150/0u glucoses 151-200/2u glucoses 201-250/4u glucoses 251-300/6u glucoses >400 md. discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: 1) aortic dissection with mesenteric ischemia, s/p aortic fenestration and sma grafting 2) b/l renal stenosis secondary to aortic dissection, s/p bil. stents 3) bowel ischemia, s/p multiple small bowel resections, ileostomy 4) sacreal decubitus ulcer 5) short gut syndrome discharge condition: stable followup instructions: follow up with dr as directed, please call . Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Other partial resection of small intestine Other partial resection of small intestine Left heart cardiac catheterization Enteral infusion of concentrated nutritional substances Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other and unspecified partial excision of large intestine Temporary ileostomy Temporary tracheostomy Other gastroenterostomy without gastrectomy Aortography Revision of stoma of small intestine Open and other right hemicolectomy Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Open and other resection of transverse colon Other intra-abdominal vascular shunt or bypass Injection or infusion of oxazolidinone class of antibiotics Re-entry operation (aorta) Re-entry operation (aorta) Diagnoses: Other postoperative infection Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Cardiac complications, not elsewhere classified Atrial fibrillation Atherosclerosis of renal artery Other complications due to other vascular device, implant, and graft Pressure ulcer, lower back Anticoagulants causing adverse effects in therapeutic use Acute vascular insufficiency of intestine Cholangitis Other and unspecified postsurgical nonabsorption Dissection of aorta, thoracic Mechanical complication of colostomy and enterostomy Chronic vascular insufficiency of intestine

chief complaint/history of present illness: the patient is an 85 year old male with known coronary artery disease and history of myocardial infarction in who presented to an outside hospital with a complaint of shortness of breath and dyspnea on exertion. an echocardiogram at the outside hospital demonstrated an ejection fraction of 45% with mitral regurgitation 2 to 3+ as well as inferior, posterior hypokinesis. he had computerized tomographic angiography which demonstrated no pulmonary embolus. dobutamine stress demonstrated large anterior apical inferior, posterior and lateral reversible defects. chest x-ray also done at the outside hospital showed right middle lobe infiltrates. the patient was transferred to for cardiac catheterization. past medical history: significant for coronary artery disease, ischemic cardiomyopathy, right middle lobe infiltrates, atrial fibrillation, hypercholesterolemia, gout, noninsulin dependent diabetes mellitus, persistent elevated cpks, hypertension and chronic renal insufficiency. past surgical history: no tobacco use, social alcohol use and previously a heavy drinker, no street drug use. married times 51 years, retired army sergeant in the army for 26 years. family history: father died in his 70s of cancer, mother died in her 70s. he has five children, three boys and two girls-the three boys all live at home. medications prior to admission: 1. potassium chloride 20 meq q.d. 2. aspirin 81 mg q.d. 3. tagamet 400 mg b.i.d. 4. aldactone 12.5 mg q.d. 5. levaquin 500 mg q.d. 6. ditropan 2.5 mg b.i.d. 7. lopressor 12.5 mg b.i.d. 8. amitriptyline 30 mg q.h.s. 9. zestril 20 mg q.d. 10. allopurinol 100 mg q.d. 11. amlodipine 5 mg q.d. 12. insulin nph 28 units b.i.d. 13. regular insulin 14 units at 2 pm 14. zocor, no dose stated 15. lasix 80 mg b.i.d. 16. coumadin 5 mg on monday, tuesday, wednesday, friday and saturday, 4 mg on sunday and thursday allergies: he is allergic to codeine. physical examination: physical examination at the time of admission revealed vital signs with heartrate of 74, blood pressure 134/67, respiratory rate 18. head, eyes, ears, nose and throat, pupils equally round and reactive to light. extraocular movements intact. mucous membranes moist, full benches. neck, no lymphadenopathy and no jugulovenous distension. chest is clear to auscultation bilaterally. heartsounds, regular rate and rhythm. s1 and s2 with systolic ejection murmur best heard in the lower sternal border, iii/vi. abdomen is nontender, nondistended, positive bowel sounds, obese. groin, no bruits, no bleeding. extremities, positive edema. pulses are palpable bilaterally. skin is ecchymotic at intravenous sites. laboratory data: laboratory data at the time of transfer revealed white count 8.2, hematocrit 34.2, platelets 195, sodium 138, potassium 4.5, chloride 101, carbon dioxide 32, bun 18, creatinine 1.3, glucose 118, cpk prior to admission on , on , on and on . troponins are all less than .04 except for on , they were 0.05. hospital course: the patient was brought to the cardiac catheterization laboratory, please see catheterization report or full details. in summary the catheterization report showed normal left main with left anterior descending 80% occlusion, circumflex 70% occlusion and right coronary artery totally occluded. post cardiac catheterization, cardiothoracic surgery was consulted. in summary, the patient was accepted for coronary artery bypass grafting at a later date following a complete workup including carotid dopplers, pulmonary function tests, and echocardiogram to assess left ventricular function as well as his mitral regurgitation and resolution of his right middle lobe infiltrates as well as diuresis prior to his surgery. the patient was maintained on the medical service prior to his surgery during his preoperative testing. on , he experienced an episode of nonsustained ventricular tachycardia. at that time he was seen by the electrophysiology service who recommended that the patient be loaded with amiodarone and started on heparin. on the patient complained of abdominal pain. following his complaint of abdominal pain he had decreasing level of consciousness followed by a cardiac arrest during which he had periods of asystole, lasting six to eight seconds. during that time he was pulseless. he did rule in for a non-q wave myocardial infarction following his cardiac arrest. a temporary pacing wire was placed and he was transferred to the coronary care unit for continued monitoring prior to his coronary artery bypass grafting. the hospital course was further complicated by an episode of ventricular tachycardia during which the patient was pulseless. this occurred on . the patient was shocked out of the ventricular tachycardia with 300 joules followed by ventricular pacing with the temporary wire he had in place. the following morning, , the patient was brought to the operating room where he underwent an off-pump coronary artery bypass graft times one with a left internal mammary artery to the left anterior descending, please see the operation report for full details. the patient tolerated the procedure well and he was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient's mean arterial pressure was 70, central venous pressure was 12, he was ventricularly paced at a rate of 70. he had a propofol at 20 mcg/kg/min and neosynephinre at 0.3 mcg/kg/min. the patient did well in the immediately postoperative period. he remained on his neosynephrine infusion to keep his mean arterial pressure greater than 70. he remained intubated throughout postoperative day #1 in anticipation of an angioplasty to be done on postoperative day #1. as stated, the patient was brought to the cardiac catheterization laboratory on postoperative day #1. at that time his coronary arteries were again studied. the catheterization showed his left anterior descending to have an 80% occlusion with competitive flow distally, circumflex and obtuse marginal 1 to be 80% occluded and the right coronary artery to be 100% occluded with proximal filling via left to right collaterals. his left internal mammary artery to the left anterior descending was widely patent with normal flow. at that time he underwent an angioplasty of his obtuse marginal 1 lesion. the lesion was crossed and stented with no residual lesion. the patient tolerated the procedure well, please see the catheterization report for full details. following the catheterization and stenting the patient was transferred from the catheterization laboratory to the cardiothoracic intensive care unit. upon arrival the patient's sedation was discontinued. he was weaned from his ventilator and ultimately extubated. for the next 48 hours the patient remained in the cardiothoracic intensive care unit, monitoring his hemodynamic stability and his respiratory status. on postoperative day #4 the patient was transferred to far 6 for continuing postoperative care and cardiac rehabilitation. over the next several days the patient remained on the cardiothoracic step down floor. his activity level was slowly increased with the aid of physical therapy and the nursing staff. he continued to be followed by the electrophysiology service and on postoperative day #10 he was brought to the electrophysiology suite where he underwent electrophysiology studies and automatic implanted cardioverter defibrillator placement. please see electrophysiology study report for full details. the patient remained on cardiothoracic step down floor for two additional days at which time he was deemed stable and ready for transfer to rehabilitation. at the time of transfer to rehabilitation, the patient's physical examination is as follows: vital signs temperature 97.7, heartrate 67, ventricularly paced, blood pressure 145/70, respiratory rate 18 and oxygen saturation 99% on 3 liters. weight preoperatively is 125 kg, at discharge is 121.8 kg. laboratory data on the day of discharge is white count 9.5, hematocrit 28.7, platelets 273, pt 14, ptt 28.7, inr 1.4. sodium 141, potassium 4.6, chloride 102, carbon dioxide 31, bun 24, creatinine 1.1, glucose 100. on physical examination he is alert and oriented times three, moves all extremities and is conversant. respiratory, diffuse rhonchi bilaterally, no rales. heartsounds, regular rate and rhythm. sternum is stable. incision with steri-strips, open to air, clean and dry. abdomen is soft, nontender with normoactive bowel sounds. extremities are warm with 2 to 3+ edema and palpable dorsalis pedis pulses. the patient does complain of pain in the right groin including the upper leg. this pain was noted preoperatively. he had bilateral groin ultrasounds which were negative for pseudoaneurysm. discharge medications: 1. lopressor 25 mg b.i.d. 2. lasix 80 mg b.i.d. 3. potassium chloride 40 meq q.d. 4. enteric coated aspirin 325 mg q.d. 5. plavix 75 mg q.d. 6. amitriptyline 30 mg q.h.s. 7. percocet 5/325 one to two tablets q. 4 hours prn 8. insulin nph 28 units b.i.d. 9. regular insulin sliding scale q. 6 hours 10. ocular ophthalmic drops 1 drop ou b.i.d. 11. amiodarone 400 mg q.d. 12. zestril 20 mg q.d. 13. coumadin to attain a goal inr of 2.0 to 2.5, he has received 5 mg of coumadin on as well as will receive 5 mg on . his home medication regime for coumadin was 4 mg on sunday and thursday and 5 mg all other days of the week. condition on discharge: stable. discharge diagnosis: 1. coronary artery disease, status post coronary artery bypass graft times one with left internal mammary artery to the left anterior descending and status post angioplasty of the obtuse marginal. 2. hypercholesterolemia. 3. atrial fibrillation status post automatic implanted cardioverter defibrillator placement. 4. noninsulin dependent diabetes mellitus. 5. gout. 6. hypertension. 7. chronic renal insufficiency. follow up: the patient is to be discharged to rehabilitation. he is to have follow up in the clinic in two weeks, follow up with dr. in one month, follow up with his primary care provider in one month and follow up with electrophysiology service in one week. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Catheter based invasive electrophysiologic testing Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Paroxysmal ventricular tachycardia Cardiac arrest Old myocardial infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pt is s/p mvc with multiple facial fractures, left eye injury, and evidence of small sah and frontal contusion major surgical or invasive procedure: left globe exploration facial fracture fixation, with mandibular fixation peg and trach placement history of present illness: pt was involved in mvc and sustained multiple injuries to his face, left eye and brain physical exam: on discharge: heent: pt with swollen left orbit, arch bars in place, head lacerations well healed, trach removed, dressing over stoma c/d/i cardiac: rrr chest: ctab abd:soft nt/nd +bs, peg tube inplace and without leakage/erythema or tenderness ext: +2 pulses throughout, no edema pertinent results: 06:20pm blood wbc-21.6* rbc-4.39* hgb-13.4* hct-37.9* mcv-86 mch-30.5 mchc-35.4* rdw-12.1 plt ct-130* 06:20pm blood pt-12.8 ptt-19.4* inr(pt)-1.1 06:20pm blood plt ct-130* 10:00pm blood glucose-113* urean-15 creat-1.0 na-140 k-3.8 cl-105 hco3-26 angap-13 06:20pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:31pm blood po2-38* pco2-62* ph-7.30* calhco3-32* base xs-1 comment-green top 10:07pm blood type-art temp-38.0 rates-14/ tidal v-600 peep-5 fio2-70 po2-331* pco2-52* ph-7.34* calhco3-29 base xs-1 -assist/con intubat-intubated 11:42pm blood type-art temp-38.0 rates-18/ tidal v-600 peep-5 fio2-40 po2-169* pco2-41 ph-7.40 calhco3-26 base xs-0 -assist/con intubat-intubated 06:31pm blood hgb-14.0 calchct-42 o2 sat-65 05:03pm blood hgb-9.9* calchct-30 01:14am blood hgb-10.8* calchct-32 brief hospital course: pt was admitted to trauma surgery with multiple facial fractures, as well as severe trauma to the left eye. neurosurgery, opthomology and plastics all contributed to the patients care. the patient developed a csf leak that was followed by neurosurgery that eventually subsided. nuerosurgery also followed the patient for a questionable c4-c6 ligamentous injury for which he was put in a cervical collar. opthomology took the patient to the or for left globe exploration, they found no globe rupture but significant corneal abrasion, avulsion with intact lens, and retinal hemorrhages. plastics fixed the facial fractures and applied arch bars and was trached and peggged . patient steadily improved over stay, he developed some impulsiveness that slowly subsided, he was able to maintain pos, and achieve daily caloric intake by d/c, and was cleared by pt and ot for d/c to home with follow up. radiology reports: head ct showed: 1) pneumocephalus from multiple facial bone fractures. 2) subarachnoid versus subdural blood along anterior falx just above crista galli. 3) likely left frontal contusion. 4) multiple comminuted facial bone fractures. please see the dedicated ct scan of the facial bones for more information. facial ct showed: 1. comminuted fractures involving the outer and inner tables of the frontal sinuses with pneumocephalus. 2. comminuted fractures involving the orbits and maxillary sinuses bilaterally. comminuted fracture of the left zygoma. 3. right mandibular fracture. 4. significant subcutaneous emphysema involving the soft tissues of the scalp, the orbits and neck. pansinus opacification. mri of spine showed: subtle increase in signal intensity adjacent to the spinous processes of c4 through c6 may represent injury to the interspinous ligament. cta head: impression: 1) slight decrease in prominence of subarachnoid hemorrhage anterior to the frontal lobes bilaterally, without evidence of new mass effect or new intracranial hemorrhage. stable pneumocephalus associated with multiple comminuted skull fractures. 2) stable appearance of extensive facial fractures. 3) no evidence of aneurysm or occlusion of the vessels of the circle of and its tributaries, or of the cervical portions of the carotid and vertebral arteries. visualization of the small branches of the external carotid systems is limited, and if there is clinical interest for evaluation of these vessels, standard diagnostic angiography is recommended. this recommendation was conveyed to dr. at 5:00 p.m. on . discharge medications: 1. erythromycin 5 mg/g ointment sig: one (1) drop ophthalmic qid (4 times a day): administer to left eye. disp:*qs for 2wks drop* refills:*2* 2. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic qid (4 times a day): apply to left eye. disp:*qs for 2wks * refills:*2* 3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. disp:*400 ml(s)* refills:*0* 4. quetiapine fumarate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. boost liquid sig: one (1) po three times a day. disp:*30 * refills:*2* discharge disposition: home discharge diagnosis: multiple facial fractures, with csf leak now resolved left eye injury: corneal abrasion, avulsion, retinal hemorrhage small anterior sah, left frontal contusion cervical ligamentous injury discharge condition: stable discharge instructions: take medications as perscribed, be sure to follow up with plastic surgery, opthomology, orthopaedics, and trauma surgery clinic. wear cervical collar at all times. follow recommendations of occupational therapy. followup instructions: plastic surgery will call you to arange arch bar removal, you also have an appointment on at 1pm at the building surgical specialties department, cosmetic clinic call with questions opthomology: you have an appointment for evaluation on at 11:15am at the building , with dr. call with questions neurosurgery: call for appointment with dr. in 1-2weeks trauma surgery: call to schedule an appointment in 2 weeks Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Open reduction of maxillary fracture Insertion of synthetic implant in facial bone Open reduction of mandibular fracture Other repair of cerebral meninges Elevation of skull fracture fragments Suture of cranial and peripheral nerves Procedure on four or more vessels Other open reduction of facial fracture Other adjustment of lid position Dental wiring Bone graft to facial bone Other facial bone repair Other orbitotomy Diagnoses: Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of base of skull with cerebral laceration and contusion, with no loss of consciousness Ocular laceration with prolapse or exposure of intraocular tissue Traumatic subcutaneous emphysema Closed fracture of malar and maxillary bones Closed fracture of mandible, multiple sites Open fracture of nasal bones Closed fracture of orbital floor (blow-out) Sprain of neck Injury to superficial nerves of head and neck

