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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Visual hallucinations Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ male with ___ disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations. The following history is taken from chart review: The patient was seen by his neurologist on ___ at which time he was noted to have visual hallucinations and worsening gait freezing. For his gait freezing, his mirapex was increased by 0.125 mg every week to a goal dose of 0.75 mg t.i.d. He successfully up-titrated the medicine to 0.75/0.625/0.625 but began to have visual hallucinations and confusion so on ___ his neurologist recommended decreasing the dose to 0.625 TID. Despite the changes to his Mirapex, the patient's daughter has noted progressive gait stiffness and increased difficulty standing. This has resulted in difficulty with simply getting to the bathroom leading to episodes of incontinence. A UA performed on ___ was reassuring. On the day of presentation to the hospital, the patient began to experience visual hallucinations of a motor cross race in his backyard. He subsequently had a fall while transferring from the couch to a chair. His wife was unable to get him off the floor. The fall was witnessed and there was no head strike. Per the patient's wife, his gait has acutely worsened over the past 24 hours to the point where he has been unable to ambulate on his own. The patient's daughter called his neurologist who recommended presentation to the ED. In the ED, the patient was afebrile, HRs ___, normotensive, and SpO2 100% RA. On exam he was noted to have cogwheeling of upper extremities and decrease ___ strength. Labs were remarkable for a negative urine and serum tox, Na 132, K 5.8 (hemolyzed and no EKG changes), negative troponin, normal LFTs, unremarkable CBC. Chest Xray showed no acute process and CTH was reassuring. He was evaluated by neurology who recommended admission to medicine for failure to thrive, to continue the patient's home medications, and complete a toxo-metabolic workup. The patient was given his home pramipexole and pravastatin before he was admitted. On arrival to the floor, the patient is comfortable in bed. He is not accompanied by family on my interview. He knows that he is in the hospital and that it is ___. He is not sure why he is here and begins to tell me about a party in his house with a motor cross race in his backyard. When I asked him about his fall, he mentions that he has not had a fall for ___ years. He denies any fevers, chills, cough, chest pain, abdominal pain, nausea, diarrhea, or dysuria. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: ___ disease ___ Body Dementia dyslipidemia prostate cancer (s/p prostatectomy) Social History: ___ Family History: His mother died at age ___ of "old age." His father died of prostate cancer at ___. He has an older sister (age ___ and a younger sister (age ___. He has a younger brother (age ___. As noted, he has 2 daughters. There is no family history of neurologic illness or dementia. There is no family history of neurodevelopmental mental disorders such as learning disability or ADHD. There is no family history of psychiatric problems. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: reviewed in OMR GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, ___ strength b/l ___. Normal sensation. DISCHARGE PHYSICAL EXAM ====================== 24 HR Data (last updated ___ @ 2340) Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80 (80-104), RR: 18 (___), O2 sat: 100% (95-100), O2 delivery: Ra GENERAL: In no acute distress. Talking very quietly. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, ___ strength b/l ___. Normal sensation. Pertinent Results: ADMISSION LABS: =============== ___ 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt ___ ___ 10:30PM BLOOD Neuts-48.1 ___ Monos-15.9* Eos-2.0 Baso-0.6 Im ___ AbsNeut-4.13 AbsLymp-2.86 AbsMono-1.36* AbsEos-0.17 AbsBaso-0.05 ___ 10:30PM BLOOD ___ PTT-23.4* ___ ___ 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132* K-5.8* Cl-98 HCO3-19* AnGap-15 ___ 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4 ___ 10:30PM BLOOD Lipase-47 ___ 10:30PM BLOOD cTropnT-<0.01 ___ 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0 ___ 10:30PM BLOOD VitB12-570 ___ 10:30PM BLOOD TSH-1.4 ___ 07:00AM BLOOD Trep Ab-NEG ___ 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG IMAGING: ======== ___ Imaging CT HEAD W/O CONTRAST FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the remaining paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable apart from bilateral lens replacements. IMPRESSION: 1. No acute intracranial abnormality. No hydrocephalus. ___ Imaging CHEST (PA & LAT) IMPRESSION: Mild atelectasis in the lung bases without focal consolidation. Age-indeterminate moderate to severe compression deformity of a low thoracic vertebral body. DISCHARGE LABS: =============== ___ 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1* MCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt ___ ___ 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-24 AnGap-12 ___ 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.