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob, anemia to 22, weakness major surgical or invasive procedure: bronchoscopy x2 bone marrow biopsy mechanical ventilation history of present illness: 78 yo woman with mds, presenting to with sob, hypotension, anemia (hct = 22.1, hbg = 7.6), leukocytosis (wbc = 31.4 with 21 bands), thrombocytopenia (plt = 10). pt reports productive cough for 2 months of yellow phlegm. she describes rhinorrhea x 1 month associated with sneezing. over last 3 days, she reports decreased eating/drinking and feeling "funny". denies dysuria, fevers, hematuria, n/v/c/d/cp, hematuria, joint or bone pain, myalgias. c/o increasing back pain and bruising (abd bruising d/t injections). at , her u/a was positive for infection. given ceftaz, ivf's, and 1 unit of blood. pt was transferred to for transfusion and bone marrow biopsy to r/o progression to aml. last bone marrow biopsy in was negative for leukemia, just c/w mds. past medical history: 1. myelodysplasia - 2. anemia secondary to myelodysplasia 3. right breast cyst 4. hypertension - on 480mg verapamil qd. sbp usually in 170's. 5. s/p hysterectomy 6. s/p cholecystectomy 7. glaucoma 8. lentigo melanoma on right face - with wide excision. pathology reportedly at 9. pan - polyarteritis nodosa. biopsy of heel done at . social history: widowed, active with family, minimal alcohol, nonsmoker. family history: one son and brother has hemochromatosis, a sibling died of leukemia at age 30. physical exam: t: 99.4 p: 76 bp: 112/60 rr: 22 96% on 2l nc (90% on ra) gen: alert and oriented, pleasant woman sitting upright in bed, conversant, breathing comfortably heent: nc/at, pupils surgical, anicteric, mmm, op clear cv: rrr, no m/r/g lungs: no wheezing. inspiratory crackles at l base, unchanged from prior. o/w cta bilaterally. abd: resolving ecchymoses on abdomen ( injections). abd is soft, nt/nd. +bs. ext: no edema, brisk distal pulses. pertinent results: from : cr: 1.3 (baseline 0.6) with bun = 33. troponin: 0.3 wbc = 31.4 with 21 bands, hct = 22.1, hgb = 7.6, plt = 10. u/a: 50-100 wbc, many bacteria bcx x 4: 1 of 4 bottles grew coag neg staph resistant to erythromycin and pcn. ucx: 10-25k of each coag neg staph and diphtheroids admission labs at : 03:30pm gran ct-* 03:30pm wbc-19.9* rbc-2.57* hgb-7.8* hct-23.9* mcv-93 mch-30.4 mchc-32.7 rdw-18.6* 03:30pm haptoglob-332* 03:30pm albumin-3.7 calcium-8.3* phosphate-4.1 magnesium-2.2 uric acid-10.6* 03:30pm alt(sgpt)-24 ast(sgot)-25 ld(ldh)-416* ck(cpk)-43 alk phos-66 tot bili-0.8 dir bili-0.3 indir bil-0.5 03:30pm glucose-127* urea n-30* creat-1.2* sodium-140 potassium-3.7 chloride-105 total co2-20* anion gap-19 03:30pm fibrinoge-372 03:30pm ret aut-2.2 discharge and other relevent labs: 02:00am blood wbc-1.8* rbc-2.78* hgb-8.2* hct-24.2* mcv-87 mch-29.6 mchc-33.9 rdw-14.8 plt ct-39* 02:00am blood glucose-94 urean-15 creat-0.2* na-137 k-3.9 cl-104 hco3-24 angap-13 12:00am blood fibrino-204 01:50am blood fdp-0-10 01:20am blood ret aut-6.1* 12:53am blood glucose-86 urean-17 creat-0.2* na-138 k-3.7 cl-105 hco3-25 angap-12 01:20am blood vitb12-472 folate-10.4 hapto-100 12:00am blood caltibc-164 ferritn-> trf-126* 12:00am blood hapto-<20* 12:00am blood hapto-<20* 12:45am blood hapto-<20* 04:19am blood tsh-0.91 03:56am blood anca-negative b 03:56am blood -negative 04:20am blood lactate-3.3* 04:15am blood glucose-121* lactate-1.3 abd ct : 1. no evidence of intra or retroperitoneal hemorrhage. 2. splenomegaly as above with increased heterogeneity and possible focal splenic lesions. given the timing of the contrast , ultrasound is recommended for further evaluation. 3. small left pleural effusion and associated atelectatic changes. brief hospital course: 1. respiratory: ms. was initially admitted to the bmt unit but was transferred to the with progressive hypoxia on the floor on . her o2 sats dropped to 90% on a nrb. this was originally felt to be due to a combination of causes: 1) chf due to large amt of fluid received via blood products (had 2 units prbcs, 3 units platelets in prior 3 days), and 2)? aspiration during her bone marrow biopsy . she had not been responding to lasix on the floor. upon admission to the , she improved markedly on bipap. because she was increasingly uncomfortable with the bipap mask, she was changed back to a nrb for awhile, and was eventually placed on nasal cpap. overnight on , she began having increasing hemoptysis, first having blood-tinged sputum and then coughing up frank blood. she also developed worsening diffuse bilateral infiltrates on cxr. she was intubated on so that she could undergo bronchoscopy. while it was hoped that her intubation was only for the bronch, she instead required mechanical ventilatory support until . the bronch revealed increasingly bloody fluid with successive lavage, so it was felt she may have dah (vs a fungal or bacterial pna). she underwent a course of high-dose steroids (methylprednisolone 500 mg iv bid x 6 doses) for presumed dah. on , she developed a pneumothorax on the r side that was moderate sized (r ij tlc was placed on evening of with 2 subsequent cxrs not demonstrating a ptx, had bronch , then had ptx on cxr , so unclear etiology.) this was treated with 100% o2 and resolved on its own, not requiring chest tube placement. she had another episode of bleeding and underwent repeat bronchoscopy . this was also nondiagnostic. she was very difficult to wean from the ventilator, and eventually a family meeting was had with her primary oncologist, dr. . it was decided to extubate her and see how she did, and her family preferred not to have her reintubated if she didn't do well. however, she did very well. she was able to be transferred back up to the floor on , and was slowly weaned off her oxygen. by discharge, she was alternating between room air and 2 liters o2 per nasal cannula. she has persistent patchy alveolar and interstitial infiltrates on cxr, esp in her lll. the etiology of her respiratory failure was never fully confirmed. her bronch grew out a spore called sporobolomyces salmonicolor, which both the id fellow and the microbiology lab felt was a contaminant (as it didn't grow out until ). she may have had a pneumonia, as she improved on caspofungin, ceftazidime, and vancomycin. she also may have had dah. she definitely had at least a superimposed component of diastolic failure, and she was diuresed aggressively while on the floor, approximately 1-2 liters per day. she was originally on standing lasix, but by time of discharge she only received lasix (20 mg iv) after rbc transfusions. in terms of the etiology of her disease, there was also a question of vasculitis (as she has a hx of polyarteritis nodosum which was reportedly treated at .) however, her esr was 18, and house officers here obtained her records from which consisted only of one cbc and no notes of any sort. 2. cardiovascular: on admission, she had an echo that showed an ef >55%, with 1+ mr. on the evening of , mrs. went into a-fib with rvr, rates up to 170s and bp 70s/40s. she was given lopressor 5 mg iv x1, diltiazem 10 mg iv x1, and placed on a dilt gtt. she initially did not respond to any of these measures, and the dilt gtt was maxed out at 20 mg/hr. a few hours later, she spontaneously converted back to sinus rhythm with rates in the 80s, and the dilt gtt was discontinued. later on in the icu, she developed what was originally felt to be atrial flutter and was evaluated by cardiology. they felt she had a combination of atrial tachycardia and atrial fibrillation ,and recommended control with a dilt gtt as needed, and po verapamil. she eventually no longer required the dilt, and was maintained on verapamil with good results. she remained in nsr while on bmt as she was originally monitored on telemetry, which was eventually discontinued. ekgs were unremarkable other than a-fib. 3. id: given her fxnal neutropenia, she was begun on empiric antibiotics when she originally developed diffuse opacities on cxr. she was treated with ceftriaxone, vancomycin, bactrim, and clinda (initially). her vanc was discontinued 2 days later and she was begun on ambisome for empiric antifungal coverage. due to the lipid content in ambisome and its possible interaction with surfactant in the lung, she was changed to caspofungin. her induced sputum was immunofluroescent negative for pcp. rest of her bronch studies were negative for organisms other than the spore mentioned above. her antibiotics were all eventually stopped and she remained afebrile for a while. she also developed a sacral decubitus ulcer while in the icu, which was evaluated by the wound care nurses and dressed per their recommendations. twice in the week before discharge, she had low-grade temperatures but was asymptomatic. she had a negative urine culture and cxr showed a possible worsening of her lll infiltrate. the team recommended that she begin po levaquin, but she declined this. she expressly stated that she did not want to take any antibiotics, oral or intravenous. she understood the consequences and stated them clearly, but wished to not pursue the infectious workup any further. therefore she was not begun on any antibiotics. 4. hematology: her bone marrow biopsy on was negative for blasts, as was a repeat biopsy . while she was in the hospital, she required increasing frequency of transfusions. she received packed red blood cells and platelets every other day, to keep a hematocrit greater than 25 and platelets greater than 20k (given the fear that she had bled into her lungs, it was felt that a platelet transfusion threshold of 20k was more advantageous than 10k). it was felt that her low hematocrit was to her mds and was not the result of another process. she had a negative dat x 2. she did have evidence of hemolysis, with a low haptoglobin, elevated ldh, elevated indirect bilirubin, and a reticulocyte count of 6%. because of her large transfusion requirements and possible hemolysis, a super-coombs and an anti-platelet antibody test were sent, and were pending at time of discharge. it was also felt likely that these processes were all due to her myelodysplasia. on examination of her bone marrow biopsy, the attending heme pathologist felt that it was likely her cells were so dysplastic they did not survive long in the periphery. prior to d/c a conversation was had with the patient where it was discussed and agreed upon by everybody (including the attending hematologist) that there was no further treatment indicated for her mds, and she would continue with symptomatic transfusions. on d/c her wbc count was also low, with an anc of 1100. this is also felt to be mds. 5. liver: there was a question of whether the patient had hemochromatosis, whether iatrogenic or otherwise. (has son and brother with this disease.) the hemochromatosis genetic mutations were sent and were pending at time of discharge. her ferritin was greater than . it was decided not to chelate her at this time. medications on admission: danazol 100mg po bid procrit 20,000units sq qd neupogen verapamil sa 480mg qd zestril 5mg qd iron 325mg qd fosamax 10mg qmonday ca++ 600mg qd mvi qd potassium prn? 20mg po qd asa 81mg qd colace prn discharge medications: verapamil 120 mg po tid protonix 40 mg po daily ambien 5 mg po qhs:prn tylenol prn lasix 20 mg iv only post-rbc transfusions discharge disposition: extended care facility: - discharge diagnosis: myelodysplastic syndrome discharge condition: stable discharge instructions: please take your medications as prescribed. it is very important to continue taking your verapamil as it keeps your heart from beating too quickly, as it did when you were in the icu. you do not need to resume taking epogen, neupogen, or danazol. followup instructions: please f/u with your hematologist, dr. at , his discretion. he will receive a copy of your d/c summary. ***important: pt, family, and team all had discussion regarding her further care. she does not wish to have any antibiotics, and wishes only to have transfusions as needed. she is dnr/dni. she does not have a health care proxy form, but wishes to have her son as her health care proxy and will contact her lawyer regarding this. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Non-invasive mechanical ventilation Biopsy of bone marrow Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Diagnoses: Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Unspecified glaucoma Pulmonary collapse Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Pressure ulcer, lower back Diastolic heart failure, unspecified Personal history of malignant melanoma of skin Unspecified procedure as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Pulmonary eosinophilia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, dyspnea on exertion major surgical or invasive procedure: cardiac catheterization with stent placed at left anterior descending artery history of present illness: yo woman with htn brought to ed from her facility after c/o several weeks of doe after walking across the room, fatigue. history is difficult to obtain from pt secondary to dementia, most history is provided by nephew. chest pain, dizziness, paraesthesias. past medical history: dementia kyphosis hypertension social history: lives in facility no tobacco physical exam: t 98.0 hr 80s bp 110/80 rr 14 94% ra no acute distress, obese, oriented to person only no jvd cardiac exam rrr nl s1s2 no mrg soft b/l basilar rales abdomen soft no nd nabs extremities with trace edema pertinent results: echo: measurements: left atrium - long axis dimension: *4.7 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.5 cm (nl <= 5.2 cm) right atrium - four chamber length: 4.9 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: *1.2 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.5 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 3.3 cm left ventricle - fractional shortening: *0.27 (nl >= 0.29) left ventricle - ejection fraction: 35% (nl >=55%) aorta - valve level: 2.9 cm (nl <= 3.6 cm) mitral valve - e wave: 0.8 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 183 msec tr gradient (+ ra = pasp): *45 to 50 mm hg (nl <= 25 mm hg) interpretation: findings: left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. left ventricle: mild symmetric lvh. normal lv cavity size. moderately depressed lvef. no lv mass/thrombus. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic root diameter. aortic valve: mildly thickened aortic valve leaflets. trace ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. moderate (2+) mr. tricuspid valve: moderate to severe tr. moderate pa systolic hypertension. pericardium: no pericardial effusion. conclusions: 1. the left atrium is mildly dilated. 2. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed. anterior, distal septal, apical, distal lateral, and distal infeior akinesis is present. 3. the aortic valve leaflets are mildly thickened. trace aortic regurgitation is seen. 4. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. 5. moderate to severe tricuspid regurgitation is seen. 6. there is moderate pulmonary artery systolic htn. . . cardiac catheterization procedure: right heart catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 french pulmonary wedge pressure catheter, advanced to the pcw position through a 8 french introducing sheath. cardiac output was measured by the fick method. left heart catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 french right catheter, advanced to the ascending aorta through a 6 french introducing sheath. coronary angiography: was performed in multiple projections using a 6 french xblad 3.5 and a 6 french jr4 catheter, with manual contrast injections. visualization of the left coronary artery was repeated after the i.c. administration of 50 mcg of nitroglycerine. percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. hemodynamics results body surface area: 1.62 m2 hemoglobin: 10.7 gms % fick **pressures right atrium {a/v/m} 25/26/24 right ventricle {s/ed} 55/25 pulmonary artery {s/d/m} 55/30/41 pulmonary wedge {a/v/m} 32/33/31 aorta {s/d/m} 131/68/94 **cardiac output heart rate {beats/min} 70 rhythm sinus o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 81 card. op/ind fick {l/mn/m2} 2.5/1.5 **resistances systemic vasc. resistance 2240 pulmonary vasc. resistance 320 **% saturation data (nl) svc low 42 pa main 43 ao 99 other hemodynamic data: the oxygen consumption was assumed. **arteriography results morphology % stenosis collat. from **right coronary 1) proximal rca normal 2) mid rca normal 2a) acute marginal normal 3) distal rca normal 4) r-pda normal 4a) r-post-lat normal **arteriography results morphology % stenosis collat. from **left coronary 5) left main normal 6) proximal lad discrete 100 12) proximal cx normal 13) mid cx normal 13a) distal cx normal 14) obtuse marginal-1 discrete 70 15) obtuse marginal-2 normal 16) obtuse marginal-3 normal **ptca results lad **baseline stenosis pre-ptca 100 **technique ptca sequence 1 guiding cath xblad 3. guidewires choice p initial balloon (mm) 2.5 x 15 final balloon (mm) 2.5 x 24 # inflations 8 max pressure (psi) 270 **result stenosis post-ptca 0 success? (y/n) y ptca comments: we elected to treat the totally occluded proximal lad with ptca/stenting using heparin and integrilin prophylactically. a choice ptxs wire crossed into the lad with significant difficulty (a wizdom ss wire and several pt intermediate wires would not cross). a 2.5 x 15 mm voyager was used to predilate in five inflations at 8-9 atm. an export catheter would not cross beyond the proximal lad, but suctioning of this area resulted in minor improvement in flow. a 2.5 x 24 mm taxus des was deployed proximally and into the mid-lad at 12 atm, and another 2.5 x 24 mm taxus des was deployed in overlapping fashion more distally at 12 atm. the second sds was used to post-dilate the overlap area at 18 atm. there was significant spasm and no-reflow in the , intracoronary nitroglycerin and nitroprusside were adminstered through the guide, and more intracoronary nitroprusside was administered through the lumen of a 2.0 x 30 mm maverick positioned just distal to the second stent. final angiography demonstrated no dissection, no residual stenosis within the stented segments with loss of a major diagonal branch (closed at the start of the case), and timi-3 flow into a diffusely diseased distal lad. technical factors: total time (lidocaine to test complete) = 1 hour 38 minutes. arterial time = 1 hour 34 minutes. fluoro time = 43.1 minutes. contrast: non-ionic low osmolar (isovue, optiray...), vol 175 ml, indications - hemodynamic premedications: asa 325 mg p.o. anesthesia: 1% lidocaine subq. anticoagulation: heparin 1000 units iv other medication: fentanyl 12.5 mcg iv furosemide 80 mg iv integrilin 10 cc iv bolus integrilin 4.5 cc/hr nitroprusside 550 mcg ic plavix 300 mg po cardiac cath supplies used: .014 cordis, wizdom ss 300 .014 , pt , 300cm .014 , pt , 300cm 2.5 guidant, voyager 15 2.0 , maverick, 30 6f cordis, xblad 3.5 2.5 , taxus express 2 otw, 24 2.5 , taxus express 2 otw, 24 3f , export aspiration catheter comments: 1. selective coronary angiography demonstrated a right dominant system with two cad. the left main had mild disease. the lad had a 70% lesion at it's origin and a 100% proximal occlusion. the left circumlfex artery had a 70% lesion in the om1 branch. the rca had mild disease. 2. resting hemodynamics demonstrated markedly elevated right and left sided filling pressures with a mean ra pressure of 24 mm hg and mean pcwp of 31 mm hg. moderate pulmonary hypertension was present. the cardiac index was markedly reduced, based on an assumed oxygen consumption index. central aortic pressure was normal. 3. left ventriculography was not performed. 4. successful pci of the lad with two overlapping taxus des (2.5 x 24 mm and 2.5 x 24 mm). final diagnosis: 1. two coronary artery disease. 2. markedly reduced cardiac index with elevated left and right sided filling pressures but normal central aortic pressure. 3. acute anterior stemi treated with primary pci. . . 10:36pm ck(cpk)-606* 10:36pm ck-mb-58* mb indx-9.6* brief hospital course: the patient is a year old woman with hypertension, hyperlipidemia, and no known cad. she presented to the emergency department with dyspnea. ecg demonstrated anterior stemi. after a discussion with the patient's nephew, the patient was brought to the catheterization laboratory where she was found to have occlusion of the lad with 80% stenosis at om1. she had a cypher stent placed to the lad. she was found to have a low cardiac index with low mvo2 during catheterization. she was diuresed 1 liter over the course of her hospitalization which she tolerated well, and resulted in marked improvement in her oxygenation. hospitalization was complicated by increased bleeding at access site after catheterization, for which hemostasis was eventually obtained but integrellin was discontinued early. her hematocrit remained stable. as post mi echo showed akinesis, pt was started on coumadin for a 6 month course after determining she was not a fall risk with physical therapy and with her pcp. was also found to have a uti for which she was treated with levaquin. medications on admission: zyprexa, lipitor discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 3. sertraline hcl 50 mg tablet sig: 0.5 tablet po daily (daily). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). 7. olanzapine 5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. atorvastatin calcium 20 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: acute myocardial infarction dementia hypertension discharge condition: stable discharge instructions: return to the emergency department if you develop chest pain, shortness of breath, or dizziness. followup instructions: dr. partner will see you while you are at rehab. dr. will see you once you are back at . . you will follow up with a cardiology appointment at out patient clinic with provider: , .d. where: cardiac services phone: date/time: 11:00 . ***** to follow up: 1) patient started on lasix 40mg qd, as well as potassium. please monitor cr levels and potassium levels. at time of discharge, cr is 1.5. 2) patient recently started on coumadin 5mg qd. at time of discharge, inr is 1.4 (after 2 doses of coumadin). she is being discharged on 3mg dose qd. import follow-up instructions follow-up instructions: Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Other persistent mental disorders due to conditions classified elsewhere Diseases of tricuspid valve Kyphosis (acquired) (postural)

allergies: iodine; iodine containing / dilantin / percocet attending: chief complaint: chest discomfort and shortness of breath x 2 months major surgical or invasive procedure: mediastinoscopy with lymph node biopsy - pathology pending history of present illness: the patient is a 37 year old female with pmh endometrial cancer s/p tah w/ r oopherectomy who presented to a clinic with two month history of shortness of breath and chest pain. she describes the chest pain as "like an elephant standing on her chest". she notes that it is associated with dyspnea, diaphoresis, and lightheadedness. she was referred to a cardiologist for a nuclear stress test about 6 weeks ago which was normal per pt. symptoms persisted over last three weeks with increased fatigue and weakness. she also notes waxing and feversv(tm 100-101), productive cough and 18 pound weight loss during this time. at the clinic on , a chest x-ray was done which was significant for mediastinal widening. she was immediately taken by ambulance to falumouth ed. at , a chest ct showed diffuse mediastinal adenopathy and multiple pulmonary nodules and splenomegaly. an echo showed small- moderate pericardial effusion and increased tuerculation in rv apex c/w rva thrombus. nl ef/valves. doppler us le - left popliteal dvt. v/q scan - indetermingate - 50% chance of pe. patient was stable during one day admission at and was transferred to for further work up of the pulmonary nodules and lymphadenopathy. while in the , the patient was seen by pulmonary and oncology. she was sent for a chest and abdominal ct which suggested a 5x4 cm mediastinal mass with precarinal lymph nodes, multiple smaller nodules throughout both lungs and a small-moderate pericardial effusion. she was hemodynamically stable in the and transferred to the floors on pm. the patient denies headaches/abdominal pain/melena/hematochezia/ change in bowel movements/dysuria. the patient does note 10 year history of perimenopausal symptoms - fatigue, myalgias, hot flashes, low grade temps. past medical history: 1. ?endometrial cancer - age 25 - s/p tah and ro, no chemo/xrt (encapsulated tumor) 2. migraine headaches - since age 8. takes tylenol and motrin. 3. cesarean section x 3 4. history of fibrocystic breast disease - s/p multiple mammograms and 7 negative biopsies 5. per path report -cervical cancer in situ social history: the patient works as a bar manager. she has 3 children and is separated tobacco -(+) -3 ppd x 22 years (~40 pack-year) alcohol - rare ivda - none family history: ancestry - scandinavian, english mother - sister - similar symptoms of fatigue, weakness, "perimenopausal" on testosterone supplement great aunt - breast cancer aunt - cervical cancer "history of clotting in legs" in family physical exam: temp max 99.6; tcurrent 98.6, bp 109/58, hr 86-100, rr 17-21, 93-94%ra gen - alert, no acute distress, anxious, thin heent - perrl, extraocular motions intact, anicteric, mucous membranes moist neck - supple, no jvd, positive r shotty cervical lad, chest - diffuse expiratory wheezes, some scattered crackles; otherwise clear to auscultation bilaterally cv - normal s1/s2, rrr, no murmurs, rubs, or gallops abd - soft, nontender, nondistended, with normoactive bowel sounds back - no costovertebral angle tendernes; left paraspinal (c7), firm rubbery mass (+)tender to palpation extr - no clubbing, cyanosis, or edema. 2+ dp pulses bilaterally. no axillary lad neuro - alert and oriented x 3, cranial nerves intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact skin - no rash pertinent results: 07:16pm wbc-7.5 rbc-3.63* hgb-10.9* hct-33.2* mcv-92 mch-30.1 mchc-32.9 rdw-12.7 plt 211 neuts-75* bands-0 lymphs-21 monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-0 07:16pm caltibc-216* ferritin-142 trf-166*iron-17* 07:16pm glucose-91 urea n-7 creat-0.5 sodium-138 potassium-3.9 chloride-100 total co2-27 anion gap-15 07:16pm alt(sgpt)-3 ast(sgot)-9 ld(ldh)-153 alk phos-74 tot bili-0.3 albumin-3.5 calcium-8.5 phosphate-3.7 magnesium-2.0 07:16pm fsh-3.4 lh-4.8 ct of the chest without contrast: there is no axillary lymphadenopathy. small axillary lymph nodes do not meet the criteria for pathologic enlargement and measure up to 6 mm in size. a large mediastinal mass, which measures up to 5.4 x 4.7 cm in axial dimension, which extends from the right paratracheal region at the level of the thoracic inlet to the precarinal lesion is present with central regions of hypodensity suggesting necrotic change. in addition, there is an enlarged 4.5 x 2.5 cm subcarinal lymph node. bulkiness in the right hilum is present as well. evaluation of the central airways demonstrate patency to the segmental bronchi bilaterally. examination of the lung windows demonstrate a dominant 13 x 11 mm nodule within the right upper lobe, with a satellite lesion in the subpleural right apex measuring 7 mm in size. most of these lesions show some characteristics of spiculation. in addition, there is a 5 mm nodular region in the subpleural right lower lobe, which has well- defined forbers. the right lower lobe demonstrates mild atelectasis, possibly with a smaller degree of consolidation as well. there is a trace right-sided pleural effusion. the left lung is essentially clear, without evidence of pleural effusion. there are some peripheral blebs suggestive of paraseptal emphysema. note is also made of a hypodense appearance of the blood relative to myocardium suggestive of anemia. there is a small pericardial effusion. ct of the abdomen without contrast: allowing for the noncontrast technique, the liver, gallbladder, spleen, kidneys, stomach, and small bowel appear unremarkable. the pancreas is grossly unremarkable as well. adrenal glands are not clearly visualized due to the lack of iv contrast, and no bulky lymphadenopathy is the retroperitoneum or mesentery is noted. there is no abdominal free fluid present. ct of the pelvis without contrast: the large bowel and bladder are unremarkable. distal ureters are not well visualized without iv contrast. the uterus is not seen, and the ovaries appear unremarkable. examination of the osseous structures show no suspicious lytic or blastic lesions. imression: 1. large mediastinal mass with precarinal and subcarinal lymph nodes. these have hypodense central regions suggestive or necrosis. these would be most ammenable for transbronchial biopsy. 2. multiple lung nodules, two of which are spiculated at the right lung apex. 3. there is a small pericardial effusion. mri brain. clinical information: patient with history of cervical cancer with pulmonary nodule and mediastinal mass and patient allergic to iv contrast for ct, for further evaluation to exclude metastatic disease. technique: t1 sagittal and axial, and flair, t2 and susceptibility axial images of the brain were obtained before gadolinium. t1 axial, sagittal and coronal images were obtained following the administration of gadolinium. findings: in the right posterofrontal lobe, there are two small areas of signal abnormality seen within on the flair images, one laterally along the anterior aspect of the central sulcus and the second superiorly to the posterior frontal lobe near the midline. both of these foci demonstrate enhancement following the administration of gadolinium. no other focal abnormalities are identified. specifically, no evidence of periventricular signal abnormalities are seen. no other areas of enhancement are noted. the ventricles and extraaxial spaces are normal in size. no evidence for midline shift, mass effect or hydrocephalus is seen. impression: foci of signal abnormalities in the right frontal lobe with enhancement. the differential diagnosis includes metastatic disease and demyelinating process, given patient's age. however, given the clinical history and the location of the lesions, metastatic disease is considered more likely. brief hospital course: 37 year old female with h/o cervical cancer s/p tah transferred from outside hospital with progressive chest discomfort, sob, and weight loss with left popliteal dvt, possible pe and chest xray/ ct evidence of mediastinal mass and multiple bilateral nodules with mediastinal lymphadenopathy. 1. pulmonary nodules - on admission a chest xray suggested a small focal opacity in right upper lobe and right paratracheal opacity. a chest ct the following day suggested a large mediastinal mass with precarinal and subcarinal lymph nodes with hypodense central regions suggestive of necrosis. it also showed multiple nodules, two spiculated lung nodules at right lung apex. these lesions were most consistent with lung cancer versus lymphoma so a mediastinoscopy was planned. other things originally on the differential were: tb -ppd negative, histoplasmosis -antigen still pending, coccidoiomycoses, nocardia, sarcoidosis (scandinavian) - ace-normal. on she had a mri-brain, which showed two foci of signal abnormalities in the right frontal lobe with enhancement. no edema or mass effect was seen secondary to the brain lesions. on , she had a mediastinoscopy. the frozen section was positive for non-small cell lung cancer; paratracheal lymph nodes were sent for pathology (still pending). 2. non-small cell lung cancer - multiple necrotic lymph nodes radiographically and grossly, mri of the brain with focal right frontal brain mets; and a 1 by 1 inch paraspinal hard, rubbery lesion on her left upper back; presentation consistent with metastatic nsclc. patient was told her diagnosis with her mother and grandfather in the room. she seemed to take the news well, appropriately becoming teary eyed. she was then seen by a social worker and told the social worker that she was coping well and did not need to be seen anymore. she was seen by oncology consult and set up for an outpatient follow up with multidisciplinary oncology team on thursday . during that time she will discuss chemo vs biologic therapies vs palliation. she will also have a bone scan to evaluate for bone mets also on thursday as an o/p. on the last day of admission, the patient noted blurriness in left periphery; no deficit on visual fields or neuro exam; the patient was advised to have a head ct to reevaluate for mass effect or bleeding in the brain lesions, but she refused and wanted to go home with no further treatment. she was counseled to go to the ed if she had worsening vision deficits, headaches. the patient's shortness of breath was stable during the admission; she required 2l oxygen especially during long conversations; the patient will be sent home on home oxygen. 2. hypercoagulable state - dvt/pe/?rv thrombus - echo at outside hospital also with possible thrombus in rv; pt obviously hypercoagulable most likely secondary to primary lung malignancy; she was maintained on heparin throughout the admission and was switched to lovenox and underwent lovenox administration teaching prior to discharge 3. pericardial effusion - found on echo at ; stable on chest ct at .most likely secondary to the primary lung malignancy; patient did not experience any decreases in blood pressure, increased shortness of breath, or increased chest pain during the admission. she was monitored throughout the admission for tamponade physiology and did not present with any. 4. fevers - low grade throughout admission; most likely secondary to the malignancy; fungal, blood cultures were negative; lyme antibody was negative; patient never mounted an increased white blood cell count. 5. pain/nausea - the patient had back and chest (pleural) pain throughout the admission well controlled prn dilaudid q 3-4 hours. she was started on a fentanyl patch for pain on with dilaudid for breakthrough. she also noted increased nausea with the dilaudid which was well controlled with phenergan. after the mediastinoscopy, she had increased throat pain which was relieved with viscous lidocaine. 6. 10 year hisory of perimenopausal symptoms - fsh, lh within normal limits; no further work-up during the admission 7. ppx - she was maintained on a multivitamin and zantac during the admission with colace and senna to releive constipation in the setting of narcotics.) 8. code status - full code medications on admission: tylenol (heparin gtt from outside hospital) 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. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. fentanyl 50 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours): please place new patch on thursday . disp:*10 patch 72hr(s)* refills:*2* 4. promethazine hcl 25 mg tablet sig: one (1) tablet po q3-4h () as needed. disp:*84 tablet(s)* refills:*0* 5. lidocaine hcl 2 % solution sig: one (1) ml mucous membrane q3-4h () as needed for throat pain. disp:*112 ml(s)* refills:*0* 6. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*30 subcutaneous injection* refills:*2* 7. dilaudid 2 mg tablet sig: 1-2 tablets po every four (4) hours. disp:*60 tablet(s)* refills:*2* 8. ambien 10 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 9. zantac 150 mg capsule sig: one (1) capsule po twice a day. discharge disposition: home discharge diagnosis: non-small cell lung cancer left popliteal deep vein thrombosis/pulmonary embolus discharge condition: stable discharge instructions: please go the the emergency department if you have increasing shortness of breath or chest pain or if you have worsening blurry vision or headaches. followup instructions: please go for bone scan on thursday, at 9:30 am. main entrance - by elevators. please follow up with dr. in the thoracic oncology center this thursday, at 10:30 am. Procedure: Fiber-optic bronchoscopy Mediastinoscopy Simple excision of other lymphatic structure Closed [percutaneous] [needle] biopsy of mediastinum Diagnoses: Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Other pulmonary embolism and infarction Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Other specified diseases of pericardium Secondary hypercoagulable state Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Personal history of malignant neoplasm of cervix uteri

history of present illness: this is a year old female with a history of gastritis, hypertension and hypercholesterolemia who was admitted to the service on for the complaint of progressive chest pain. the patient described a two to three month history of progressive shortness of breath and substernal chest pain. the patient stated that the chest pain originally occurred at rest and reported that her episodes had become more severe over the ensuing time. the patient's episodes were characterized by pain radiating to both arms that would occasionally wake her up at night and lasted approximately 30 minutes in duration. the patient was reportedly evaluated by her primary care physician and was presumptively diagnosed with gastritis; an esophagogastroduodenoscopy conducted on demonstrated mild gastritis which resulted in outpatient treatment with maalox and protonix prn. the patient continued to demonstrate worsening symptoms, resulting eventually in a mibi stress test on which demonstrated severe lateral wall reversible defects. the patient was subsequently advised to come immediately to the emergency department at , where she was noted to have st depressions in leads 2, avf, v5 and 6 and an old t wave inversion in leads 1 and avl. the patient was subsequently started on heparin and nitroglycerin drip which brought immediate relief of her chest pain symptoms and she was subsequently admitted to the medicine service on for further evaluation and treatment. past medical history: hypertension; hypercholesterolemia; colon cancer; status post colectomy; breast cancer; peripheral vascular disease; gastritis; status post right total hip repair; status post thyronodular excision. home medications: sinemet; levo carbidopa; lipitor; atenolol; norvasc; hydrochlorothiazide; protonix; benicar; timolol; maalox; tylenol; multivitamin; calcium; fish oil. allergies: no known drug allergies. social history: widowed and lives in with daughter, formerly worked as a secretary and is now retired. no smoking and no alcohol history. hospital course: the patient was admitted to the service on . initial inpatient therapy included aspirin, statins, heparin, and nitroglycerin drip, on which regimen the patient was noted to have significant relief of her chest pain. cardiac catheterization performed on demonstrated three vessel coronary artery disease, moderate mitral regurgitation, moderate diastolic ventricular dysfunction, and mild systolic ventricular dysfunction. a 30 cc intra-aortic balloon pump was inserted without complication through the course of the procedure. the patient's ejection fraction was noted to be approximately 50%. following catheterization, the patient was admitted to the cardiac care unit for further evaluation and management. the patient was subsequently evaluated by the cardiothoracic surgery service and scheduled for urgent coronary artery bypass graft on . on , the patient underwent an off pump coronary artery bypass graft times one with anastomosis of the left internal mammary artery to the left anterior descending with a plan for postoperative stenting. the patient tolerated the procedure well without complications. the patient's pericardium was left open; lines placed including an arterial line, swan-ganz catheter, and intra-aortic balloon pump; wires placed included ventricular pacer wires; two slits including mediastinal, right and left pleural tubes. on transfer to the cardiothoracic surgery recovery unit, the patient demonstrated a mean arterial pressure of 92, central venous pressure of 0, pad of 8 and of 18. the patient demonstrated a heartrate of 84 in normal sinus rhythm. drips on transfer included neo 0.7 and propofol at 10. in the cardiothoracic surgery recovery unit, the patient progressed well clinically and was successfully extubated on postoperative day #1, . the patient was returned to the catheterization laboratory on postoperative day #1, where stents were placed both to the circumflex and ramus. on postoperative day #2, the patient was cleared for transfer to the floor, at which point her iabp was removed and her cordis was changed to a triple lumen catheter without complication. the patient was subsequently admitted to the cardiothoracic service on direction of dr. . postoperatively the patient progressed well clinically. physical therapy evaluation recommended the patient for rehabilitation following discharge, after which point the patient was successfully screened for placement. on postoperative day #4, the patient's chest tubes were removed without complication; subsequent chest x-ray demonstrated no evidence of pneuomothorax. the patient was successfully advanced to a regular p.o. diet and was noted to have adequate pain control via oral pain medications. on postoperative day #5, , the patient was cleared for discharge to a rehabilitation facility with instructions for follow up. condition on discharge: the patient is to be discharged to an extended care facility with instructions for follow up. status on discharge: stable. discharge medications: 1. lasix 40 mg p.o. q. 12 hours 2. pantoprazole 40 mg p.o. q. 12 hours 3. potassium chloride 20 meq p.o. q. 12 hours 4. docusate sodium 100 mg p.o. b.i.d. 5. aspirin 325 mg p.o. q.d. 6. plavix 75 mg p.o. q.d. 7. carbidopa levodopa 20/100 mg tablets one tablet p.o. t.i.d. 8. carbidopa levodopa 25/100 mg tablets one tablet p.o. b.i.d. 9. atorvastatin 20 mg p.o. q. day 10. timolol maleate 0.25% eye drops one drop ophthalmic q.h.s. 11. losartan 25 mg p.o. q.d. 12. lopressor 50 mg p.o. b.i.d. discharge instructions: the patient is to maintain her incisions clean and dry at all times. the patient may shower but she should pat dry incisions afterwards; no bathing or swimming. the patient may resume a regular diet. the patient has been advised to limit physical activities, no heavy exertion, no driving while taking prescription pain medications. follow up with primary care provider within one to two weeks following discharge. follow up with dr. within four weeks of discharge. the patient has been advised to call to schedule both appointments. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Iatrogenic pneumothorax Primary pulmonary hypertension Diastolic heart failure, unspecified

history of present illness: mr. is a 79-year-old male who was recently discharged from preoperatively after being referred to dr. for coronary artery bypass grafting. he has a history of hypertension, angina, abdominal aortic aneurysm, hypercholesterolemia and was recently discharged from hospital prior to his admission last week at for lithotripsy and bladder calculi. he presented with an episode of nausea and vomiting, weakness and chest discomfort. he had known renal and bladder calculi as well as an incidental finding of a 4.4-cm abdominal aortic aneurysm by report from his outside hospital. he developed hematuria and was transferred from hospital to the week prior to this admission. please refer to the discharge summary dated . on the way home from the hospital in , he had developed vertigo, nausea and vomiting. he was then transferred in to our institution for work-up for cardiac disease preoperatively to his abdominal aortic aneurysm repair or possible stenting. past medical history: 1. myocardial infarction . 2. hypertension. 3. angina. 4. bph. 5. bladder calculi and renal calculi. 6. abdominal aortic aneurysm. 7. hypercholesterolemia. past surgical history: includes open cholecystectomy. he was evaluated by cardiology and was allowed to return home to get urology clearance from his primary care physician and the urologist who had treated him the week prior in hospital and to return for surgery on with dr. . laboratory data: ekg showed normal sinus rhythm with occasional pvcs, normal pr and q-waves in leads ii, avr and avf and question of q-wave inversion in lead iii. persantine mibi was performed which showed a moderate, partially- reversible inferior wall perfusion defect and ejection fraction of 55%. echocardiogram performed prior to this admission showed an ejection fraction of 55% or greater, 1+ mr and no pericardial effusion. please refer to the echo report. a ct of the abdomen done on prior to this admission also showed extensive atherosclerotic changes with associated 5.4-cm infrarenal abdominal aortic aneurysm with no evidence of rupture. the left common iliac was also aneurysmal and total occlusion of the right common iliac with reconstitution of the right internal iliac and femoral arteries. it also showed massive prostatic enlargement and a right-sided posterior diaphragmatic hernia containing mesenteric and omental fat. repeat ct of the abdomen was done the following day which also showed a simple, multiple renal cyst bilaterally. chest x-ray done on showed no evidence of free intraperitoneal air and small bilateral pleural effusions with some mild pulmonary vascular congestion. cardiac catheterization performed also showed a right dominant system with a left main 30% lesion, a diffusely-diseased lad with a 90% mid-vessel stenosis, a 99% om1 lesion and a totally-occluded proximal rca. ef was 60% at catheterization with no mitral regurgitation. carotid dopplers also performed showed less than 40% stenosis on both the right and left internal carotid arteries. the patient was allowed to return to home for urology clearance and was readmitted to the hospital on for coronary artery bypass grafting. he also had been treated for urinary tract infection over the weekend. he was seen by urology who recommended continuous bladder irrigation which we were unable to perform in the or so the decision was made to keep the patient in-house for several days to wait until his gross hematuria cleared. he was admitted on the 7th and followed by our service. on hospital day 2, he had some supraventricular tachycardia with activity. his ekg showed no ischemic changes and he had no chest pain. his hematuria continued to resolve. preop labs were as follows: white count 7.1, hematocrit 34.8, platelet count 272,000, sodium 140, k 3.9, chloride 103, bicarbonate 29, bun 18, creatinine 1.1, blood sugar of 117, pt 13.8, ptt 27.8, alt 52, ast 32, alkaline phosphatase 59, amylase 35, total bilirubin 0.8, lipase 34. he was started on ciprofloxacin 500 mg p.o. twice a day and continued with lopressor beta blockade and continue also with aspirin and finasteride. his pressure was 152/74 that morning. he was in sinus tachycardia at 52 with respiratory rate of 20 and saturating 99% on room air. iv nitroglycerin was started briefly for blood pressure control and the plan was to continue to irrigate him over the weekend for his hematuria, and bring him back to the or on monday. on , he underwent coronary artery bypass grafting x3 by dr. with a lima to the lad, a vein graft to the pda and a vein graft to the om. he was transferred to cardiothoracic icu in stable condition on titrated propofol and phenylephrine drips. he was also seen by urology who cleared him for cabg prior to the procedure. on postop day 1, his index was 2.6. he remained stable in the cardiothoracic icu. postop labs were as follows. white count 12.7, hematocrit 32, k 4.4, bun 12, creatinine 1.0. his sugars were covered by sliding scale insulin. he was seen by dr. , his cardiologist. he was on insulin drip at 3 units an hour and lidocaine drip at 2 mg per minute. on postoperative day 2, he went into atrial fibrillation with a ventricular response rate of 129. he maintained good blood pressure of 114/52. his chest tubes were pulled. his atrial fibrillation was treated. he received magnesium repletion also. his creatinine remained stable at 1.2 and his exam was unremarkable. when he was weaned from his drips, he was transferred out to the floor and was seen and evaluated by urology and by physical therapy to start working on ambulation with the nurses and the therapists. on the 13th, his urine was clear. he was managing his pain control with p.o. medications. he was in sinus rhythm with some pvcs. he was restarted on his cholesterol medicines. he was continued with iv diuresis with lasix. his blood pressure was 145/69 so his blood pressure was titrated up. he did have some complaints of nausea but this was not overwhelming. his pacing wires were discontinued. on postoperative day 4, he had another event of atrial fibrillation overnight with a blood pressure of 132/68. his foley was discontinued per urology. his exam was unremarkable. incisions were clean, dry and intact. he was alert and oriented with a nonfocal neurological exam. his lungs were clear bilaterally. he was also seen by social work. the following morning he was back in sinus rhythm again with a good blood pressure. he continued his diuresis with lasix and continued to increase his ambulation and his activity tolerance level. on the 17th, he went back into atrial fibrillation and heparin was started as a possible bridge to coumadin. his exam was unremarkable. he was saturating well on 2 liters nasal cannula. his heparin was discontinued per dr. . his pressure came down to 101/54. on the 19th, amiodarone was started for his atrial fibrillation at 400 mg p.o. twice a day. he was doing very well, ambulating with minimal support. his creatinine was stable at 1.2. his exam was unremarkable, clean, dry and intact incisions. the central venous line had been removed. he continued on proscar 5 mg p.o. once a day for his enlarged and somewhat raw prostate. his urine was clear. his beta blockade had been increased to 75 mg p.o. three times a day and he was discharged to home in stable condition with vna services, with the following discharge diagnoses. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting x3. 3. hypertension. 4. status post myocardial infarction . 5. abdominal aortic aneurysm. 6. hyperlipidemia. 7. renal and bladder calculi, status post lithotripsy . it was recommended that he followup with dr. service for postop surgical visit in the office at 4 weeks, to see dr. , his primary care physician, 2 weeks, to see dr. , his cardiologist, in 2 weeks, and to see dr. , his urologist at the outside hospital, after his discharge. discharge medications: 1. proscar 5 mg p.o. once daily 2. colace 100 mg p.o. twice a day 3. zantac 150 mg p.o. twice a day 4. enteric-coated aspirin 81 mg p.o. once a day 5. crestor 5 mg p.o. once daily 6. metoprolol 75 mg p.o. three times a day 7. amiodarone 200 mg p.o. once a day 8. coumadin 1 mg p.o. with no dose to be taken on the evening of . inr check was scheduled with blood draws on , the day after discharge, with results to go to dr. , his primary care physician, therapeutic inr dosing with coumadin. the patient had been started on coumadin the evening prior to discharge. again, the patient was discharged to home in stable condition on . , m.d. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Monitoring of cardiac output by other technique Removal of other urinary drainage device Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Old myocardial infarction Retention of urine, unspecified Personal history of urinary calculi Abdominal aneurysm without mention of rupture Urinary complications, not elsewhere classified

allergies: vicodin / erythromycin base attending: chief complaint: chest pain, stemi major surgical or invasive procedure: left heart catheterization and balloon angioplasty history of present illness: 54yo male with past medical history significant for coronary artery disease s/p multiple interventions including cabg in , htn, hld who is presenting with stemi. the patient reports that he was standing in his kitchen at rest this afternoon around 4pm and he had sudden onset of chest pressure, which is how his angina always presents. he took nitroglycerin x4 and the chest pain did not improve, so he called ems. . upon arrival of ems, the patient was given nitro and aspirin. he was taken to osh, where ekgs were done and the decision was made to transfer to . on arrival to the cath lab, he reported his pain as . in the cath lab, the patient had balloon angioplasty of the tca but no placement of stent. there was thrombosis of the distal rca that was refractory to balloon angioplasty, despite iv heparin, iv integrillin and prasugrel. the final injection showed timi 1 flow into the distal vessel and st segment elevation consistent with continued inferior wall stemi. his cp was . . the patient reports that he has been in his baseline state of health since , when he was experiencing increasing anginal symptoms and so he had repeat coronary angiography, done as an outpatient, where he was found to have severe in stent restenosis of the rca and had des placed. since that time, he has had much improved symptoms and has been able to keep up with his exercise regimen of walking 2miles 5 days a week at a speed of miles per hour. on friday, 4 days prior to presentation, the patient noted that he was "at the edge of his exertion" while he was doing his 2 mile walk. by this he means that if he had increased his speed, he would have had angina, but since he maintained his speed, he was not having angina. on sunday, 2 days prior to presentation, the patient had acute onset of chest pain and realized he had forgotten to take his am meds, so he took them and he took one nitroglycerin and felt resolution of the pain. . in the ccu, the patient reports 2/10 chest pain, denies dyspnea. . on review of systems, he denies any prior history of stroke, 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 notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: -diabetes, +dyslipidemia, +hypertension 2. cardiac history: - cabg: : lima -> lad, svg -> rpda, svg -> diagonal, svg -> ramus, left radial -> om ptca and beta-brachytherapy of vg -> pda s/p ptca/beta-brachytherapy of the svg->pda - percutaneous coronary interventions: -: imi treated with retavase and overlapping proximal rca stents and distal rca stent - s/p rotational atherectomy of the mid rca and stenting with two taxus des 3.0 x 12mm in the distal rca with an overlapping 3.0 x 24mm taxus. - focal severe in-stent restenosis in the right coronary; drug-eluting stent (3.5 x 12 mm dilated to 3.75 mm). - pacing/icd: none 3. other past medical history: anxiety/depression low back pain (resolved) left ankle fracture with surgery elbow fracture with surgery ? tia word finding difficulty, micrographia after receiving retavase. social history: divorced, has 3 kids- son, 22 has substance abuse issues; daughter, 20, is at ; son, 17 is honors high school student. occupation: electrical engineer; went out on disability several years ago. tobacco: quit (smoked 1-2ppd x7 years) etoh: quit 20 yrs recreational drug use: denies family history: mother died at age 85 parkinson's disease. dad died in his 40's from liver disease. brother- died in his 60s from chronic inflammatory demyelinating polyneuropathy. sister- breast cancer, obesity. sister-depression. 3 children healthy. physical exam: admission exam: . vs: t=af bp= 92/54 hr=65 rr=14 o2 sat= 98% 2l general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp at clavicle. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: admission labs: . 07:50pm blood wbc-8.7# rbc-3.86* hgb-11.6* hct-34.3* mcv-89 mch-30.0 mchc-33.8 rdw-12.8 plt ct-187 07:50pm blood pt-12.3 inr(pt)-1.1 07:50pm blood glucose-107* urean-14 creat-0.9 na-138 k-4.0 cl-110* hco3-21* angap-11 . pertinent labs and studies: . 07:50pm blood ck(cpk)-84 03:07am blood ck(cpk)-364* 04:45pm blood ck(cpk)-1084* 03:07am blood ck-mb-44* mb indx-12.1* ctropnt-0.27* 08:50am blood ck-mb-90* ctropnt-0.68* 04:45pm blood ck-mb-105* mb indx-9.7* ctropnt-1.28* . echocardiogram the left atrium is elongated. left ventricular wall thickness, cavity size, and global systolic function are normal. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal to mid inferior wall. the remaining segments contract normally (lvef = 55 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: mild regional left ventricular systolic function with preserved left ventricular ejection fraction. mild mitral regurgitation. mild pulmonary hypertension. brief hospital course: this is a 53 year-old male with past medical history significant for cad s/p cabg and multiple pcis, p/w stemi s/p des to rca with poor flow after stenting ho presented with st-elevation myocardial infarction and underwent cardiac catheterization. . acute care: . # coronary artery disease - the patient has had multiple pcis and is s/p cabg. he had a left heart catheterization with balloon angioplasty of the rca at the time of admission without placement of stent, he was medically managed. he was treated with heparin gtt, integrillin gtt, pprasugrel and aspirin. his integrillin and heparin infusions were discontinued following his catheterization. a 2d-echo showed mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal to mid inferior wall (lvef 55%). we did decreased his lisinopril from home dose of 40 mg to 10 mg this admission and stopped his plavix and decided to utilize prasugrel. . chronic care: . # hyeprtension - we continued home lisinopril but at 10 mg daily and resumed his metoprolol medication. . # hyperlipidemia - continued atorvastatin 80 mg po daily. . issues of transitions in care: 1. exchanged plavix for prasugrel for anti-platelet therapy. 2. will follow-up with outpatient cardiologist and primary care physician. 3. at the time of discharge, the patient had no pending radiologic studies, labroatory studies, or microbiologic data. medications on admission: 1. ntg 0.4mg tablet sl prn chest pain 2. aspirin 325mg daily, 3. plavix 75 mg daily, 4. lisinopril 40 mg daily, 5. atorvastatin 80mg daily 6. toprol-xl 200 mg daily. discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual as directed as needed for chest pain: take 1 capsule x3, separated by 5 minutes. 3. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 5. prasugrel 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol succinate 200 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: 1. acute st-elevation myocardial infarction . secondary diagnoses: 1. hypertension 2. hyperlipidemia 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 for a heart attack that was caused by a blockage in your right coronary artery. as you know, you did not have placement of another stent in your coronary artery but the artery was opened with a balloon. your chest pain improved with medical management and you will continue to follow with your cardiologist and to take medications for your heart. please note the following changes to your medications: 1. stop taking plavix, take prasugrel instead to prevent blockages in your heart arteries 2. decrease lisinopril to 10 mg daily instead of 40 mg. please be sure to follow up with your physicians. followup instructions: . department: cardiac services when: monday at 10:20 am with: , md building: campus: east best parking: garage . name: , pa. location: primary care address: , , phone: when: tuesday, :15 am * is covering for dr. . department: cardiac services when: monday at 2:20 pm with: , md building: campus: east best parking: garage Procedure: Coronary arteriography using two catheters Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Aortocoronary bypass status Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Old myocardial infarction Acute myocardial infarction of other specified sites, initial episode of care