___ male with ___ disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations concerning for progression of his neurologic disorder. ACUTE/ACTIVE ISSUES: ==================== ___ disease ___ Body Dementia #Visual Hallucinations The patient appears to have acute on chronic progression of his ___ disease. Unclear if this is disease progression or underlying medical cause. Continued mirapex, rasagiline, and rivastigmine. Neurology recommended started Seroquel for his hallucinations. He was evaluated by physical therapy who recommended rehab. This recommendation was discussed with the family who opted for discharge to home with home physical therapy as this was in line with the patient's goals of care. TRANSITIONAL ISSUES: [] f/u visual hallucination symptoms on Seroquel [] f/u physical therapy at home Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rasagiline 1 mg PO DAILY 2. Pramipexole 0.625 mg PO TID 3. rivastigmine 9.5 mg/24 hr transdermal DAILY 4. Pravastatin 40 mg PO QPM 5. Cyanocobalamin Dose is Unknown PO DAILY 6. Loratadine 10 mg PO DAILY Discharge Medications: 1. QUEtiapine Fumarate 25 mg PO QHS RX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30 Tablet Refills:*0 2. Loratadine 10 mg PO DAILY 3. Pramipexole 0.625 mg PO TID 4. Pravastatin 40 mg PO QPM 5. Rasagiline 1 mg PO DAILY 6. rivastigmine 9.5 mg/24 hr transdermal DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ___ Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were sent to the emergency room by your neurologist who was concerned that you were having visual hallucinations. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were started on a new medication to help treat your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Visual hallucinations Major Surgical or Invasive Procedure: N/A History of Present Illness: [MASKED] male with [MASKED] disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations. The following history is taken from chart review: The patient was seen by his neurologist on [MASKED] at which time he was noted to have visual hallucinations and worsening gait freezing. For his gait freezing, his mirapex was increased by 0.125 mg every week to a goal dose of 0.75 mg t.i.d. He successfully up-titrated the medicine to 0.75/0.625/0.625 but began to have visual hallucinations and confusion so on [MASKED] his neurologist recommended decreasing the dose to 0.625 TID. Despite the changes to his Mirapex, the patient's daughter has noted progressive gait stiffness and increased difficulty standing. This has resulted in difficulty with simply getting to the bathroom leading to episodes of incontinence. A UA performed on [MASKED] was reassuring. On the day of presentation to the hospital, the patient began to experience visual hallucinations of a motor cross race in his backyard. He subsequently had a fall while transferring from the couch to a chair. His wife was unable to get him off the floor. The fall was witnessed and there was no head strike. Per the patient's wife, his gait has acutely worsened over the past 24 hours to the point where he has been unable to ambulate on his own. The patient's daughter called his neurologist who recommended presentation to the ED. In the ED, the patient was afebrile, HRs [MASKED], normotensive, and SpO2 100% RA. On exam he was noted to have cogwheeling of upper extremities and decrease [MASKED] strength. Labs were remarkable for a negative urine and serum tox, Na 132, K 5.8 (hemolyzed and no EKG changes), negative troponin, normal LFTs, unremarkable CBC. Chest Xray showed no acute process and CTH was reassuring. He was evaluated by neurology who recommended admission to medicine for failure to thrive, to continue the patient's home medications, and complete a toxo-metabolic workup. The patient was given his home pramipexole and pravastatin before he was admitted. On arrival to the floor, the patient is comfortable in bed. He is not accompanied by family on my interview. He knows that he is in the hospital and that it is [MASKED]. He is not sure why he is here and begins to tell me about a party in his house with a motor cross race in his backyard. When I asked him about his fall, he mentions that he has not had a fall for [MASKED] years. He denies any fevers, chills, cough, chest pain, abdominal pain, nausea, diarrhea, or dysuria. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: [MASKED] disease [MASKED] Body Dementia dyslipidemia prostate cancer (s/p prostatectomy) Social History: [MASKED] Family History: His mother died at age [MASKED] of "old age." His father died of prostate cancer at [MASKED]. He has an older sister (age [MASKED] and a younger sister (age [MASKED]. He has a younger brother (age [MASKED]. As noted, he has 2 daughters. There is no family history of neurologic illness or dementia. There is no family history of neurodevelopmental mental disorders such as learning disability or ADHD. There is no family history of psychiatric problems. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: reviewed in OMR GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, [MASKED] strength b/l [MASKED]. Normal sensation. DISCHARGE PHYSICAL EXAM ====================== 24 HR Data (last updated [MASKED] @ 2340) Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80 (80-104), RR: 18 ([MASKED]), O2 sat: 100% (95-100), O2 delivery: Ra GENERAL: In no acute distress. Talking very quietly. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, [MASKED] strength b/l [MASKED]. Normal sensation. Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt [MASKED] [MASKED] 10:30PM BLOOD Neuts-48.1 [MASKED] Monos-15.9* Eos-2.0 Baso-0.6 Im [MASKED] AbsNeut-4.13 AbsLymp-2.86 AbsMono-1.36* AbsEos-0.17 AbsBaso-0.05 [MASKED] 10:30PM BLOOD [MASKED] PTT-23.4* [MASKED] [MASKED] 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132* K-5.8* Cl-98 HCO3-19* AnGap-15 [MASKED] 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4 [MASKED] 10:30PM BLOOD Lipase-47 [MASKED] 10:30PM BLOOD cTropnT-<0.01 [MASKED] 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0 [MASKED] 10:30PM BLOOD VitB12-570 [MASKED] 10:30PM BLOOD TSH-1.4 [MASKED] 07:00AM BLOOD Trep Ab-NEG [MASKED] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG IMAGING: ======== [MASKED] Imaging CT HEAD W/O CONTRAST FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the remaining paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable apart from bilateral lens replacements. IMPRESSION: 1. No acute intracranial abnormality. No hydrocephalus. [MASKED] Imaging CHEST (PA & LAT) IMPRESSION: Mild atelectasis in the lung bases without focal consolidation. Age-indeterminate moderate to severe compression deformity of a low thoracic vertebral body. DISCHARGE LABS: =============== [MASKED] 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1* MCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt [MASKED] [MASKED] 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-24 AnGap-12 [MASKED] 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.[MASKED] male with [MASKED] disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations concerning for progression of his neurologic disorder. ACUTE/ACTIVE ISSUES: ==================== [MASKED] disease [MASKED] Body Dementia #Visual Hallucinations The patient appears to have acute on chronic progression of his [MASKED] disease. Unclear if this is disease progression or underlying medical cause. Continued mirapex, rasagiline, and rivastigmine. Neurology recommended started Seroquel for his hallucinations. He was evaluated by physical therapy who recommended rehab. This recommendation was discussed with the family who opted for discharge to home with home physical therapy as this was in line with the patient's goals of care. TRANSITIONAL ISSUES: [] f/u visual hallucination symptoms on Seroquel [] f/u physical therapy at home Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rasagiline 1 mg PO DAILY 2. Pramipexole 0.625 mg PO TID 3. rivastigmine 9.5 mg/24 hr transdermal DAILY 4. Pravastatin 40 mg PO QPM 5. Cyanocobalamin Dose is Unknown PO DAILY 6. Loratadine 10 mg PO DAILY Discharge Medications: 1. QUEtiapine Fumarate 25 mg PO QHS RX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30 Tablet Refills:*0 2. Loratadine 10 mg PO DAILY 3. Pramipexole 0.625 mg PO TID 4. Pravastatin 40 mg PO QPM 5. Rasagiline 1 mg PO DAILY 6. rivastigmine 9.5 mg/24 hr transdermal DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: [MASKED] Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were sent to the emergency room by your neurologist who was concerned that you were having visual hallucinations. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were started on a new medication to help treat your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]

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

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

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

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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ with history of coronary artery disease c/b ischemic MR ___ DES to LCX ___, TTE ___ with mild regional LV systolic dysfunction), heart failure with preserved ejection fraction (LVEF 50% ___, peripheral vascular disease, chronic kidney disease (stage IV), prior unprovoked DVT c/b severe UGIB while on AC, HTN, dyslipidemia, and T2DM who presents with several days of shortness of breath. Patients says that she first noticed rather acute onset dyspnea starting ___ when trying to walk up the stairs in her home. She had to sit down and catch her breath, whereas just days prior she was able to mount ___ of stairs without difficulty. Patient denies any associated chest pain or palpitations. No dizziness or lightheadedness. Patient further denies any cough, fevers/chills, or pleuritic chest discomfort. She has not experienced any symptoms consistent with orthopnea or PND. No increased ___ swelling, patient notes that she has experienced this in the past. Patient takes her weight nearly every day, 7lbs reported weight gain over the past week (154lbs -> 161lbs), which she attributes to eating more over the ___. She is