allergies: ? vicodan-hives neuro: arrived sedated on propofol. propofol weaned to off. currently lethargic but oriented x 3 and mae. cv: hr mainly 80's nsr, no ectopy noted. cont's on ntg gtt at 0.5 mcg/kg/min for radial artery graft. neo gtt restarted for sbp into 70's, map into high 50's. titrated according to bp and currently off. received total 1.2l lr for bp support d/t large u/o. hct stable. ct o/p initially minimal then increasing after turning in bed. currently decreasing. left hand with normal cap refill, warm, no numbness. ca+ and k+ repleted. resp: bs slightly diminished at lower lobes. weaned from imv to cpap w/ stable abg's. extubated at 1830 to 4l np. gi: ogt w/ small amt bilious dng. removed w/ extubation. gu: large u/o via foley. id: warm on arrival. vanco to cont. endo: ssri iv x 1 for glucose in 150's. comfort: med w/ mso4 and toradol. after extubation, pt with minimal c/o pain. social: wife called and updated on pt's condition. a: hemodynamically stable on/off neo. extubated without difficulty. mod ct o/p. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Old myocardial infarction Other complications due to other cardiac device, implant, and graft

discharge medications: 1. colace 100 mg p.o. twice a day. 2. enteric coated aspirin 325 mg p.o. q. day. 3. isosorbide mononitrate 30 mg p.o. q. day. 4. lasix 20 mg p.o. q. day times seven days. 5. 20 meq p.o. q. day times seven days. 6. lipitor 10 mg p.o. q. day. 7. multivitamin, one p.o. q. day. 8. lopressor 12.5 mg p.o. twice a day. 9. niferex 150 mg p.o. q. day. 10. lisinopril 5 mg p.o. q. day. 11. percocet 5/325, one to two p.o. q. four hours p.r.n. condition at discharge: good. disposition: the patient was discharged home. discharge instructions: 1. he is to follow-up with dr. in six weeks. 2. to follow-up with dr. who is the primary care physician, two weeks. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Old myocardial infarction Other complications due to other cardiac device, implant, and graft

history of present illness: the patient is a 44 year old male with known coronary artery disease status post inferior myocardial infarction and status post stenting of the right coronary artery in . the catheterization at that time also demonstrated multiple lesions of the left anterior descending and left circumflex. subsequently he was stable and underwent a second catheterization in because of more recurrent chest pain, which showed good result in the right coronary artery, no change in the left coronary artery lesion. since then he continued on a stable course until the past week when he developed progressive episodes of chest pain. the pain began to occur at rest and it was not relieved with nitroglycerin sublingual. he was promptly brought to . past medical history: 1. hypertension. 2. hypercholesterolemia. 3. decreased hdl. 4. coronary artery disease; myocardial infarction in 12/. past surgical history: 1. status post right coronary artery stenting in . 2. status post left ankle surgery. allergies: include vicodin and question of an intravenous antibiotics, unknown name. medications on admission: 1. aspirin 325 mg p.o. q. day. 2. toprol xl 100 mg p.o. q. day. 3. lisinopril 5 mg p.o. q. day. 4. lipitor 10 mg p.o. q. day. 5. multivitamin one p.o. q. day. 6. calcium supplement q. day. social history: the patient is married with three children, exercises on a regular basis. he is a past smoker who quit in . denies any etoh. physical examination: on admission, the patient has vital signs which are stable. heent is within normal limits. neck shows no lymphadenopathy, no bruits. chest is clear to auscultation. heart is regular rate and rhythm with no murmur. abdomen is soft, nontender. extremities with normal pulses; no edema. laboratory: on admission, white blood cell count of 6.0, hematocrit of 39, platelets of 216. sodium of 143, potassium of 4.5, bun of 14, creatinine of 1.2, glucose of 69, inr 1.0. ekg was significant for normal sinus rhythm with normal axis. no evidence of ischemia. hospital course: on the day of admission, the patient underwent cardiac catheterization. this revealed 90% stenosis of the right coronary artery, 70% stenosis of the proximal left anterior descending, mid-lad, and 70% stenosis of the diagonal 1, 70% stenosis of the proximal circumflex and 90% stenosis of the obtuse marginal 1. on hospital day two, the patient went to the operating room where he underwent coronary artery bypass graft times five. he had left internal mammary artery to the left anterior descending, saphenous vein graft to diagonal, saphenous vein graft ramus; saphenous vein graft to right coronary artery and left radial artery to the obtuse marginal. he tolerated this procedure well; was transferred to the intensive care unit, intubated and on a nitroglycerin drip. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnostic ultrasound of heart (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Old myocardial infarction Other complications due to other cardiac device, implant, and graft

history of present illness: a 62 male, status post abdominal aortic aneurysm repair with known thoracic aneurysm presents with sudden onset of back pain described as tearing, brought to the emergency department with vital signs of heart rate of 60, blood pressure of 164/80. cta showed a type b dissection from the distal aorta to the left subclavian to aorto--femoral graft with a true celiac lumen, half fma true lumen and half false lumen and left renal true lumen but with right renal false lumen. transferred to the intensive care unit on labetalol and nipride. review of systems: positive for nausea and emesis times one at home, one episode of loose stool at home, positive shortness of breath, no jaw or arm pain, no palpitations, no fevers or chills, no confusion and no weakness, numbness or tingling. past medical history: deep venous thrombosis, osteoarthritis. past surgical history: status post 8 cm abdominal aortic aneurysm repair, status post wound dehiscence. social history: history of tobacco use. one pack per day tobacco history. quit . lives in with his wife. two to three alcoholic beverages per week. medications on admission: lopressor 25 mg p.o. b.i.d., aspirin 81 mg p.o. q.d. no known drug allergies. physical examination: patient was afebrile with heart rate of 60, blood pressure 120/53, respiratory rate 18, 94 percent on 4 liters. in general he is alert, oriented times three lying flat on a stretcher in moderate distress. heent: npat, pupils equal, round, reactive to light, extraocular movements intact. oropharynx moist mucous membranes without erythema or exudate. neck supple, full range of motion, no lymphadenopathy, no bruits. cv: regular rate and rhythm, normal s1 and s2 without murmurs, rubs or gallops. chest clear to auscultation throughout. abdomen obese, positive bowel sounds, midline scar, nontender, no masses, no audible bruits. extremities: 1+ pretibial edema, no cyanosis, no clubbing. pulses: 2+ dorsalis pedis and posterior tibial, femoral, radial. neurologic: sensation intact 5 out of 5 strength, 2+ refluxes upper extremity and lower extremity bilaterally. laboratory values: on admission wbc 13.8, hematocrit 45, platelets 237 with a normal differential. chemistries: sodium 142, potassium 4.6, chloride 103, bicarb 28, bun 30, creatinine 1.0, glucose 111, coagulation profile normal. ck was 129, troponin was less than .01. cta showed an acute aortic dissection beginning distal to the left subclavian and extending down to the aorto--femoral graft. celiac showed a two lumen sma half true, half false with contrast to arcades. left renal true lumen, right renal false lumen with decreased enhancement with contrast. assessment: a 62 year-old male status post abdominal aortic aneurysm repair and aorto--femoral graft now with acute type b dissection with sma and right renal artery involvement. no evidence of compromise to viscera. patient was admitted for medical management. hospital course by problem: 1. aortic dissection: patient was started on a labetalol and nipride drip with a goal of systolic blood pressure of less than 120. he was continued on those drips with titration for the first four days of his hospitalization. at that time other antihypertensives were added including an ace inhibitor, hydralazine and spironolactone. at the time of dictation the patient has been weaned off his lebatolol and nipride drip. he has also been weaned off most of his antihypertensive medications and is currently on a regimen that includes an ace inhibitor, hydrochlorothiazide, beta blocker and clonidine. his clonidine is slowly being titrated off as the ace inhibitor is titrated up. eventually he will only a regimen of an ace inhibitor beta blocker and hydrochlorothiazide. his blood pressure currently is 120/80. 2. mrsa pneumonia. the patient developed acute hypoxia during this hospitalization and has sputum cultures positive for mrsa. he was treated with a ten day course of vancomycin and a 14 day course of levofloxacin. he was intubated for six days during the course of his hospitalization for acute mental status changes and in the setting of benzodiazepine use and hypoxia thought to be secondary to his pneumonia. at the time of dictation the patient has an oxygen requirement of three liters, is saturating in the high 90s and the goal of care is to wean oxygen as tolerated in the rehabilitation setting. 3. constipation: the patient was continued on a bowel regimen including colace, senna, dulcolax, enemas and lactulose. 4. acute mental status changes: probably secondary to benzodiazepine use. during the subsequent course of his hospitalization patient was taken off benzodiazepines and for the remainder he should avoid benzodiazepines as they clear cause mental status changes. 5. fluid, electrolytes and nutrition: the patient after intubation was maintained on a low sodium diet. he was diuresed after extubation. 6. prophylaxis: patient is on a proton pump inhibitor and received subcutaneous heparin while he was immobile. currently the patient is ambulating for deep venous thrombosis prophylaxis. condition at discharge: stable. condition status: to rehabilitation. discharge medications: tylenol 325 to 650 p.o. q 4 to 6 p.r.n., albuterol nebs 1 q three hours p.r.n., captopril 37.5 mg p.o. t.i.d., hydrochlorothiazide 25 mg p.o. q.d., atrovent mdi 2 puffs q 4 hours p.r.n., clonidine .1 mg p.o. q 6 hours times four doses, folic acid 1 mg p.o. q.d., guaifenesin 5 to 10 ml p.o. q 6 p.r.n., heparin 5,000 units subcutaneous q 12 hours while immobilized, lopressor 25 mg p.o. b.i.d., protonix 40 mg p.o. q.d., senna 2 tabs p.o. b.i.d., p.r.n. follow up: patient will follow up with his primary care physician and vascular surgeon, dr. after his rehabilitation stay. , r. m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Infection with microorganisms resistant to penicillins Constipation, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Methicillin susceptible pneumonia due to Staphylococcus aureus Dissection of aorta, thoracoabdominal

allergies: lorazepam / benzodiazepines attending: chief complaint: 63 yo male with h/o 8cm aaa resection with aortobifemoral graft in , who was diagnosed in with type b dissection from distal aorta to l subclavian to aortobifem graft. pt admitted elective thoracoabdominal aortic aneurysm repair with reimplant sma/celiac/l renal/r renal fem-fem bypass on . bronchoscopy on notable for mod thin secretions and several blood clots. pt was reintubated due to mucus plugs, requiring several bronchs while intubated. pt also developed acute renal failure, volume overload. pt was extubated on , is currently npo with ng tfs, and we were consulted to evaluate pt for swallow. pmh / psh: cad, dvt, oa both knees, mrsa pneumonia, s/p knee/ankle/elbow sx, gum sx, deviated septum, emphysema, (+) h/o smoking, depression major surgical or invasive procedure: procedure: repair of thoracoabdominal aneurysm, reimplantation intercostal arteries, and reimplantation of the superior mesenteric artery, celiac access, and the right and left renal arteries. preoperative diagnosis: thoracoabdominal aneurysm following type b dissection, medically managed. surgery was indicated due to increase in size of the aneurysm to about 8 cm. the patient was essentially asymptomatic. postoperative diagnosis: thoracoabdominal aneurysm following type b dissection, medically managed. surgery was indicated due to increase in size of the aneurysm to about 8 cm. the patient is essentially asymptomatic. preoperative diagnosis: thoracoabdominal aortic aneurysm. postoperative diagnoses: thoracoabdominal aortic aneurysm. procedure: 1. repair of thoracoabdominal aortic aneurysm. 2. reimplantation of the left renal artery, superior mesenteric artery and celiac artery. 3. reimplantation of the right renal artery. 4. left femoral artery, left femoral vein bypass. procedure indications: 1. respiratory failure. 2. assessment of airways patency. scope: number 6. preoperative diagnosis: respiratory failure. postoperative diagnosis: severe mucous plugging in the left main stem. procedure: 1. flexible bronchoscopy. 2. therapeutic aspiration of thick mucous plugging in the left main stem. ice: csu date: date of birth: sex: m surgeon: , first assistant: , md preoperative diagnosis: respiratory failure. postoperative diagnosis: patent airways. procedure: flexible bronchoscopy. date of birth: sex: m surgeon: , assistant: , md procedure: flexible bronchoscopy and therapeutic aspiration. service: csu date: date of birth: sex: m surgeon: , md 2367 preoperative diagnosis: loculated left pleural effusion with pulmonary collapse. postoperative respiratory insufficiency and tracheobronchitis. postoperative diagnosis: loculated left pleural effusion with pulmonary collapse. postoperative respiratory insufficiency and tracheobronchitis. procedure: 1. left thoracoscopy with partial lung decortication. 2. percutaneous tracheostomy tube placement. 3. flexible bronchoscopy with aspiration of tracheobronchial tree. history of present illness: 63 year old man with h/o 8cm aaa resection with aortobifemerol graft in , who was diagnosed in with type b dissection from distal aorta to l subcalvian to aortobifem graft. pt admited for elective thoracoabdominal aortic aneurysm repair with reimplant sma/celiac/l renal/r renal fem-fem bypass on . bronchoscopy on notable for mod thin secretions and several blood clots. pt was reintubated due to mucus plugs, requiring several bronchs while intubated. pt also developed acute renal failure, volume overload. pt was extubated on . chest ct on showed bilateral effusions with near total collapse of r lung and on pt was bronched and trached. we were consulted to assess his ability to tolerated wearing a passy-muir speaking valve. hpi / subjective complaint: 63 y/o male with 8cm aaa resection with aortobifemoral graft in , but then presented to in with back pain. found to have type b dissection from distal aorta to l subclavian to aortobifem graft. underwent thoracoabdominal aortic aneurysm repair with reimplant sma/celiac/l renal/r renal fem-fem bypass on . bronchoscopy on notable for mod thin secretions and several blood clots. past medical history: pmh / psh: dvt, oa both knees, mrsa pneumonia, ankle sx, knee sx, elbow sx, gum sx, deviated septum, emphysema past medical history: deep venous thrombosis, osteoarthritis. past surgical history: status post 8 cm abdominal aortic aneurysm repair, status post wound dehiscence. social history: social history: history of tobacco use. one pack per day tobacco history. quit . lives in with his wife. two to three alcoholic beverages per week family history: nc physical exam: on admit axo x3 nad well developed cta/bl s-nt/nd no rt/no guarding ext good distal pulses warm well perfused extremities pertinent results: admission labs 10:14pm wbc-4.5 rbc-3.62*# hgb-11.0*# hct-30.0*# mcv-83 mch-30.4 mchc-36.7* rdw-13.8 10:14pm wbc-4.5 rbc-3.62*# hgb-11.0*# hct-30.0*# mcv-83 mch-30.4 mchc-36.7* rdw-13.8 10:36pm type-art rates-8/ tidal vol-800 o2-100 po2-193* pco2-41 ph-7.34* total co2-23 base xs--3 aado2-489 req o2-81 intubated-intubated vent-controlled 10:28pm pt-17.9* ptt-42.0* inr(pt)-2.0 discharge labs 03:57am blood wbc-8.8 rbc-2.93* hgb-9.0* hct-27.0* mcv-92 mch-30.8 mchc-33.4 rdw-17.6* plt ct-319 03:50am blood wbc-9.7 rbc-3.07* hgb-9.2* hct-28.0* mcv-91 mch-30.1 mchc-33.0 rdw-17.5* plt ct-314 03:57am blood plt ct-319 03:57am blood glucose-112* urean-29* creat-0.9 na-139 k-4.4 cl-103 hco3-32* angap-8 03:50am blood glucose-104 urean-27* creat-1.0 na-140 k-3.8 cl-104 hco3-30* angap-10 12:04am blood alt-44* ast-33 alkphos-175* amylase-23 totbili-2.4* 03:57am blood mg-2.2 12:53am blood type-art po2-84* pco2-55* ph-7.42 calhco3-37* base xs-8 05:03am blood o2 sat-97 brief hospital course: the following procedures are earmarks of the events that have occured t mark the hospital course: procedure: repair of thoracoabdominal aneurysm, reimplantation intercostal arteries, and reimplantation of the superior mesenteric artery, celiac access, and the right and left renal arteries. preoperative diagnosis: thoracoabdominal aneurysm following type b dissection, medically managed. surgery was indicated due to increase in size of the aneurysm to about 8 cm. the patient was essentially asymptomatic. postoperative diagnosis: thoracoabdominal aneurysm following type b dissection, medically managed. surgery was indicated due to increase in size of the aneurysm to about 8 cm. the patient is essentially asymptomatic. preoperative diagnosis: thoracoabdominal aortic aneurysm. postoperative diagnoses: thoracoabdominal aortic aneurysm. procedure: 1. repair of thoracoabdominal aortic aneurysm. 2. reimplantation of the left renal artery, superior mesenteric artery and celiac artery. 3. reimplantation of the right renal artery. 4. left femoral artery, left femoral vein bypass. procedure indications: 1. respiratory failure. 2. assessment of airways patency. scope: number 6. preoperative diagnosis: respiratory failure. postoperative diagnosis: severe mucous plugging in the left main stem. procedure: 1. flexible bronchoscopy. 2. therapeutic aspiration of thick mucous plugging in the left main stem. ice: csu date: date of birth: sex: m surgeon: , first assistant: , md preoperative diagnosis: respiratory failure. postoperative diagnosis: patent airways. procedure: flexible bronchoscopy. date of birth: sex: m surgeon: , assistant: , md procedure: flexible bronchoscopy and therapeutic aspiration. service: csu date: date of birth: sex: m surgeon: , md 2367 preoperative diagnosis: loculated left pleural effusion with pulmonary collapse. postoperative respiratory insufficiency and tracheobronchitis. postoperative diagnosis: loculated left pleural effusion with pulmonary collapse. postoperative respiratory insufficiency and tracheobronchitis. procedure: 1. left thoracoscopy with partial lung decortication. 2. percutaneous tracheostomy tube placement. 3. flexible bronchoscopy with aspiration of tracheobronchial tree. major issues are below which have been resolved prior to d/c neuro: pt was intubated and sedated for some time and had a waxing and course with regards to confusion, he at times was floridly confused but after resolution of electrolye and pulmonary issues his nerologic issues resolved, was evaluated by neurologic team and cleared from their prospective cv: pt has had stable course from cardiovascular propspective, was supported initially with pressors and then was given agents for control pulm: pt was admitted postoperativly from his thoracoabdominal repair his renal funtion was marginal in the first several days postoperatively he with he had emphysema with difficulty weening from the vent and was extubated and re-intubated early in his post -op course, he was finally extubated and needed several subsequent bronchoscopy evalutations and finally his pulmonary issues led him to a tracheostomy from which he has been stable from a pulmonary function. renal: pt was followed by renal service for atn in post op period which resolve overtime to normal creatinine prior to d/c fen: all electorlyte abnormalities were corrected prior to d/c, free water was used to correct dehydration and increased na dispo to rehab because of chronic debilitation and trach mask medications on admission: fluoxetine hcl 10mg--one every day - increase to 2 every day as needed discharge medications: 1. acetaminophen 500 mg/5 ml liquid sig: five (5) ml po q4h (every 4 hours) as needed for fever or pain. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid (4 times a day) for 5 days. 4. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. amiodarone hcl 200 mg tablet sig: one (1) tablet po daily (daily). 8. trazodone hcl 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 9. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. 10. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). 11. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 12. ascorbic acid 100 mg/ml drops sig: five (5) ml po daily (daily). 13. heparin sodium lock flush 100 unit/ml solution sig: one (1) ml intravenous daily (daily) as needed: for picc catheter . discharge disposition: extended care facility: - - discharge diagnosis: thoraco-abdominal aneurysm discharge condition: good discharge instructions: may shower, no bathing for 1 month no creams, lotions, ointments to incisions p instructions: with dr. upon discharge from rehab with dr. in weeeks Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Other intubation of respiratory tract Decortication of lung Reopening of recent thoracotomy site Temporary tracheostomy Resection of vessel with replacement, thoracic vessels Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Resection of vessel with replacement, aorta, abdominal Other repair of vessel Injection or infusion of nesiritide Injection or infusion of oxazolidinone class of antibiotics Perioperative autologous transfusion of whole blood or blood components Diagnoses: Pneumonia, organism unspecified Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Atrial fibrillation Pulmonary collapse Hemorrhage complicating a procedure Other diseases of pharynx, not elsewhere classified Unspecified sleep apnea Dissection of aorta, thoracoabdominal Other and unspecified coagulation defects Empyema without mention of fistula Delirium due to conditions classified elsewhere

allergies: succinylcholine / aspirin attending: chief complaint: sepsis, respiratory failure major surgical or invasive procedure: intubation, extubation, central line/picc placement history of present illness: 80y m, nh resident s/p recent subdural hematoma evacuation who was in his usoh until 3.30am today when (per nh records) he suddenly became hypotensive and hypoxic. a stat abg at the time was 7.48/25/66/18.7, his sbp was in 70s and was treated with iv ns, x2 bld cx were drawn and the pt was started on empiric vanc for presumed uti. his labs were significant for: wbc 25.7 and na 133. the pt was transferred to to r/o sepsis and pe. . per ed notes, this morning pt was also noted to have increasing confusion, decreased urine output, fever and elevated white cell count. he was tachycardiac, and had fever to 103, lactate 5 and sbp to 80s. he was treated w/ ivf w/ inc in bp to 111/49, 1 dose vanc/levo/flagyl. . recent admission () to ed for mental status changes and hypotension in setting of uti (pan-sensitive p.aeruginosa) treated w/ 7d course po cipro. . on arrival to the , the pt was deep suctioned by the respiratory therapist and his secretions were significant for food particles and bloody secretions. past medical history: dm- not on meds on diet control paget's disease subdural hematoma s/p l craniotomy w/ hematoma evacuation ( and . has some residual right sided weakness, aphasic, cognitive impairment) recent admission for uti h/o mssa acute infarct noted on mri (left posterior frontal region indicative of an acute infarct). social history: lives alone in an apartment in , ma. divorced, has nephew and brother in local area, children in other states. former smoker no alcohol family history: non contributory physical exam: vs: t: 98.4, hr: 115, bp: 109/82, rr:30, o2 sats: 88% on 15l high-flow gen: elderly male, awake, sitting up in bed, in obvious respiratory distress, audible wheezing. heent: op clear but very dry, no lad, perrla cv: (difficult to auscultate diffuse, loud ronchi) rrr, s1+s2, no obvious m/r/g pulm: diffuse rhonchi and wheezing throughout both lung fields. abd: soft, nt, nd, +bs, no hsm extrem: no c/c/e. warm periphery. neuro: pt thinks he is in . once oriented to place, he can recall it after 10 minutes, recalls dob. not oriented to time or date. tone lue>rue. downgoing left plantar, equivocal right plantar. decreased bulk throughout. pertinent results: lactate 5->3 phenytoin: 9.0 chem7: (83% n with 1 band), occ bacteria, occ yeast cbc: wbc 52, hct 31.7->29.8 ua: wbc . radiology: cxr: rll opacity-> pna vs aspiration, extensive paget's disease of the right humerus, scapula and clavicle . ett placement: 6cm above carina. it's below the clavicles. . 5:30 pm urine site: catheter **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. yeast. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 64 i tetracycline---------- =>16 r vancomycin------------ =>32 r . 11:05 pm bronchoalveolar lavage specimen collected via lavage with sterile water. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 1+ (<1 per 1000x field): gram positive cocci. in pairs and singly. respiratory culture (final ): 10,000-100,000 organisms/ml. oropharyngeal flora. staph aureus coag +. >100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s . 12:00 pm bronchial washings gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth. legionella culture (preliminary): no legionella isolated. brief hospital course: 80 year old male with dm, recurrent uti, paget's, s/p recent subdural hematoma evacuation admitted to w/ respiratory failure found to have mrsa pna vre urosepsis, now improved, called out of to medicine. . # respiratory distress: patient was in acute respiratory distress on admission to the . he was noted to have thick bloody secretions on deep suctioning with visible food particles. he was intubated and a bronchoscopy was performed on which showed inflamed friable mucosa with moderately thick mucous in the lll bronchus. no foreign body was visualized and a bal was sent for culture. his acute respiratory distress was attributed to aspiration pna and urosepsis, however, his cxr on was concerning for possible ards. he was started on protective ards vent settings. he was extubated successfully on . his sputum culture eventually grew mrsa and patient was continued on linezolid for coverage of mrsa pna and vre uti. pt also developed pulmonary edema from fluids that were received, and received lasix for diuresis with good effects. pt's o2 was weaned as tolerated. at the time of dicharge, pt was satting at 95% on ra. . # vre urosepsis/aspiration, mrsa pneumonia: patient was admitted to the for sepsis given hypotension, hypoxia, tachycardia, fever and leukocytosis. the pt was noted to have a uti. a culture sent from the ed grew out enterococcus and patient was noted to have bibasilar consolidations r > l accompanied by small-to-moderate pleural effusions concerning for pna. patient was started on vancomycin, levofloxacin, and zosyn. blood cultures were sent from the ed remained ngtd. however, urine cx returned positive for vre, and patient was started on linezolid iv for coverage of his mrsa pna and vre uti. the bal also came back + for mrsa which is covered by linezolid. attempted to d/c foley and pt unable to void after trial and foley was replaced. will need another voiding trial after treatment of uti. . # hypotension: patient arrived from the ed on levophed. he was aggressively fluid resuscitated and he was weaned off the levophed on . it was noted that the patient was developing a non-gap hyperchloremic acidosis from the normal saline which had been used for volume resusciation so his ivf was changed to lactated ringers with good resolution. on he failed his stim test and was started on stress-dose steroids. his blood pressure stablized and his steroids were continued. iv steroid was switched to po and po steroids tapered to off on . . # mental status changes: patient is s/p subdural hematoma evacuation. it is unclear what his baseline mental status is although per report, he is able to follow commands, and there was a notable decline which in part tiggered this admission. likely etiology of new decline in mental status is infection. given his past history of cva, heparin sc was withheld. patient was continued on his seizure prophylaxis with phenytoin (currently 9.0; goal ) for his history of subdural hematoma. he should be continued on this for an additional 2 weeks. . # dm: patient was maintained on an iss. . fen: patient was npo while intubated. nutrition was consulted and tube feeding was initiated on . pt self discontinued his ngt and a swallow study was performed. the video swallow showed no aspiration but pt should have pills crushed for pocketing. in addition, he does not have teeth and therefore should cont on pureed solids. pt was taking poor po and had another family discussion about peg tube placement. family does not want a peg tube but this should be readdressed with family if pt continues to take poor po. daughter will address with her family. pt was started on megace on . * ppx: hepain sc, ppi, bowel regimen * access: picc * code status: full code (discussed with son, , who lives in ) * communication: son (w:, c:) medications on admission: phenytoin for sz ppx sc heparin 5000u tid pantoprazole 40mg qd thiamine 100mg qd mvi folic acid 1mg qd phenytoin 500mg qd (200mg and 100mg at noon) senna 1 tab prn docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). lopressor 25 mg iss recently completed course ciprofloxacin 500 mg tablet q12h on discharge medications: 1. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 2. phenytoin 100 mg/4 ml suspension sig: two hundred (200) mg po qam and qpm () for 2 weeks. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): until ambulatory then stop. 4. therapeutic multivitamin liquid sig: one (1) cap po daily (daily). 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. phenytoin 100 mg/4 ml suspension sig: one hundred (100) mg po at noon (). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day). 10. senna 8.8 mg/5 ml syrup sig: five (5) ml po bid (2 times a day) as needed for constipation. 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 12. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours). 13. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): please see sliding scale. . 14. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 6 days. 15. megestrol 40 mg/ml suspension sig: one (1) po daily (daily). 16. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) flush intravenous daily (daily) as needed: 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. order was filled by pharmacy with a dosage form of syringe and a strength of 100 u/ml. 17. piperacillin-tazobactam 2.25 g recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 3 days. 18. bisacodyl 5 mg tablet sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary diagnoses: aspiration/mrsa pneumonia sepsis vre urosepsis . secondary diagnoses: hypertension discharge condition: stable, afebrile discharge instructions: call your doctor or come to emergency department if you develop fevers, chills, nausea, vomiting, worsening cough, shortness of breath, or any other worrisome symptoms. please call your pcp to make an appointment in weeks after you leave the rehab facility. followup instructions: please follow-up with your pcp weeks. follow up with dr. with head ct on . provider: scan phone: date/time: 2:00 md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Anemia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Severe sepsis Infection with microorganisms resistant to penicillins Hypopotassemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other late effects of cerebrovascular disease Septic shock Infection with microorganisms without mention of resistance to multiple drugs Methicillin susceptible pneumonia due to Staphylococcus aureus Other malaise and fatigue Aftercare following surgery for injury and trauma Osteitis deformans without mention of bone tumor Late effects of cerebrovascular disease, aphasia Late effects of cerebrovascular disease, cognitive deficits

allergies: succinylcholine / aspirin attending: chief complaint: found down with subdural hematoma on ct major surgical or invasive procedure: left sided craniotomy for subdural hematoma evacuation x2 history of present illness: 80 y/o male transferred from outside hospital with subdural hematoma. mr is a 80 y/o gentleman who was found down by a friend this morning,? tripped over rug. however friend of patient reports change in mental status the last 24 hours driving was off while driving to foxwoods. his friend asked him to call him when he got home but he didn't so friend went and checked on him and found him down on the floor. he was found to have an inr of 1.6 at outside hospital. mr relates a fall approximately 1 month ago when he hit his head on the corner of the stove and had a loc. past medical history: diabetes not being treated, paget disease social history: lives alone in an apartment in , ma. divorced, has nephew and brother in local area, children in other states. former smoker no alcohol family history: non contributory physical exam: t:98.0 bp:143/75 hr:80 r18 o2sats 100% gen: wd/wn, comfortable, nad. heent: pupils: eoms full neck: in collar lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: bruise on right leg, poor toe nails, warm and well-perfused. no c/c/e. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: to name and hospital, date recall: 0/3 objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming impaired. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, to mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to finger rub bilaterally. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. right sided drift ue (bicep/tricep) hands are arthritic lower extremities ip at 3+/5 g bilaterally sensation: intact to light touch reflexes: b t br pa ac right 2+ 2+ left 2+ 2+ pertinent results: 08:20am pt-14.3* ptt-30.5 inr(pt)-1.3* 08:20am plt smr-normal plt count-169 08:20am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 08:20am neuts-48* bands-1 lymphs-12* monos-38* eos-0 basos-1 atyps-0 metas-0 myelos-0 nuc rbcs-1* 08:20am wbc-5.1 rbc-4.10* hgb-12.8* hct-36.2* mcv-88 mch-31.2 mchc-35.4* rdw-16.3* 08:20am ck-mb-13* mb indx-3.7 ctropnt-0.06* 08:20am ck(cpk)-348* 08:20am glucose-102 urea n-14 creat-0.5 sodium-142 potassium-3.4 chloride-107 total co2-25 anion gap-13 brief hospital course: mr was admitted to the trauma icu on the trauma service. after discussion with the patient and his nephew it was felt having a craniotomy to evacuate his large left sided subdural would be in his best interest. on he went to the or and had left sided craniotomy, he was extubated post operatively and had a subdural drain in place. he was moving all extremities with good strength however less strenght on the right sided he continued to be disorientated at time. on pod#1 he has a ct which showed evacuation of the chronic portion with some reaccumulation of the acute blood but overall improved. he received 1 unit of blood for crit 27. he was transferred to the step down unit, he had some agitation after transfer however, a second ct was stable, repeat crit was 31. on pod#3 he was noted have some increase lethargy, a repeat ct showed an interval increase of acute subdural blood he was brought to the or for a repeat subdural evacuation of craniotomy. he spent overnight in the pacu, his exam he was having difficulty speaking (which was similar post his first surgery) slightly weaker on the right side though moving all extremities. he had an mri slow diffusion in the left posterior frontal region indicative of an acute infarct. he continued to follow one step commands, slightly weaker on the right. on his drain was removed and a repeat head ct showed continued evidence for a mixture of acute and chronic blood products, as well as gas within the left frontal-temporal subdural hemorrhage. additionally, there is slight widening and a somewhat biconvex contour to what may be an epidural collection of gas subjacent to the craniotomy flap. neurologically he was awake alert, following commands but continued with some aphasia though had no difficulty swallowing or eating. his right side appeared weaker than the left. on he appeared brighter following commands trying to speak a few words. he continues to move the right arm less than the left. he does have motor strength in that arm. his appetite is excellent. medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. multivitamin capsule sig: one (1) cap po daily (daily). 9. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 11. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 12. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po bid (2 times a day). 13. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po daily (daily). discharge disposition: extended care facility: & rehab center - discharge diagnosis: subdural hematoma discharge condition: neurologically stable discharge instructions: keep incision clean and dry. have staples removed on watch incision for redness, drainage, swelling, bleeding or fever greater than 101.5 call dr office also call for any mental status changes such as lethargy followup instructions: have staples out on at dr office or at nursing facility have sutures on left side of head removed follow up with dr in 4 weeks with head ct at that time md Procedure: Transfusion of packed cells Transfusion of other serum Other craniotomy Other craniotomy Transfusion of platelets Diagnoses: Abnormal coagulation profile Anemia, unspecified Unspecified transient mental disorder in conditions classified elsewhere Hemorrhage complicating a procedure Dehydration Subdural hemorrhage Osteitis deformans without mention of bone tumor Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Aphasia Fall from other slipping, tripping, or stumbling Tachycardia, unspecified Precipitous drop in hematocrit

allergies to amoxicillin. cardiac--bp 118-140's /50's. hr sr without ectopy at 60-70's. denies pain. no ekg changes seen on current ekg. resp--o2 sat on 4 l is 99%. lungs clear bilaterally. gi---remains npo. states he need to hav a bm soon. ngt is clamped but drainage is clear. egd is planned for today gu--no foley, no void at this time. endo--unremarkable at this time. skin--intact. coping--wife is here with pt. they both seem very knowledgeable. a---no bleeding obvious at this time. Procedure: Endoscopic control of gastric or duodenal bleeding Diagnoses: Unspecified essential hypertension Aortocoronary bypass status Old myocardial infarction Chronic obstructive asthma, unspecified Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction

history of present illness: please see previously-dictated summary. briefly, is a former 864 gram product hospitalized in the neonatal intensive care unit at since birth. he underwent a rigid bronchoscopy at on . he returned postoperatively to the neonatal intensive care unit at . hospital course by system: ventilatory settings of peak inspiratory pressure of 23 over positive end expiratory pressure of 5, intermittent mandatory ventilatory rate of 30, 36% oxygen. he was extubated within several hours of his return to nasal cannula oxygen. he has had several episodes of laryngospasm with respiratory arrest and accompanying profound bradycardia. the bronchoscopy performed on showed findings of normal vocal cords with normal motion, a moderately inflamed larynx with frequent laryngospasm, a normal subglottis, normal trachea, mild left bronchomalacia, and a normal right bronchus. there were three severe episodes of laryngospasm during the procedure. it was felt that this the most likely cause of his episodes. in view of those findings, optimization of his anti-ge reflux regimen, and the repeated episodes in the week postoperatively, the decision has been made to move forward with a tracheostomy. the procedure is scheduled for at 10:30 a.m. since the initial bronchoscopy, has remained in nasal cannula oxygen 500 cc flow, 35-40% fraction of inspired oxygen. he remains on diuril for treatment of his chronic lung disease. he has also been treated with atrovent and albuterol nebulizers in an attempt to treat his laryngospasms. 2. cardiovascular: as previously noted, has a large atrioseptal defect. most recent echocardiogram was on . a murmur remains present at the time of transfer. 3. fluids, electrolytes and nutrition: continues to have problems with hypoglycemia. at the time of transfer, he is nothing by mouth on intravenous fluids. when feeding, he is on 150 cc/kg/day of preemie enfamil 34 calories/ounce with additional promod protein supplement. he receives a four hour volume infused over three hours, i.e., three hours on, one hour off. weight at the time of transfer is 2.77 kg. most recent electrolytes were on , with a serum sodium of 139, potassium 5.6, chloride 99, total carbon dioxide 33, bun 15, creatinine 0.2. 4. infectious disease: there have been no new infectious disease issues over the last week of hospitalization. 5. gastrointestinal: as previously noted, receives treatment for conjugated hyperbilirubinemia with actigall. his most recent serum bilirubin was a total of 7.7, a direct of 5.5. a right inguinal hernia has been noted, and is soft and reducible. 6. hematology: postoperative hematocrit was 35.4% on . a preoperative cbc has been drawn, with results pending at the time of this dictation. 7. sensory: audiology screening has still not yet been performed. condition at discharge: fair. discharge disposition: transferred to for elective tracheostomy and gastrostomy tube placement with an ultimate plan for discharge or transfer to rehabilitative care. no primary pediatrician has yet been identified. care recommendations: 1. feedings: nothing by mouth in preparation for the operating room. intravenous fluids of 10% dextrose with 2 meq of sodium chloride and 1 meq of potassium chloride per 100 cc at 120 cc/kg/day. the patient has been nothing by mouth since 7 a.m. 2. medications: ranitidine 5 mg by mouth every eight hours, carnitine 100 mg by mouth twice a day, potassium phosphate 2.3 millimoles by mouth twice a day, vitamin d 300 iu by mouth once daily, calcium glubionate 46 mg as elemental calcium by mouth twice a day, reglan 0.2 mg by mouth every eight hours one-half hour prior to feeds, fer-in- 25 mg/ml dilution 0.25 cc by mouth once daily, diuril 50 mg by mouth twice a day, potassium chloride supplement 1 meq by mouth twice a day, actigall 30 mg by mouth twice a day, vitamin e 5 iu by mouth once daily. 3. immunizations: his second hepatitis b vaccine is due , previously administered on . all other immunizations are up to date. he has not received synagis. discharge diagnosis: 1. prematurity at 34 weeks gestation 2. severe intrauterine growth restriction 3. respiratory distress syndrome 4. chronic lung disease 5. atrioseptal defect 6. global cardiac dysfunction 7. suspicion for sepsis ruled out 8. c ellulitis of the left wrist 9. congenital carnitine deficiency 10. conjugated hyperbilirubinemia 11. right humeral fracture 12. of the right eye 13. hypoglycemia 14. laryngospasms 15. right inguinal hernia , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other incision with drainage of skin and subcutaneous tissue Other incision with drainage of skin and subcutaneous tissue Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal bradycardia Neonatal hypoglycemia 33-34 completed weeks of gestation Cellulitis and abscess of upper arm and forearm Common truncus Closed fracture of unspecified part of humerus

rest of social and family history non-contributory. labor and delivery: neonatology called by dr. to attend emergent c-section for fetal bradycardia and concerns outlined above. infant emerged with spontaneous crying, good tone, and good color. infant suctioned, dried and stimulated. responded well. apgars 8,8. infant transported to nicu for further management of prematurity. early postpartum/nicu course: in nicu, infant began to demonstrate respiratory distress and was intubated. ua line placed for access. blood work drawn. abx and ivf begun, including dextrose bolus for hypoglycemia. exam: growth parameters: wt 864 gms = <<10%; hc 27 cm = <<10%; l 34 cm = <<10% vital signs per careview. of note, need for bbo2 to maintain saturations. initial d/s 9. full exam recorded on newborn examination form in bedside chart. notable for respiratory distress and severe iugr. labs/studies: initial d/s 9 cbc, blood cx, glucose - pending cxr reviewed - ribs expanded. hazy lung fields. rotated film with heart shadow into left lung fields. cardiomegaly. babygram post uac placement pending. impression: 1. preterm male newborn. 2. severe, symetric growth restriction. no clear etiology at this point. will need to assess for genetic and infectious causes. will need to monitor metabolic homeostasis (ca, glc). 3. respiratory distress. course, cxr c/w mild rds. also need to assess for pulmonary insufficiency, pulmonary hypolasia. however, current expansion on cxr reassuring. 4. r/o sepsis given prematurity, unknown gbs status and prolonged leaking of fluid by maternal report. 5. hypoglycemia 6. cardiomegaly probably represents small thoracic cage and iugr rather than cardiac disease. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other incision with drainage of skin and subcutaneous tissue Other incision with drainage of skin and subcutaneous tissue Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal bradycardia Neonatal hypoglycemia 33-34 completed weeks of gestation Cellulitis and abscess of upper arm and forearm Common truncus Closed fracture of unspecified part of humerus