currently taking torsemide 40mg qd, no missed doses. No issues with abdominal bloating or constipation. No recent travel. Patient's husband just recovered from a viral URI. In the ED, initial VS were: 97.2 90 186/87 22 100% RA Exam notable for: Obvious bilateral wheezing. No overt volume overload. EKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479, q-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no STEs. Labs showed: CBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97) BMP 142/4.8/105/___/2.4/189 Trop <.01 proBNP 4512 VBG 7.33/40 UA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG, blood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG, RBC 1, WBC 1, few bacteria Imaging showed: CXR ___ FINDINGS: Lungs are moderately well-expanded. There is an asymmetric right lower lung opacity, new from ___. The heart appears mildly enlarged and there is mild pulmonary vascular congestion. No pleural effusion or pneumothorax. IMPRESSION: Right lower lobe opacity could represent pneumonia in the right clinical setting, although atelectasis or asymmetric pulmonary edema could account for this finding. Dedicated PA and lateral views could be helpful for further assessment. Consults: NONE Patient received: ___ 21:45 IH Albuterol 0.083% Neb Soln 1 NEB ___ 22:08 IH Albuterol 0.083% Neb Soln 1 NEB ___ 22:08 IH Ipratropium Bromide Neb 1 NEB ___ 22:47 IH Albuterol 0.083% Neb Soln 1 NEB ___ 22:47 IH Ipratropium Bromide Neb 1 NEB ___ 22:51 IV Azithromycin ___ 22:51 IV CefTRIAXone ___ 22:51 PO PredniSONE 60 mg ___ 22:51 IV Furosemide 80 mg ___ 23:01 IV CefTRIAXone 1 gm ___ 00:13 IV Azithromycin 500 mg ___ 00:23 PO/NG Atorvastatin 80 mg ___ 00:23 PO/NG Carvedilol 25 mg ___ 00:23 PO NIFEdipine (Extended Release) 60 mg ___ 00:23 IH Albuterol 0.083% Neb Soln 1 NEB ___ 00:23 IH Ipratropium Bromide Neb 1 NEB ___ 00:26 PO/NG Gabapentin 100 mg ___ 00:44 SC Insulin 4 Units Transfer VS were: 98.2 77 141/76 18 100% 2L NC On arrival to the floor, patient recounts the history as above. She says that she feels improved after treatment in the ED, no ongoing SOB. 10-point ROS is otherwise NEGATIVE. Past Medical History: Coronary artery disease Peripheral vascular disease Type II Diabetes Mellitus c/b diabetic retinopathy Obesity Esophageal ring Hypertension Dyslipidemia Bilateral unprovoked posterior tibial DVTs (___) off AC given severe UGIB CKD Stage IV iso DM/HTN, secondary hyperparathyroidism Anemia Gout Social History: ___ Family History: Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ============================== ADMISSION PHYSICAL EXAM ============================== VS: 97.5 162/93 78 16 100RA GENERAL: Pleasant female appearing younger than her stated age, taking deep breaths while speaking HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: JVD 10 CM. HEART: RRR, S1/S2, no murmurs, gallops, or rubs. LUNGS: CTAB, no wheezes. ABDOMEN: Obese abdomen, normoactive BS throughout, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. PULSES: 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused, no excoriations or lesions, no rashes. ============================== DISCHARGE PHYSICAL EXAM ============================== VS: Afeb, 144/78, HR 57, 97% RA, RR 12 GEN: Well appearing in NAD Neck: No JVD appreciated CV: RRR no m/r/g, no carotid bruits appreciated PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion EXT: warm well perfused, no pitting edema Pertinent Results: ============================== ADMISSION LABS ============================== ___ 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8* MCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt ___ ___ 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4* Eos-1.8 Baso-0.3 Im ___ AbsNeut-4.49 AbsLymp-1.05* AbsMono-0.26 AbsEos-0.11 AbsBaso-0.02 ___ 06:40AM BLOOD ___ PTT-25.9 ___ ___ 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142 K-4.8 Cl-105 HCO3-20* AnGap-17 ___ 09:37PM BLOOD proBNP-4512* ___ 09:37PM BLOOD cTropnT-<0.01 ___ 06:40AM BLOOD CK-MB-6 cTropnT-0.05* ___ 02:01PM BLOOD CK-MB-5 cTropnT-0.04* ___ 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3 ___ 09:41PM BLOOD ___ pO2-30* pCO2-40 pH-7.33* calTCO2-22 Base XS--5 ============================== IMAGING ============================== TTE ___: The left atrial volume index is mildly increased. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal, inferior, inferolateral as well as mid inferior/inferoseptal wall motion abnormalities. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) Mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory. 2) Grade II LV diastolic dysfunction. Compared with the prior study (images reviewed) of ___, LV sytolic function appears mildly less vigorous. Regional wall motion abnormalities encompassess slightly greater territory. CXR PA & LAT ___: No focal consolidation or pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___: 1. Nonocclusive thrombosis of one of the paired posterior tibial veins in the bilateral lower extremities which appears grossly unchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either extremity. 