service: neonatology history of present illness: is the former 864 gram product of a 34 week gestation pregnancy born to a 25 year-old g2 p0 woman. prenatal screens: blood type 0 positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status abortion at seven months. this pregnancy was notable for an abnormal alpha fetoprotein and triple screen, which was followed with serial ultrasounds. they showed normal biophysical profiles and structurally normal fetus. there was a lag in prenatal care. the mother presented to her office on the day of delivery showing poor fetal growth and reported leaking of amniotic fluid for two months. on oligohydramnios were noted. no kidneys or lungs were visualized. she was transferred from to the . she underwent a cesarean section for concern for fetal heart rate decelerations. apgars were 8 at one minute and 8 at five minutes. the baby required blow by o2, drying and bulb suctioning. he was admitted to the neonatal intensive care unit for management of his prematurity. hospital course/pertinent laboratory data: respiratory: was intubated shortly after admission and given one dose of surfactant. he was extubated to nasal cannula o2 on day of life number one. he remained on nasal cannula o2 until day of life number twenty five when due to increased work of breathing he was placed on nasopharyngeal cpap. he remained on the nasopharyngeal continuous positive airway pressure through day of life number forty nine. since that time he has remained on high flow nasal cannula o2 400 to 500 cc of flow, 45 to 65% fraction of inspired oxygen. his evolving chronic lung disease is treated with diuril. a trial of bronchodilators showed no added benefit. on three occasions within a week he has had respiratory arrest events marked by profound bradycardia. the etiology of these is unclear, and a bronchoscopic examination is planned at for . cardiovascular: heart size on chest x-ray was noted to be large. an echocardiogram was performed on day of life number two and showed moderate to severe biventricular dysfunction. a small pericardial effusion was noted. the heart was otherwise structurally normal with a small atrial septal defect. the echocardiograms were repeated several times, which showed gradual improvement in the cardiomyopathy. most recent echocardiogram was on showing a moderate atrial septal defect, mild right ventricular overload and left peripheral pulmonic stenosis. he required treatment with dopamine through day of life number nine. at the time of discharge his heart rates are in the 140 to 160 range with mean pressures 50 to 60s. fluids, electrolytes and nutrition: was initially npo and maintained on intravenous fluids. he required monitoring with an umbilical arterial catheter for the first two weeks of life. enteral feeds were started on day of life number ten and gradually advanced to full volume. feedings have always been well tolerated. at the time of discharge he is on mother's breast milk fortified to 34 calories per ounce, 4 with human milk fortifier, 6 by calories by medium chain triglyceride oil and 4 calories by polycose. on a 32 calorie per ounce regimen, he had only gained 9 gms/kg/d. the etiology of the poor growth is also unknown. weight on the day of discharge is 2.56 kilograms. serum electrolytes have been closely monitored due to the diuretic treatment. most recent electrolytes were on with a serum sodium of 137, serum potassium of 3.9, chloride 97, pco2 of 29. he is on sodium, potassium, chloride and potassium phosphate supplements. infectious disease: had a sepsis evaluation at the time of birth. a white blood cell count was 4200 with 34% polys, 9% bands, 49% lymphocytes. blood culture was obtained prior to starting antibiotics. the culture was no growth. he received a seven day course of ampicillin and gentamycin. on an abscess was noted over the left wrist. the abscess was unroofed and citrobacter koseri was cultured. due to prior concern for sepsis was being treated with vancomycin and gentamycin. his coverage was changed to include ceftazidime to provide better coverage. a second incision and drainage was performed on and again the same citrobacter koseri was cultured. he received a total of fourteen days of the vancomycin, gentamycin and ceftazidime with resolution of the abscess. also of concern with infectious disease with his hepatic workup he was found to be hepatitis a antibody positive. further testing showed him to have the hepatitis a immunoglobulin negative. gastrointestinal: has presented with some unidentified liver dysfunction. an extensive metabolic and gastrointestinal workup has been undertaken and multiple metabolic tests sent. a hida scan showed a normal gallbladder and ruled out biliary atresia, alpha one antitrypsin level had mm typing. the only metabolic test found to be abnormal was the carnitine panel with his level slightly low, carnitine replacement therapy was started and his most recent carnitine levels were on . free carnitine is 90 with a range of 27 to 49. total is 104 with a rate of 38 to 68. the axo carnitine is 14 with a range 7 to 19 and the aso to free carnitine ratio was 0.2 with a normal of 0.2 to 0.5. the free and total carnitine levels being slightly higher then normal range represent the change on the increased carnitine supplementation. has also had an elevated direct bilirubin, which peaked at 8.3 on day of life 45. he has been treated with both phenobarbital and actigall. the phenobarbital was discontinued . most recent direct bilirubin was 6.4 mg per deciliter on . pt and ptt were normal on . hematologic: is blood type o positive antibody negative. his hematocrit at birth was 36.8%. he has received multiple transfusions of packed red blood cells. most recent transfusion was on . most recent hematocrit was 31.4% on with a reticulocyte count of 3.6%. he is receiving supplemental iron. endocrine: has had persistent problems with hypoglycemia despite multiple attempts to wean him from continuous feeds. he responds with intermittent blood glucoses less then 40. serum insulin growth hormone and cortisol levels have been drawn on numerous occasions with the episodes of hypoglycemia and all levels have been within the normal range. endocrine consult from is involved in following. the etiology of his glucose requirement is unclear. it does not appear to be a result of hyperinsulism and may explain his poor growth. endocrine does not have suggestions at present for further evaluation. we have consulted the metabolism team. neurology: head ultrasound has been performed on two occasions during his admission. both were within normal limits. musculoskeletal: a fracture of the right humerus was noted incidentally on a chest x-ray. this was likely a result of severe metabolic bone disease. sensory: audiology screening has not yet been performed. ophthalmology, defect later described as a coloboma was noted shortly after birth. serial retinal examinations have been performed and showed mature retinas on . condition on discharge: fair. discharge disposition: transfer to . the primary pediatrician has not yet been identified. care and recommendations at the time of discharge: npo in preparation for the operating room. when feeding expressed breast milk 45 to 34 calories per ounce, 4 calories by human milk fortifier, 6 calories by medium chain triglyceride oil, 4 calories by polycose. one half teaspoon promod powder per 100 cc of the breast milk. medications: ranitidine 4.8 mg po q 8 hours, carnitine 100 mg po b.i.d., potassium phosphate 2.3 millimoles po b.i.d., vitamin d 300 international units po q day, calcium glubionate 46 mg as elemental calcium po b.i.d., reglan 0.2 mg po q 8 hours administered one half hour prior to feeds. fer-in- 25 mg per ml dilution 0.25 cc po q.d., diuril 43 mg po pg b.i.d., sodium chloride supplement 1 milliequivalent po b.i.d., potassium chloride supplement 1 milliequivalent po b.i.d., actigall 30 mg po b.i.d., vitamin e 5 international units po q day. car seat positioning screening not yet performed. state newborn screening have been sent on multiple occasions with only the carnitine abnormality detected. immunizations were administered between and and included hepatitis b vaccine, diptheria, cellular pertussis, hemophilus influenza, the injectable polio vaccine and the pneumococcal seven valent conjugate vaccine. immunizations recommended, synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria - born at less then 32 weeks gestation, born between 32 and 35 weeks with plans for day care during rsv season, with a smoker in the household or with preschool siblings or with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other care givers should be considered for immunization against influenza to protect the infant. follow up: follow up with consult services at to include endocrine, cardiology, genetics, metabolism, gastrointestinal and otorhinolaryngology. discharge diagnoses: 1. prematurity at 34 weeks gestation. 2. severe intrauterine growth restriction. 3. respiratory distress syndrome. 4. chronic lung disease. 5. atrial septal defect. 6. global cardiac dysfunction. 7. suspicion for sepsis ruled out. 8. citrobacter koseri cellulitis of the left wrist. 9. congenital carnitine deficiency. 10. conjugated hyperbilirubinemia. 11. right humeral fracture. 12. coloboma of the right eye. 13. hypoglycemia. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other incision with drainage of skin and subcutaneous tissue Other incision with drainage of skin and subcutaneous tissue Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal bradycardia Neonatal hypoglycemia 33-34 completed weeks of gestation Cellulitis and abscess of upper arm and forearm Common truncus Closed fracture of unspecified part of humerus

allergies: doxycycline / morphine attending: chief complaint: transfer from osh with stemi major surgical or invasive procedure: cardiac catheterization with percutaneous balloon angioplasty and stening. history of present illness: 49 yo female with past medical history significant for fibromyalgia was transferred from an osh with three weeks of intermittent chest pain and ste in ii, iii, and avf. the patient describes the chest pain as burning, diffuse left-sided chest pain, radiating to jaw and left shoulder, lasting anywhere from 5-20 minutes, and with no relationship to activity or food. patient reports pain improves somewhat with leaning forward. associated symptoms include shortness of breath. one day prior to admission, patient had a severe episode of this chest pain while driving and was brought into from home. ecg at osh demonstrated 1mm ste in ii, iii, and avf with twi in v1-v2, i, and avl. patient received plavix 600mg, aspirin 325mg, integrilin bolus and drip, and heparin bolus and drip. patient also received 1x nitroglycerine at osh with sbp decrease to the 70s, per report. . in the cath lab, patient with 95% thrombotic lesion in the mid rca and had a 3 x 18 vision stent placed with subsequent timi 3 flow. past medical history: hypercholesterolemia fibromyalgia social history: tobacco - 1 ppd; 40 ppy history etoh - social drinker at the holidays illicit drugs - denies not currently employed, takes care of grandchildren family history: no cardiac disease diabetes mellitus physical exam: t 96.8 / hr 74 / bp 115/60 / rr 16 / po2 100% on 2l nc gen: lying comfortably in bed, no acute distress heent: clear op, mmm neck: supple, no lad, no jvd cv: rr, nl rate. nl s1, s2. no murmurs, rubs or gallops lungs: (limited anterior exam) cta, bs bl, no w/r/c abd: soft, nt, nd. nl bs. no hsm ext: no edema. palpable 2+ dp/pt pulses bilaterally; 2+ femoral pulses bilaterally with mild oozing at right femoral site but no hematoma; right femoral bruit skin: no lesions neuro: a&ox3. appropriate. cn 2-12 grossly intact. moving all extremities equally psych: listens and responds to questions appropriately, pleasant pertinent results: 08:30am pt-13.5* ptt-150* inr(pt)-1.2* 08:30am plt count-257 08:30am neuts-80.6* lymphs-14.4* monos-3.9 eos-0.8 basos-0.3 08:30am wbc-13.9* rbc-4.18* hgb-14.6 hct-41.5 mcv-99* mch-34.9* mchc-35.1* rdw-12.9 08:30am calcium-7.8* phosphate-1.9* magnesium-1.9 08:30am ck-mb-13* mb indx-10.3* ctropnt-0.11* 08:30am ck(cpk)-126 08:30am glucose-119* urea n-13 creat-0.8 sodium-139 potassium-4.0 chloride-109* total co2-24 anion gap-10 11:34am plt count-240 11:34am wbc-11.1* rbc-3.94* hgb-13.0 hct-39.5 mcv-100* mch-33.0* mchc-32.9 rdw-12.6 11:34am ck-mb-28* mb indx-10.1* ctropnt-0.49* 11:34am ck(cpk)-276* 11:34am glucose-107* urea n-11 creat-0.6 sodium-140 potassium-4.3 chloride-112* total co2-20* anion gap-12 06:30pm ck(cpk)-412* 06:30pm ck-mb-46* mb indx-11.2* ctropnt-1.32* 08:23pm ck(cpk)-327* 08:23pm ck-mb-39* mb indx-11.9* ctropnt-1.18* 06:30pm glucose-88 urea n-9 creat-0.7 sodium-139 potassium-5.3* chloride-109* total co2-22 anion gap-13 08:23pm glucose-140* urea n-10 creat-0.6 sodium-138 potassium-4.2 chloride-109* total co2-23 anion gap-10 11:34pm ck(cpk)-270* 11:34pm ck-mb-31* mb indx-11.5* ctropnt-0.96* - cardiac cath comments: 1. selective coronary angiography of this right dominant dominant system revealed single vessel disease. the lmca, lad, and lcx all had mild diffuse disease but no angiographically significant stenoses. the rca had a 95% thrombotic lesion in the mid-vessel. 2. limited resting hemodynamics revealed elevated right and left sided filling pressures with a mean ra 14mmhg and pcwp 18mmhg. the cardiac index was preserved at 2.86 l/min/m2. 3. left ventriculography was deferred. 4. successful pci of the mid rca using a 3.0x18mm vision bare metal stent deployed at 14atm. final diagnosis: 1. single vessel coronary artery disease. 2. successful pci of the mid rca using a bare metal stent. tte - cardiology report echo study date of patient/test information: indication: left ventricular function. right ventricular function. s/p stent mid rca. height: (in) 67 weight (lb): 129 bsa (m2): 1.68 m2 bp (mm hg): 115/63 hr (bpm): 67 status: inpatient date/time: at 08:30 test: portable tte (complete) doppler: full doppler and color doppler contrast: none tape number: 2006w056-0:00 test location: west ccu technical quality: adequate referring doctor: dr. measurements: left atrium - long axis dimension: 3.6 cm (nl <= 4.0 cm) left atrium - four chamber length: 4.1 cm (nl <= 5.2 cm) right atrium - four chamber length: 3.8 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 0.8 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 0.8 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.9 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 2.9 cm left ventricle - fractional shortening: 0.41 (nl >= 0.29) left ventricle - ejection fraction: 45% (nl >=55%) aorta - valve level: 2.7 cm (nl <= 3.6 cm) aorta - ascending: 2.9 cm (nl <= 3.4 cm) aorta - arch: 2.4 cm (nl <= 3.0 cm) aortic valve - peak velocity: 1.4 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 0.8 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 141 msec pulmonic valve - peak velocity: 0.8 m/sec (nl <= 1.0 m/s) interpretation: findings: left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness. normal lv cavity size. mildly depressed lvef. lv wall motion: regional lv wall motion abnormalities include: basal inferoseptal - akinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior - akinetic; inferior apex - hypo; right ventricle: normal rv wall thickness. normal rv chamber size. normal rv systolic function. aorta: normal aortic root diameter. normal ascending aorta diameter. normal aortic arch diameter. aortic valve: normal aortic valve leaflets (3). no ar. mitral valve: mildly thickened mitral valve leaflets. moderate (2+) mr. pericardium: no pericardial effusion. conclusions: 1. the left atrium is normal in size. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed. resting regional wall motion abnormalities include basal and mid inferior and inferoseptal akinesis with apical inferior hypokinesis. 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. 5.the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. 6.there is no pericardial effusion. brief hospital course: 49 yo male with past medical history significant for hyperlipidemia transferred from osh with inferior stemi, found to have mid-rca lesion, and now s/p bms and chest pain free. . 1. coronary artery disease at cardiac catheterization, patient found to have a 95% thrombotic lesion of mid-rca with bms placed. patient was chest pain free for the duration of her hospitalization after cardiac cath. her course was complicated by formation of large ecchymoses at the site of cardiac cath. she was noted to have a right femoral bruit both before her catheterization and remained stable after her catheterizations. she was started on aspirin 325mg, plavix 75mg, atorvastatin 80mg, and was converted to toprol xl 25mg po daily. given that patient's ef was not diminished, patient was not started on ace inhibitor. patient was evaluated by physical therapy during this admission who cleared patient to be discharged home. patient was discharged home with cardiology follow-up with dr. . . 2. hyperlipidemia patient reports a history of hyperlipidemia and was started on high dose atorvastatin during this admisison. medications on admission: transfer meds: aspirin 325mg po daily integrilin drip heparin drip plavix 75mg po daily . home meds: occasional advil or ibuprofen discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: st elevation myocardial infarction . secondary: hypercholesterolemia tobacco abuse discharge condition: good. chest pain free. ambulating unassisted. tolerating oral medications and nutrition. discharge instructions: you were evaluated and treated for chest pain. you were found to have a heart attack which was caused by a blockage in one of your coronary arteries. followup instructions: 1) primary care physician: spoke to dr. office and have given him information regarding your hospital stay. you should expect a call from his office by thursday to schedule an appointment. if you do not hear from his office, please give his office at family practice a phone call to follow-up. the phone number at family practice is . . 2) cardiology: you also have an appointment scheduled with your new cardiologist, , m.d., for 1:00. his phone number is . . 3) echocardiogram: we also recommend that you have an echocardiogram (an ultrasound of your heart) within the next weeks to assess your heart function. your appointment is thursday at 11am. if you need to reschedule . your appointment will be in the of the clinical center on the . Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Acute myocardial infarction of other inferior wall, initial episode of care Myalgia and myositis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bleeding ampullary mass major surgical or invasive procedure: endoscopic retrograde cholangiopancreatography (ercp) transduodenal ampullary resection with ccy ip did thorocentesis of pleural fluid on the right. us guided aspiration of fluid collection around liver ct guided drainage of subcapsular liver fluid endoscopic retrograde cholangiopancreatography (ercp) history of present illness: this is a 72 year old male that presents from hospital after having one week of symptoms of dizziness and syncope secondary to an upper gi bleed. he noted bright red blood per rectum on the day prior to presentation. he was also having headaches. he was rescucitated at the hospital with 5 units of prbcs for a hct of 23, which improved to hct 35. an endoscopy showed a bleeding ampullary lesion. he was transferred to for ercp and work-up of mass. he denies weight loss prior to symptoms. he did have decreased appetite, chronic constipation, but denies prior episodes of blood per rectum. past medical history: carotid disease - attempted stent placement . started on asa and plavix. tia's parkinsons htn seizure disorder hyperlipidemia chronic constipation social history: lives alone retired family history: noncontributory physical exam: vs: 98.1, 48, 103/68, 20, 98% ra, weight 152lbs gen: nad, a+o x 3 head: no scleral icterus, no jaundice, no lad, no thyroidmegaly cv: rrr chest: ctab abd: soft, nontender, nodistended, no masses, no hernia, no organomegaly ext: pt, dp, radial pulses +2 bilat., no edema pertinent results: carotid series complete 8:59 am carotid series complete reason: tia medical condition: 72 year old man with tia reason for this examination: eval for carotid stenosis carotid study history: tia. findings: no prior studies for comparison. there is complete occlusion of the left ica and associated internalization of the external carotid artery on the left. there is also absent flow involving the left vertebral artery. there is a significant focal hypoechoic plaque involving the right ica. similar plaque involving the right eca. the peak systolic velocities on the right are 264, 56, and 15 cm per second for the ica, cca, and eca respectively. the ica to cca ratio is 5.3. there is antegrade flow involving the right vertebral artery. impression: 1. occluded left-sided ica and left-sided vertebral artery. 2. 70-79% right ica stenosis. 3. near occlusion of the right external carotid artery. specimen submitted: gi bx 1 ampulla. procedure date tissue received report date diagnosed by dr. . /vf diagnosis: ampulla, mucosal biopsy: fragments of adenoma. ct abdomen w/contrast 4:32 pm cta abd w&w/o c & recons; ct abdomen w/contrast reason: eval pancreas for ductal dilation, vessels, a mass, per panc field of view: 36 contrast: optiray medical condition: 72 year old man with ampullary mass reason for this examination: eval pancreas for ductal dilation, vessels, a mass, per pancreas protocol contraindications for iv contrast: none. ct angiogram technique: multidetector ct through the abdomen and pelvis with angiogram protocol. nonenhanced, arterial, and venous phase were obtained. coronal, sagittal, volume rendering, and mip reconstructions are provided. there are no prior studies available for comparison. history: 72-year-old man with ampullary mass. abdomen ct: dependent changes are seen in the bases of the lungs. there are no enhancing focal lesions in the liver. there is no biliary duct dilatation. in segment ivb, there is a 6-mm hypoenhancing area, too small to be characterized. there is a 10-mm stone within the gallbladder lumen. the gallbladder wall is not thickened. the pancreas, adrenal glands, and spleen are unremarkable. few splenules are seen near the spleen measuring up to 11 mm. both kidneys have few hypoenhancing cortical and exophytic lesions, too small to be characterized, likely cysts. in the ampullary region, there is an enhancing well-defined round lesion measuring 10 x 10 mm. otherwise, the small bowel loops are unremarkable. there is no free air or free fluid in the abdomen. few non-pathologically enlarge lymph nodes are seen within the mesentery. pelvic ct: the bladder, distal ureters, prostate gland, rectum, and sigmoid colon are unremarkable. there is no free fluid or lymphadenopathy within the pelvis. bone windows: there are no concerning bone lesions. ct angiogram: the aorta is normal in caliber. the celiac, sma, bilateral duplicated renal arteries, and are patent. there is conventional vascular distribution. there is a short segment of moderate stenosis in the origin of the inferior left renal artery and in the proximal portion of the superior right renal artery. the hepatic, portal, superior mesenteric, and splenic veins are patent. ct reconstructions were essential in delineating the anatomy and pathology. impression: ampullary mass. there is no biliary duct dilatation or dilatation of the main pancreatic duct. bilateral renal cysts. cholelithiasis. sinus bradycardia. no diagnostic abnormality. no previous tracing available for comparison. read by: , intervals axes rate pr qrs qt/qtc p qrs t 51 162 90 29 52 mr contrast gadolin 1:58 pm mr head w & w/o contrast; mra neck w&w/o contrast reason: please eval for prior evidence of stroke. eval cerebral contrast: magnevist medical condition: 72 year old man with occlusion and stenosis. reason for this examination: please eval for prior evidence of stroke. eval cerebral vessels exam: mri of the brain and mra of the head and neck. clinical information: patient with left internal carotid artery occlusion and right ica stenosis, for further evaluation to exclude stroke and also to evaluate the cerebral blood vessels. technique: t1 sagittal and flair, t2 susceptibility and diffusion axial images of the brain were obtained. 2d time-of-flight mra of the neck vessels and 3d time-of-flight mra of the circle of was obtained. gadolinium- enhanced mra of the neck was acquired. the gadolinium-enhanced mra is somewhat limited possibly related to delay in timing and venous contamination. source images were evaluated to obtain maximum information. findings: brain mri: the diffusion images demonstrate no evidence of acute infarct. mild-to- moderate brain atrophy seen. no evidence of territorial infarcts noted. minimal changes of small vessel disease are noted in the white matter. no evidence of acute or chronic blood products seen. impression: no evidence of acute infarct. mild-to-moderate brain atrophy. mra of the neck: the neck mra demonstrates normal flow signal in the right vertebral artery. the right internal carotid demonstrates high-grade approximately 70% stenosis at the bifurcation. the evaluation of the right carotid stenosis on the post- gadolinium mra is limited secondary to venous contamination. the left internal carotid is occluded at the bifurcation. no flow is visualized in the distal cervical left internal carotid artery. no flow is seen in the left petrous carotid artery. the evaluation of the left vertebral artery on source images demonstrate flow signal in a markedly narrowed left vertebral artery in the proximal portion. subtle flow signal is also seen in the left v3 segment of the vertebral artery. this finding is indicative of diffuse atherosclerotic disease involving the left vertebral artery. the visualized great vessels of the thoracic inlet demonstrate no evidence of high-grade stenosis. impression: 1. occlusion of the left internal carotid artery at the bifurcation. 2. high-grade stenosis of the right internal carotid bifurcation. normal right vertebral artery. 3. diffuse atherosclerotic disease involving left vertebral artery with partial visualization in the proximal and distal portions. mra of the head: the head mra demonstrates absence of flow signal in the distal left internal carotid artery. the supraclinoid internal carotid artery is minimally visualized with flow visualized from the left pca to the left middle cerebral artery. on the right side normal flow signal is seen in the supraclinoid internal carotid, right mca and both anterior cerebral arteries. the posterior communicating artery is also visualized on the right side. in the posterior circulation, diffuse narrowing of the basilar artery is visualized with absence of flow signal in the distal basilar artery indicative of diffuse atherosclerotic disease with high-grade stenosis or occlusion of the distal basilar artery. both distal vertebral arteries demonstrate narrowed flow signal caliber. impression: 1. occlusion of the left internal carotid with collateral flow to the left mca through the left posterior communicating artery. normal flow signal in the right supraclinoid internal carotid, right mca and both anterior cerebral arteries. diffuse atherosclerotic disease of the basilar artery with probable occlusion or high-grade stenosis in the distal basilar artery. exercise mibi exercise mibi reason: pt with h/o carotid artery disease, scheduled for surgery this week for bleeding ampullary mass, cardiology reguests radiopharmeceutical data: 3.2 mci tl-201 thallous chloride; 22.0 mci tc-m sestamibi; history: 72 y/o male with carotid artery disease and pre-operative for a bleeding ampullary mass, for pre-op risk stratification. summary of the preliminary report from the exercise lab: dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min. two minutes after the cessation of infusion, tc-m sestamibi was administered iv. interpretation: image protocol: gated spect resting perfusion images were obtained with thallium. tracer was injected 15 minutes prior to obtaining the resting images. this study was interpreted using the 17-segment myocardial perfusion model. the image quality is adequate. left ventricular cavity size is normal. resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. gated images reveal normal wall motion. the calculated left ventricular ejection fraction is 69%. impression: 1. normal myocardial perfusion. 2. normal left ventricular cavity size and function. radiology final report ugi sgl contrast w/ kub 9:18 am ugi sgl contrast w/ kub reason: please do thin barium study by injecting contrast via ngt, a medical condition: 72 year old man with duod./ampullary mass s/p resection and reanast. pod#5. reason for this examination: please do thin barium study by injecting contrast via ngt, and doing a sbft. the patient had a duodenal resection, so the purpose of the study is to eval. integrity of anastomosis. indication: duodenal and ampullary mass status post resection and reanastomosis. query leak. duodenal/small bowel barium study: a scout was performed showing a midline horizontal staple line, with a nasogastric tube in the stomach and a right- sided jp drain. phleboliths are also seen in the pelvis and a bone island in the right iliac. after instillation of approximately 100 cc of gastrografin through the nasogastric tube, spot fluoroscopic images were obtained, which showed the contrast collecting first in the stomach and then promptly emptying into the duodenal sweep. no evidence of leak is seen. contrast promptly enters the jejunum. there is no evidence of obstruction. impression: no evidence of leak at the duodenal anastomosis. ct abdomen w/contrast; ct pelvis w/contrast reason: concern for abcess/leak. gastrographin contrast field of view: 38 contrast: optiray medical condition: 72 year old man pod 7 s/p transduodenal ampullectomy and ccy with fevers, hypotension reason for this examination: concern for abcess/leak. gastrographin contrast contraindications for iv contrast: none. indication: post op day 7 after transduodenal ampullectomy and cholecystectomy with fevers and hypotension, assess for abscess or leak. comparison: cta of the abdomen from . technique: multidetector ct scanning of the abdomen and pelvis was performed through the administration of gastrografin oral contrast and optiray intravenous contrast. coronal and sagittal reformations were obtained. ct of the abdomen: there are small bilateral pleural effusions, right greater than left with associated atelectasis at the lung bases. the heart and pericardium appear unremarkable. the liver parenchyma appears unremarkable. there is pneumobilia identified, primarily in the left lobe. the patient is status post cholecystectomy. the adrenal glands, spleen, and pancreas appear unremarkable. the kidneys enhance and excrete contrast symmetrically. again seen are hypodensities which are incompletely characterized on the current study in both kidneys. the loops of small and large bowel appear normal in caliber. a nasogastric tube terminates in the antrum of the stomach. contrast has reached the distal small bowel. there is no evidence of extraluminal contrast. a surgical drain is seen in the right upper quadrant. there is ascites fluid in the right upper quadrant, tracking down the right pericolic gutter, there is higher density posteriorly suggesting some blood. there are also foci of free intraperitoneal air consistent with the recent surgery. skin staples are seen across the anterior abdomen, and there is mild subcutaneous soft tissue stranding. no fluid collections are identified within the abdomen. there is some stranding in the right upper quadrant in the region of the recent surgery. vascular structures demonstrate atherosclerosis of the abdominal aorta. the major arteries and veins are patent. ct of the pelvis: a foley catheter is seen within the bladder, and there is nondependent air in the bladder lumen. the prostate, seminal vesicles and rectum appear unremarkable. there is small amounts of free fluid in the pelvis. note of a small left-sided fat-containing inguinal hernia. osseous structures demonstrate no concerning lytic or sclerotic lesions. impression: 1. no evidence of anastomotic leak or drainable fluid collection. 2. postoperative appearance in the right upper quadrant with foci of pneumoperitoneum, small amount of ascites, pneumobilia, and nonspecific fat stranding. 3. small bilateral pleural effusions, right greater than left with associated atelectasis. reason: us guided aspiration of fluid collection around liver medical condition: 72 year old man s/p tranduodenal ampullary resection with elevated wbc and fever. reason for this examination: us guided aspiration of fluid collection around liver ultrasound-guided perihepatic fluid collection drainage. history: 72-year-old male s/p transduodenal ampullary resection with elevated while blood count and fever and fluid collection around the liver procedure: the risks and benefits of the procedure were explained to the patient. written informed consent was obtained. preprocedure timeout was called to confirm the identity of the patient and the procedure to be performed. the patient was prepped and draped in the usual sterile fashion. lidocaine 1% was used for local anesthesia. moderate sedation was provided, by a nurse, by administering divided doses of 25 mcg of fentanyl and 0.5 mg of versed, throughout the total intraservice time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored. under direct ultrasound guidance with freehand technique, a suitable spot in the right upper quadrant was chosen and after administration of lidocaine, an 8-french catheter was placed into the perihepatic fluid collection. 110 cc of greenish fluid were aspirated. a sample was sent for microbiology. the patient tolerated well the procedure. there were no complications. the attending radiologist, dr. was present during the entire procedure. the patient tolerated well the procedure. impression: successful ultrasound-guided placement of drainage catheter in the perihepatic fluid collection. ct abdomen w/contrast; ct pelvis w/contrast reason: compare to ct abdomen on to make sure that everything h field of view: 36 contrast: optiray medical condition: 72 year old man pod 7 s/p transduodenal ampullectomy and ccy with fevers, hypotension reason for this examination: compare to ct abdomen on to make sure that everything has imprvoved contraindications for iv contrast: none. indication: 72-year-old man postoperative day 16, status post transit duodenal ampullectomy for ampullary mass, also cholecystectomy with fevers and leukocytosis on antibiotics. technique: multidetector ct images were obtained through the abdomen and pelvis with oral and intravenous contrast. coronal and sagittal reformatted images were obtained. comparison: ct abdomen and pelvis . ct of the abdomen with contrast: the lung bases show right lower lobe atelectasis with a moderate-sized right pleural effusion and small left pleural effusion. the size of the pleural effusions have not significantly changed since the prior scan. the heart and pericardium are unremarkable. within the abdomen, there has been interval placement of a pigtail drainage catheter within the lateral perihepatic collection, and there is less fluid and air within this collection. there has been interval development of a new fluid collection posterior to the right lobe of the liver measuring 4.0 (anterior to posterior) by 6.7 (transverse) by 6.8 (superior to inferior) cm. the fluid within this collection is of low density and there is no surrounding, enhancing rim. there are no focal liver lesions. the previously identified air within the biliary system has resolved. there is no biliary ductal dilatation. the patient is status post cholecystectomy. the pancreas, spleen, and adrenal glands are normal in appearance. again seen are tiny hypodensities within the bilateral kidneys, the largest of which is within the mid pole of the left kidney, and measures 13 mm, and is most consistent with a simple renal cyst. the remaining low-density foci within the kidneys are too small to characterize. the kidneys enhance symmetrically and excrete contrast normally. there is no evidence of hydronephrosis or hydroureter. there is an unchanged amount of intraabdominal ascites. again seen is a surgical drain coursing from the second portion of the duodenum posterior to the liver and exiting the abdomen through the right lower abdominal wall. this drain does not appear to communicate with the newly identified liver subcapsular fluid collection. the stomach and intra-abdominal loops of small and large bowel are unremarkable in appearance. there is no bowel dilatation, bowel wall thickening, or inflammatory fat stranding within the mesenteric fat. there is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy. there is no free air. ct of the pelvis with contrast: the rectum, sigmoid colon, seminal vesicles, prostate, distal ureters, and bladder are normal in appearance. there is no pathologically enlarged inguinal or pelvic lymphadenopathy. there is an unchanged small-to-moderate amount of intrapelvic free fluid. there is a small fat-containing left inguinal hernia, which is unchanged. there is edema in the subcutaneous tissues consistent with anasarca. bone windows: there are no suspicious lytic or sclerotic osseous lesions. impression: 1. new, approximately 4 x 6 cm subcapsular fluid collection posterior to the right lobe of the liver. . 2. interval placement of a percutaneous pigtail catheter within the previously identified fluid- and air-containing collection lateral to the right lobe of the liver. interval decreased in size of this collection from the prior scan of . 3. unchanged small amount of intraabdominal ascites. 4. left lower lung lobe atelectasis, stable, with stable size of bilateral pleural effusions, right greater than left. these findings were discussed with the clinical team and infectious disease team caring for the patient at the time of interpretation at 3:00 p.m. on . reason: please drain hepatic fluid collection. do not leave drain un medical condition: 72 year old man w/p whipple, ccy on for a bleeding ampulary mass. reason for this examination: please drain hepatic fluid collection. do not leave drain unless puss. please send fluid for gram stain, culture, and amylase. contraindications for iv contrast: none. clinical details: post-op. loculated posterior perihepatic fluid collection. existing catheter in situ. procedure: pre-procedure written consent and confirmation of patient identity and nature of procedure performed. the patient was placed in a lateral position to allow accfess to the loculated 6.7 cm x 4.1 cm fluid density collection along the right posterior superior aspect of the liver. following usual aseptic technique, local and intravenous analgesia using a right posterior intercostal approach, a 10 french multipurpose pigtail catheter was inserted into this fluid collection. initial aspiration yielded 10-15 cc of serous fluid samples, of which have been sent for microbiological culture, gram stain, and amylase. no immediate complications. dr. (attending radiologist) was present. ct-guided manipulation of existing pigtail catheter the non-contrast ct scan confirms the existing pigtail catheter in good position along the lateral aspect of the right lobe of the liver. minimal residual rim of fluid density measuring up to 1.6 cm in depth. the existing 8-french pigtail catheter was flushed and aspirated. minimal (less than 5 cc) amount of serous fluid aspirated. non-contrast ct scan of the abdomen: minimal right basal pleural effusion, consolidation in the posteromedial aspect of the right lower lobe. on the unenhanced ct, no liver lesions or intrahepatic biliary dilatation. no upper abdominal collections or lymphadenopathy. conclusion: 1. successful placement of 10-french pigtail catheter into the loculated right posterior perihepatic fluid collection, 2. the existing multipurpose pigtail catheter line was flushed and aspirated and remains in good position along the lateral aspect of the right lobe of liver. minimal (less than 1.6 cm) rim of fluid at that level. chest (pa & lat) reason: lung exam worsened. crackles in lungs increased in lungs medical condition: 72 year old man with ampullary mass reason for this examination: lung exam worsened. crackles in lungs increased in lungs bilateral. history: ampullary mass and increased crackles in the lungs. comparison: . chest: pa and lateral views. there is a moderate right pleural effusion and right lower lobe atelectasis has increased compared to 4:17 p.m. on , but appears similar to 8:35 a.m. on . small left effusion is unchanged. there is no pulmonary edema. left subclavian central venous catheter remains in unchanged position. a pigtail catheter is present within the right pleural effusion. impression: 1. moderate right pleural effusion, increased since the post-thoracentesis radiograph of , but similar to the pre-thoracentesis radiograph. 2. unchanged small left pleural effusion. 05:04am complete blood count white blood cells 11.3* k/ul 4.0 - 11.0 performed at west stat lab red blood cells 3.43* m/ul 4.6 - 6.2 performed at west stat lab hemoglobin 9.9* g/dl 14.0 - 18.0 performed at west stat lab hematocrit 29.3* % 40 - 52 performed at west stat lab mcv 85 fl 82 - 98 performed at west stat lab mch 28.7 pg 27 - 32 performed at west stat lab mchc 33.6 % 31 - 35 performed at west stat lab rdw 16.1* % 10.5 - 15.5 basic coagulation (pt, ptt, plt, inr) platelet count 644* k/ul 150 - 440 performed at west stat lab fluid,other perihepatic. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. abscess site: peritoneal **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): reported by phone to overland fa9a 3p . albicans, presumptive identification. sparse growth. anaerobic culture (final ): no anaerobes isolated. 3:35 pm pleural fluid pleural fluid. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): pathology examination name birthdate age sex pathology # , 72 male report to: dr. gross description by: dr. , dr. /mtd specimen submitted: gallbladder, rt. lateral margin and ampullary adenoma. procedure date tissue received report date diagnosed by dr. . /lo?????? previous biopsies: gi bx 1 ampulla. ************this report contains an addendum*********** diagnosis: 1. gallbladder (a1-b1): unremarkable gallbladder mucosa and cholelithiasis, pigmented type. 2. right lateral margin (c1): duodenal mucosa with marked cautery artifact, no malignancy identified. 3. ampullary mass, resection (a-e): invasive adenocarcinoma. see synoptic report. dr. reviewed slides b-d. small intestine: polypectomy; segmental resection; whipple procedure (pancreaticoduodenectomy, partial or complete, with or without partial gastrectomy synopsis macroscopic specimen type: polypectomy. tumor site: duodenum, ampulla. tumor configuration: exophytic (polypoid). tumor size greatest dimension: 2.3 cm. additional dimensions: 1.3 cm x 0.8 cm. other organs received: none. microscopic histologic type: adenocarcinoma (not otherwise characterized). histologic grade: g1: well differentiated. extent of invasion primary tumor: pt1: tumor invades lamina propria or submucosa. regional lymph nodes: pnx: cannot be assessed. lymph nodes number examined: 0. distant metastasis: pmx: cannot be assessed. margins mucosal margin: uninvolved by carcinoma. deep margin: uninvolved by carcinoma. addendum: the original frozen sections were reviewed retrospectively by drs. and . it is felt that the invasive carcinoma seen on the permanent sections is not present on the original frozen section slides. addendum added by: dr. . /jg???????????? date: clinical: pancreatic mass. gross: the specimen is received in fresh in three, each labeled with the patient's name, ", " and the medical record number. part 1 is additionally labeled "gallbladder". the specimen consists of a single intact distended gallbladder measuring 11.3 x 4.6 x 4.4 cm. the serosa is tan-pink and focally red and the specimen is opened longitudinally to reveal approximately 30 cc of dark brown honey-colored viscus fluid. there is a single green gallstone measuring 0.9 x 0.9 x 0.9 cm which is bisected to reveal a green crystalline interior. the mucosa is tan-pink and notable for multiple small yellow flecks. the wall thickness measures up to 0.2 cm. the specimen is sectioned and represented as follows: cystic duct margin and body in a1, fundus in b1. part 2 is additionally labeled "right lateral margin". the specimen consists of a single piece of soft pink red tissue measuring 1.2 x 0.8 x 0.3 cm. one side of the specimen has either been previously inked in black or darkened by cautery. this side is inked over in black. there is a single suture demarcating one side of the specimen which is inked in yellow and the specimen is submitted entirely with the black ink side face down, in cassette labeled c1. part 3 additionally labeled "ampullary adenoma" consists of a 2.3 x 1.3 x 0.8 cm polypoid fragment of tan pink mucosa containing a 0.4 cm stalk. the stalk has been identified by the surgeon with a blue stitch and contains the pancreatic and biliary duct margins. there is a 0.3 cm area of mucosal ulceration at one end of the polyp. the resection margin is inked black, shaved off and submitted for frozen section diagnosis en face. a representative cross section of the polyp is also submitted for frozen section diagnosis. frozen section diagnosis by dr. and dr. is "ampullary adenoma with focal high grade dysplasia. no invasion seen on sampled sections. the adenoma focally extends to the side margin. the shaved common bile duct and pancreatic duct margin are free of dysplasia." the stalk margin frozen section remnant is entirely submitted in a and the polyp frozen section remnant is entirely submitted in b. the remainder of the specimen is serially sectioned and entirely submitted in c-e, with the ulcerated area in d. brief hospital course: the patient was admitted on . an ercp with biopsy showed adenocarcinoma. a ct confirmed the presence of an ampullary mass. #carotid disease a noninvasive carotid study showed complete occlusion of the left ica and the right ica with 70-79% narrowing. #vascular consult an angio obtained form an osh (, ) showed the right ica to be 35% occluded. a neuro consult was requested to work up his tia's vs. parkinsonism. a mri brain/ mra carotids revealed mild-to-moderate brain atrophy and occlusion of the left internal carotid artery at the bifurcation, high-grade stenosis of the right internal carotid bifurcation. normal right vertebral artery, normal flow signal in the right supraclinoid internal carotid, right mca and both anterior cerebral arteries. dr. felt that there was no intervention needed prior to abdominal surgery. #neuro consult neuro found no evidence of symptomatic right brain lesion on exam, but there may be a small stroke not detected clinically. #cardiology consult cardiology recommended an echo and stress mibi which were negative for st changes and showed normal myocardial perfusion, and normal left ventricular cavity size and function. he was then cleared to go to the or on and had an open cholecystectomy and transduodenal ampullary resection. he tolerated the procedure well. he was npo, had a ngt and iv fluids. he was started on a pca for pain control. he needed further teaching on the use of his pca before he was able to have pain control.he had a jp drain in place and staples to his abdominal incision. #pain consult a pain consult was obtained after the patient required narcan for sedation, a respiratory rate of 8, and pinpoint pupils. aps recommended that he continue with subcutaneous dilaudid until he is able to take po meds. he was then changed to po dilaudid on pod 6. #seizure pod 3, the patient had a 30 second episode of non-responsiveness, blank downward gaze and increase fine tremors of the bilateral upper extremities, right>left. afterwards, he was unable to remember the names of his daughters, or remember the event. the family states that the last seizure was 5 years ago. neurology was consulted and recommended ativan iv for any further seizure activity and to restart tegretal 200mg tid once he is able to take pos. he was restarted on tegretal on pod 4, and has had no further seizure activity. pod 4, a ugi sgl contrast w/ kub showed no evidence of leak at the duodenal anastomosis. the ngt was d/c'd and he was started on sips. his diet was advanced as bowel function returned. stool was sent for c.diff due to a frequent loose stool which was negative. pod 6, he was found down on the floor, obtund ed. he denies hitting his head, he was reportedly confused and talking, but thought it was . neurology was called immediately. labs were sent and a tegretol level was adequate at 7.6, wbc 28.4 and temp of 101.9 axillary. he then became diaphoretic and was not responding to questions and was not opening his eyes. it seems likely that the patient was confused due to sepsis and hypotension as opposed to a seizure related event. he was transfered to the sicu. he was given iv fluids and started on vancomycin, levo, flagyl. a head ct showed no evidence of intracranial hemorrhage or mass effect. on he spiked a fever to 102f. an abdominal ct on showed no evidence of drainable fluid collection or abscess, but increased bilateral pleural effusions. he was started on zosyn (levo/flagyl d/c'd) and continued the vancomycin. a jp amylase on was . on pod 12 a ugi/air with kub showed no evidence of a leak. his jp revealed and he was started on fluconazole. his wbc continued to be elevated 28.4, 33.5, 29.6, 23.5, 15.8, 20.6, 17.3, up to 33.7 on pod 13. infectious disease was consulted and they suggested broad spectrum antibiotics and that we should sample the pleural effusion. pod 13, a picc line was placed and he was started on tpn. pod 14, urine cultures were negative. he continued to spike a temperatures, up to 102.4 and he had increased work of breathing. interventional pulmonology was contact to perform a thoracentesis for the right sided pleural effusion and they removed 1.2 liters of fluid. the pleural effusion was negative. occupational and physical therapy was consulted and he was started on aggressive pulmonary toilet. pod 15 a left subdiaphragmatic collection was drained by us guidance seen on the ct. the drain was negative for bacteria and positive for albicans. pod 19 on an interval ct scan there was a subcapsular fluid collection. unclear the etiology. pod 22 the subscapular fluid collection was drained by ct guidance. the cultures have been negative for bacteria. pod 24: the subscapular pigtail was d/c'd pod 25: the pigtail drain the fluid around the liver was d/c'd medications on admission: lipitor 20 tegretol 200 tid hctz colace protonix 40 atenolol 25 lisinopril asa 81 for 2 yrs and plavix for 2 months, but both stopped 10 days ago discharge medications: 1. hydrochlorothiazide 25 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. hydralazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 3. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 10 days. disp:*20 tablet(s)* refills:*0* 4. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 10 days. disp:*30 tablet(s)* refills:*0* 5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. 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* 7. octreotide acetate 100 mcg/ml solution sig: one (1) injection q8h (every 8 hours). disp:*90 one injection* refills:*2* 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 11. carbamazepine 200 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 12. atenolol 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 13. tpn day 3 and/or thereafter: central standard 2-in-1 (no fat) for date: **order marked as pumped feeding weight(kg) tpn volume amino acid(g/d) dextrose(g/d) fat(g/d) kcal/day 70 1750 trace elements will be added daily standard adult multivitamins nacl naac napo4 kcl kac kpo4 mgs04 cagluc 90 0 25 40 15 20 12 18 insulin(units) zinc(mg) 30 10 total volume of solution per 24 hours. rate of continous infusion determined by pharmacy-see label 14. outpatient lab work chem 10 every wednesday 15. outpatient physical therapy ambulation with assistance once a day and aggressive chest therapy of a pulmonary toilet every day. 16. norvasc 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: nursing discharge diagnosis: bleeding ampullary mass discharge condition: good discharge instructions: * increasing pain or persistent pain * fever (>101.5 f) or vomiting * bleeding * inability to pass gas or stool * other symptoms concerning to you please take all your medications as ordered no driving while taking strong pain medication. no lifting > 10 lbs for 6 weeks. take antibiotics for only 10 more days. followup instructions: 1. please follow-up with dr. . call ( to schedule an appointment. 2. please follow up with dr. from vascular surgery to have a repeat carotid u/s. please call to schedule this appointment. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Thoracentesis Percutaneous abdominal drainage Percutaneous abdominal drainage Cholecystectomy Transfusion of packed cells Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi Excision of ampulla of Vater (with reimplantation of common duct) Diagnoses: Other postoperative infection Unspecified pleural effusion Unspecified essential hypertension Other convulsions Other and unspecified hyperlipidemia Paralysis agitans Bacteremia Personal history of other diseases of circulatory system Diarrhea Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Malignant neoplasm of ampulla of vater Peritoneal abscess Other candidiasis of other specified sites

history of present illness: the patient is an 88 year old woman with a history of osteoarthritis and psoriasis who presents with hematemesis. she noticed this on but it resolved spontaneously. she then experienced melena and hematemesis of significant amount, one to two cups of bright red blood on the morning of admission. she also felt lightheaded, although she did not experience chest pain, shortness of breath or abdominal pain. this has never occurred to her before. the patient has a history of ibuprofen use, 300 mg three times a day for months, for her osteoarthritis pain. on admission, the patient was tachycardiac to the 110s but blood pressure was stable in the 120s systolic. nasogastric lavage was performed, showing coffee-grounds and clots, which did not clear with 1.5 liters normal saline. gastroenterology was consulted and an esophagogastroduodenoscopy was performed, showing a 15 mm crated ulcer with large blood clot overlying the base. they were unable to dislodge. epinephrine was injected with success. the patient received one unit of packed red blood cells on presentation for a hematocrit of 24. past medical history: 1. osteoarthritis. 2. psoriasis. medications on admission: ibuprofen 300 mg p.o.t.i.d. allergies: the patient has no known drug allergies. family history: noncontributory. social history: the patient lives alone. she has never been married and has no children. she has a niece and nephew who visit her often and help her out. she drinks one brandy with lemonade four to five times per week and denies smoking. she has not seen a doctor in three years and is not sure who her primary care physician . code status: "do not resuscitate"/"do not intubate". physical examination: on physical examination, the patient had a blood pressure of 119/56, pulse 100, respiratory rate 17 and oxygen saturation 100% on two liters. general: awake, alert, in no acute distress, pale. head, eyes, ears, nose and throat: pupils equal, round, and reactive to light and accommodation, extraocular movements intact, anicteric sclerae, oropharynx clear. neck: supple, no bruits. chest: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm, s1 and s2, ii/vi soft systolic ejection murmur at right upper sternal border. abdomen: soft, nontender, nondistended, positive bowel sounds. extremities: no cyanosis, clubbing or edema. neurologic examination: alert and oriented times three, cranial nerves ii through xii intact, musculoskeletal in all four extremities. laboratory data: admission white blood cell count was 8.5 with 80% neutrophils, 15% lymphocytes and 3% monocytes, hematocrit 24.5, platelet count 243,000, prothrombin time 12.8, partial thromboplastin time 23.9, inr 1.1, sodium 138, potassium 3.7, chloride 104, bicarbonate 25, bun 65, creatinine 0.7, and glucose 225. urinalysis was negative. hospital course: the patient is an 88 year old woman with a history of osteoarthritis, on ibuprofen, who presents with hematemesis and melena, esophagogastroduodenoscopy showing gastric body ulcer. 1. gastrointestinal: the patient had hematemesis secondary to a gastric ulcer, likely secondary to non-steroidal anti-inflammatory drug overuse. the patient received a total of four units of packed red blood cell transfusions and her hematocrit stabilized in the 30s. she was admitted to the medical intensive care unit for one night and then transferred to the floor in stable condition. the patient had no more hematemesis or evidence of active bleeding. she was on a protonix drip and kept on nothing by mouth for the first 24 hours. it was thought to perhaps to repeat an esophagogastroduodenoscopy, however, because she was stable, it was thought to best defer this to the operating table setting. helicobacter pylori antibody was checked and was negative. the patient's hematocrit continued to remain stable. once she was on the floor, her diet was advanced and she tolerated this well, without any symptoms. she will follow up with gastroenterology in two to three weeks and have a repeat esophagogastroduodenoscopy in eight weeks. the patient was told to strictly avoid any non-steroidal anti-inflammatory drugs, e.g., motrin, advil, ibuprofen, and to use tylenol for pain instead. she was also placed on iron supplementation once a day. 2. osteoarthritis: the patient was told to use tylenol for this. she did not complain of any severe pain while in the hospital. condition at discharge: stable. discharge status: home. discharge medications: tylenol p.r.n. pain. protonix 40 mg p.o.b.i.d. iron sulfate 325 mg p.o.q.d. colace 100 mg p.o.t.i.d. discharge diagnoses: 1. osteoarthritis. 2. upper gastrointestinal bleed secondary to stomach ulcer. 3. psoriasis. discharge instructions: the patient was instructed to follow up with nurse practitioner, , for a hematocrit check on at 1:20 p.m. she is to follow up with dr. of the gastroenterology department, on at 1:00 p.m. and with me, dr. , as her new primary care physician, an initial visit appointment on at 1:30 p.m. , m.d. dictated by: medquist36 Procedure: Other endoscopy of small intestine Diagnoses: Diaphragmatic hernia without mention of obstruction or gangrene Osteoarthrosis, unspecified whether generalized or localized, site unspecified Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Other psoriasis

allergies: codeine attending: chief complaint: sob at osh, to major surgical or invasive procedure: none history of present illness: 80 yo male w/pmh significant for cad s/p mi in with 4v cabg and redo in , pacemaker/icd, dm, htn, asbestosis on home o2 who experienced sudden sob after his dinner. no associated cp. he did report orthopnea and palpitations. no fever, chills, or cough. he went to ed and was found to have a bp of 204/101 and hr of 140 in sinus rhythm, rr=34, and o2 sat of 88% on ra in respiraotry distress. he was given a heparin drip, nitroglycerin drip, 40 mg iv lasix, asa, nebs, 5 mg lopressor x3, slntg x3, morphine, and 125 mg solumedrol. his bp then dropped and he was flown to . here, his bp was 75/53, and his nitro drip was d/ced. he was started on dopamine ad his bp stabilized. bnp at osh was >6000, and initial enzymes were negative. given lasix and diuresed 800 cc. currently feels "much better", no cp, but still not at baseline. his anginal equivalent is sob, not cp. past medical history: 1.cad with mi and 4v cabg in . cabg redo in . 2. asbestosis with o2 requirement at home. 3.pacer/icd placed after syncopal episode in the airport. 4.niddm 5.chf--ef~20% by report and confirmed by echo here. 6.htn social history: libes in with his wife. daughter lives in fl. used to work in a shipyard. no drugs, occ etoh, past history of smoking, not currently. family history: non-contributory physical exam: t=96.6, hr=90, bp=94/49, rr=22, o2 sat=96% on 8lnrb, 800 cc urine at osh, 400 cc in ed gen: pleasant, mild dyspnea, but speaking in complete sentences; abdominal breathing; lying flat heent:eomi, perrla, mmm, jvd on expiration to the angle of the jaw. carotid bruit on r, none on l. cv:rrr, nl s1,s2, no s3,s4, i/vi sem at r 2nd ics. pulm:rales 1/3 up bilaterally, bronchial sounds over right mid-lung zone. skin:diaphoretic, no rashes abd: soft, nt/nd, decreased bowel sounds, no rebound or guarding. no organomegaly ext:no edema, 1+ dp pulses bilaterally, no femoral bruits. neuro:a&ox3 pertinent results: 03:49am blood wbc-25.2* rbc-3.98* hgb-9.3* hct-29.9* mcv-75* mch-23.3* mchc-31.2 rdw-16.8* plt ct-425 05:00am blood wbc-19.9* rbc-3.57* hgb-8.4* hct-26.3* mcv-74* mch-23.5* mchc-31.9 rdw-17.4* plt ct-381 10:00pm blood hct-31.0* 06:00am blood wbc-12.9* rbc-4.39* hgb-10.8*# hct-33.5* mcv-76* mch-24.7* mchc-32.4 rdw-17.8* plt ct-397 03:49am blood neuts-94.9* bands-0 lymphs-3.3* monos-1.5* eos-0.3 baso-0.1 03:49am blood pt-14.7* ptt-110.8* inr(pt)-1.4 05:00am blood pt-13.9* ptt-57.8* inr(pt)-1.3 06:00am blood pt-12.6 ptt-27.4 inr(pt)-1.1 06:00am blood plt ct-397 03:49am blood glucose-247* urean-42* creat-2.2* na-140 k-5.3* cl-104 hco3-20* angap-21* 05:00am blood glucose-98 urean-49* creat-2.0* na-141 k-5.0 cl-106 hco3-21* angap-19 06:00am blood glucose-47* urean-45* creat-1.7* na-142 k-4.5 cl-105 hco3-23 angap-19 03:49am blood alt-6 ast-27 ck(cpk)-195* alkphos-90 01:23pm blood ck(cpk)-244* 08:06pm blood ck(cpk)-190* 05:00am blood ck(cpk)-120 03:49am blood ck-mb-25* mb indx-12.8* 03:49am blood ctropnt-0.52* 01:23pm blood ck-mb-27* mb indx-11.1* 08:06pm blood ck-mb-16* mb indx-8.4* 05:00am blood ck-mb-10 mb indx-8.3* ctropnt-0.44* 03:49am blood calcium-9.0 phos-3.2 mg-1.4* iron-36* 06:00am blood calcium-9.2 phos-3.5 mg-1.6 03:49am blood caltibc-309 ferritn-631* trf-238 03:49am blood triglyc-58 hdl-41 chol/hd-3.0 ldlcalc-68 04:58am blood lactate-2.2* k-4.8 07:03am urine color-straw appear-clear sp -1.008 07:03am urine blood-lg nitrite-neg protein-neg glucose-tr ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 07:03am urine rbc-* wbc-0-2 bacteri-few yeast-none epi-0-2 01:26pm urine hours-random urean-448 creat-48 echo: conclusions: the left atrium is dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is dilated. overall left ventricular systolic function is severely depressed (ejection fraction approximately 20 percent). right ventricular chamber size is normal. right ventricular systolic function appears depressed. the aortic root is mildly dilated. the aortic valve leaflets (3) are mildly thickened but not stenotic. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. chest ct: impression: 1) extensive calcified pleural plaques consistent with prior history of asbestos exposure. right pleural effusion with equivocal smooth enhancement of the right posterior lateral pleural surface but without nodularity or other findings to suggest mesothelioma. correlation with pleural aspirate should be considered. 2) cardiomegaly and extensive coronary artery calcifications. 3) borderline enlargement of the main pulmonary arteries suggest a possible pulmonary artery hypertension. 4) atelectasis at the left lung base and bronchiectasiss. 5) extensive calcifications throughout the pancreas consistent with chronic pancreatitis. 6) small nodule in the left adrenal gland which possibly represents an adenoma. however, this cannot be fully characterized due to the lack of non- contrast series. cxr: impression: 1) chf 2) calcified pleural plaques with a large right effusion or pleural thickening. further evaluation with ct scan is reccommended to exclude malignant mesothelioma. brief hospital course: this 80 y/o male with h/o cad, dm, htn, asbestosis was admitted in fairly stable condition after a modest diuresis at the osh and the ed. he was managed for an nstemi and acute chf exacerbation. we spoke with his pcp and pulmonologist while he was here, and obtained records from his cardiologist. 1.chf: this exacerbation was likely due to a combination of ischemia(nstemi), severe htn, and chronic systolic/diastolic dysfunction. we started him on natrecor due to his underlying cri and he diuresed well with daily goals of 1l negative fluid balance. also got an echo which confirmed an ef of approx 20%, and 2+mr. his sob rapidly improved, but he was still using minimal o2 upon d/c. he is on 2lnc at home chronically. he was able to walk without o2 in the hospital though without dropping his o2 sats. patient was instructed to not eat salty foods and wife confirmed they have seen nutritionist before and have handouts at home of appropriate and inappropriate foods. he was transitioned to lasix on d/c at 20 mg/day, with instructions to weigh himself and take extra lasix iof his weight increases by 2 lbs in 1 day. hopefully this will keep him from slowly entering chf again. he was on lasix in the past, then bumex, but for now, we will try lasix with the above instructions. his cardiologist or pcp may elect to alter this regimen depending on his stability as an outpatient. 2.cad:known h/o coronary issues. his ekg showed a new incomplete lbbb and his cardiac enzymes were positive for mi. no st elevations seen. his anginal equivalent is also sob, which was his primary complaint. initially started on asa, heparin, statin. his coreg was held due to initially tenuous bp. he was briefly on dopamine, but was quickly weaned from this. his cks peaked in 200s and began trending down. there was question of whether this was result of demand ischemia or not. it was decided that he did not need a cath due to quick improvement and no further symptoms. the heparin was stopped and his coreg was restarted when his bp could tolerate it. he was sent home on coreg, but his diovan was not restarted as his bp was in normal range without it. will need this monitored. 3.ep:he has a pacemaker that was placed after syncopal episode. there were no issues with abnormal rhythms as an inpt. repeat ekgs showed qrs narrowing to more normal value. 4.renal: initial creatinine was elevated and was reported that he had cri since a hospital admission last year. records obtained showed a cr baseline close to 3 after that admission, but latest labs in records showed cr of 2.0 on . he was in this range throughout admission, with last value being 2.0. he had good urine output on natrecor here and no other issues with his kidneys. 5.asbestosis: cxr done which showed pleural plaque and effusion. ct of chest again showed plaques and effusion. his pulmonologist reported that he has had this effusion 3 times in the past and fluid analysis was negative for malig mesothelioma. it was not retapped here due to this information. we scheduled a f/u appointment for him with dr . also instructed him to continue using his oxygen at home as before. 6. initially had elevated wbc ct. possibly due to solumedrol, but believed to be elevated before this as well. no evidence of infection was found. count was followed, and gradually returned to nl. 7.he was discharged stable and at his baseline respiratory status, with close follow-up stressed to him and his family with cardiologist, pcp, pulmonologist. plan for daily weights and lasix adjustment as appropriate will hopefully help keep him from redeveloping volume overload. medications on admission: 1.coreg 6.125 mg 2.diovan 40 mg qd 3.lipitor 10 mg qd 4.amaryl 1 mg qd 5. 6.nexium 40 qd 7.celebrex 200 qd 8.bumex? discharge medications: 1. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 3. amaryl 1 mg tablet sig: one (1) tablet po once a day. 4. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). 5. furosemide 20 mg tablet sig: one (1) tablet po qd (once a day). disp:*40 tablet(s)* refills:*2* 6. aspirin, buffered 325 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 7. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: 1.chf 2.cad 3.cri (baseline cr~2.0) 4.asbestosis 5.niddm discharge condition: pt was stable. he was eating well.shortness of breath was resolved and he is at his baseline. still require o2 at night as before.no chest pain. discharge instructions: please call your doctor or return to the hospital if you experience chest pain or increasing shortness of breath. please weigh yourself every day. if your weight increases by 2 lbs or more in one day, take an extra 20 mg of lasix (in addition to your daily dose of 20 mg lasix that we started you on). if your weight remains up the next day, then call your doctor to report this. please stop your diovan. your lipitor dose was increased from 10 mg/day to 40 mg/day. we started you on aspirin, plavix, and lasix (furosemide). please take each of these daily. all of your other medications have stayed the same. followup instructions: pulmonology appointment with dr : at 5:20 pm please call your pcp to arrange an appointment in 1 week. cardiology appointment with dr on at 2:15 pm md, Procedure: Injection or infusion of nesiritide Diagnoses: Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Pulmonary collapse Automatic implantable cardiac defibrillator in situ Chronic pancreatitis Bronchiectasis without acute exacerbation Combined systolic and diastolic heart failure, unspecified Asbestosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob, doe major surgical or invasive procedure: vats history of present illness: 82 yo man with history of prostate ca, hyperlipidemia, recently diagnosed afib (incidentally found while doing an elective hand surgery)several mos ago, who presented to several weeks ago () with pleuritic chest pain and cough with productive green/yellow sputum; had a rul pna and stemi (troponin peak at 70 with an ekg that showed 2 mm st segment elevation in v2-v5); med management. was d/c'ed on asa and coumadin. in house, pt had adenosine mibi, which showed anterior apical and inferoapical fixed defect with peri-infarct, a reversible defect; ef 65%. cxr showed likely pna (prior xray done at wh showed interstitial markings c/w fibrosis). echo showed mild mr of 63%, mod dilated rv with depressed rvsf and mild pah, moderately dilated ra, mod depressed lv function. since discharge, pt has been doing poorly, and was re-admitted to the c/o sob and doe. was in ccu from till when was transferred to micu for management of ? underlying pulm process. his initial presentation was felt to be consistant with subacute mi and perimi chf as well as pna. he has been on nrb from admission till pm when he failed a trial of bipap and was intubated. he was net > 3l negative without improvement in oxygenation. pt was initially on dopa and vasopressin; now vasopressin weaned off. was initially on levofloxacin; switched to zosyn/vanco on . initial cxr showed diffuse alveolar opacities. ct shows diffuse ground glass, multifocal consolidations, loculated effusions. after intubation, an attempt was made to place cordis (unsuccessful); needs sgc to r/o decompensated chf; then bronch and possible vats. past medical history: prostate cancer 3 yrs ago afib on coumadin stemi 1 mos ago: never cath'ed tte ef decreased to 40%, o/w unchanged from previous social history: occasional etoh, never smoked; lives with family family history: n/c pertinent results: 12:50pm wbc-16.4* rbc-3.59* hgb-11.4* hct-33.8* mcv-94 mch-31.7 mchc-33.7 rdw-13.5 12:50pm plt count-145* 12:50pm neuts-84.1* lymphs-11.7* monos-4.0 eos-0.1 basos-0.1 12:50pm pt-33.5* ptt-46.1* inr(pt)-7.1 . 12:50pm glucose-123* urea n-25* creat-0.6 sodium-138 potassium-4.2 chloride-102 total co2-26 anion gap-14 . 12:50pm cortisol-40.6* 04:53pm lactate-1.0 12:50pm ck(cpk)-69 12:50pm ck-mb-notdone ctropnt-0.12* . 01:11pm urine color-ltamb appear-clear sp -1.023 01:11pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 01:11pm urine rbc-* wbc-* bacteria-rare yeast-none epi-0-2 trans epi- 04:53pm po2-65* pco2-44 ph-7.42 total co2-30 base xs-3 brief hospital course: 1. respiratory failure: initial differential diagnosis included (and was felt likely a combination of these): chf in the setting of a recent mi, pna, ards, interstitial disease or pe given rle dvt. there was a question of iatrogenic pneumothorax during l subclavian line placement, which resolved on serial chest x-rayds. pt was clinically diagnosed with ards and put on ards net ventilation (6cc/kg). pt required increased peep of at least 10 to maintain oxygenation. esophageal balloon was placed for a period of time to measure more accurate peep. fio2 was titrated down to 0.50. he was empirically treated for pneumonia with broad spectrum antibiotics of vanco, zosyn, levo. pt was found to be hypotensive requiring pressors and it was unclear if he was in heart failure vs sepsis. a swan ganz catheter was placed, which was more consistent with septic physiology. pt was unable to be diuresed secondary to his persistently lowish blood pressures both on and off pressors. bronch was performed on which was negative for legionella, fugus, viruses, dfa, pcp. fluid was exudative by light's criteria. sputum culture from found 2+ gnr and all other culture data including blood and urine remained negative during the hospitalization. pt's esr was 84 and was anca and negative. serial cxrs remained unchanged showed patchy alveolar and interstitial opacity of the left chest greater than the right, consistent with ards. cta was negative for pe and showed biltaeraly effusion, persistent diffuse ground glass opacity with multifocal parenchymal consolidation in an asymmetric pattern consistent with diffuse multifocal pneumonia, ards, and less likely asymmetric congestive heart failure. repeat echo was unchanged with slightly depressed lv systolic function (>50%), 3+ tr, and no pericardial effusion. pt had a vats procedure performed by thoracic surgery on with a lung biopsy which showed chronic fibrosing lung disease predominantly of end stage lung tissue with honeycomb change. very little alveolar tissue was present in the biopsy but showed focal evidence of organizing pneumonitis, raising the possibility of a superimposed acute process such as infection. some of the histologic features of the chronic fibrosing lung disease raised the possibility of usual interstitial pneumonia. pt was give high dose pulse steroids for 3 days without improvement in his oxygenation and ventilator settings. it was felt that pt did not have steroid responsive interestitial lung disease. given the fact that pt's clinical status showed no improvement over the past several weeks and it was highly unlikely that the pt could ever come off the ventilator, a family discussion was held and the decision was made to make the pt . pt was extubated and he expired shortly thereafter. . 2. cv a. rhythm: pt remained in afib, which was adequately rate-controlled on digoxin. he was anticoagulated with heparin. pt was noted to be in brachycardia in afib and digoxin was discontinued. b. ischemia: pt is s/p stemi with slightly depressed lv systolic function. pt was continued on aspirin, statin. antihypertensives were held in the setting of his hypotension. c. pump: ischmemic cardiomyopathy s/p mi. swan not consistent with cardiogenic shock; more consistent with hypovolemia, sepsis. severe tr could make swan readings misleaded. pt was bolused for cvp>12. very little diuresis was attempted/accomplished since he was likely clinically dry despite total body volume overload. . 3. rle dvt: a large rle dvt dx'd on le ultrasound. pt was continued on heparin drip, which he was already on for afib. cta was negative for pe . 4. anemia: most likely chronic disease from fe studies; mcv 95. folate and b12 both normal. . 5. fen: ngt placed by fluoro. given tube feeds. lytes repleted prn . 6. proph: ppi, heparin gtt discharge medications: none discharge disposition: expired discharge diagnosis: ards, chronic interstitial lung disease, afib, dvt discharge condition: expired discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Closed [endoscopic] biopsy of bronchus Pulmonary artery wedge monitoring Transfusion of packed cells Open biopsy of lung Transfusion of other serum Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Atrial fibrillation Acute and chronic respiratory failure Cardiac arrest Postinflammatory pulmonary fibrosis Other and unspecified coagulation defects Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Subendocardial infarction, subsequent episode of care