2. Right ___ cyst measuring up to 1.8 cm across maximal diameter is unchanged in size compared to ___. ============================== MICROBIOLOGY ============================== URINE CULTURE ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. BLOOD CULTURE ___: Blood Culture: PENDING BLOOD CULTURE ___: Blood Culture: PENDING ============================== DISCHARGE LABS ============================== ___ 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5* MCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt ___ ___ 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147 K-4.0 Cl-105 HCO3-24 AnGap-___ yo F PMH CAD c/b ischemic MR ___ DES to ___ ___, TTE ___ with mild regional LV systolic dysfunction), HFpEF (LVEF 50% ___, PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC, T2DM presents with subacute SOB, weight gain, c/f acute heart failure exacerbation. She underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. ___ showed no acute DVT, CXR without sign of consolidation. Given her improvement in dyspnea, no supplemental O2 requirement, the patient was discharged w/o medication changes. # Shortness of breath # Hypoxia # acute exacerbation of chronic diastolic heart failure with preserved LVEF (50%) Dry weight per pt 154 lbs. Admission weight above baseline, BNP elevated. Regarding trigger, suspect dietary vs uncontrolled BP. No EKG changes for ACS, trop negative, repeat TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory, as well as Grade II LV diastolic dysfunction and similar to prior ___ TTE. Doubt PNA given CXR and lack of cough/fever, doubt PE given low Wells' score 1.5, and stable repeat ___. Underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and carvedilol 25mg BID. Was stable on RA prior to discharge. # Hypertension - Patient missed her antiHTN medications earlier day of admission. Continued home carvedilol 25mg BID and nifedipine 60mg BID with holding parameters. Appears that a trial of ___ or spironolactone would be limited by hyperkalemia, so this was deferred. # Urinary frequency/urge incontinence: occurred in setting of diuresis, however UCx ordered in ED did grow enterococci, likely colonization. If symptoms persists would revaluate/treat. CHRONIC STABLE ISSUES # Normocytic anemia (recent baseline Hb 9.4 ___ - Hb was at baseline, no signs of active bleeding. Likely multifactorial, anemia of chronic disease as well as decreased erythropoiten production iso CKD. # Non anion gap metabolic acidosis - Patient has intermittently had a NAGMA in the past. No recent diarrhea. ___ suspect Type IV RTA given advanced age and history of T2DM (both of which can cause hyporeninemia). # Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD iso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na diet. Continued home calcitriol, avoided nephrotoxins and renally dosed all medications. # Coronary artery disease ___ DES to LCX ___: troponins were trended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was flat. Patient deneied any chest pain. A TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory and similar to prior ___ TTE. Continued home aspirin 81mg qd, home carvedilol 25mg BID with holding parameters, home atorvastatin 80mg qHS. # Type II Diabetes Mellitus (last HbA1C 6.4% ___ - Under excellent control, most recently in the pre-diabetic range. - Continue home 70/30 sliding scale (___t dinner if blood sugar over 130, 10 units 90-130, none if blood sugar under 90) # Dyslipidemia: continued home atorvastatin # Insomnia: continued home gabapentin # Gout: continued home allopurinol ============================== TRANSITIONAL ISSUES ============================== - Discharge weight: 69.2kg - Discharge creatinine: 2.6 - Discharge oral diuretic: torsemide 40mg daily - Transitional issue: consider outpatient epo with renal - Transitional issue: BP goal of 140/90 per accord or even 130/80 per ACC/AHA ___ guidelines however anticipate difficulty in adding additional agents iso CKD (limits use of clonidine) and baseline potassium (would likely limit ___ or spironolactone) - TTE showed prior LV hypokinesis, could consider MIBI or outpatient pharmacological stress test - had some urinary retention/incontinence while undergoing IV diuresis would assess for recurrent symptoms at routine outpatient visits #CODE: Full (confirmed) #CONTACT: ___ (husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.5 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. Gabapentin 100 mg PO QHS 6. NIFEdipine (Extended Release) 60 mg PO BID 7. Torsemide 40 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Carvedilol 25 mg PO BID 7. Gabapentin 100 mg PO QHS 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin 9. NIFEdipine (Extended Release) 60 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Torsemide 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on chronic diastolic congestive heart failure SECONDARY DIAGNOSES - Hypertension - History of prior DVT - Anemia, NOS - Chronic Kidney Disease stage IV - Coronary Artery Disease ___ drug eluting stent - Diabetes Mellitus Type 2 controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to the hospital with shortness of breath and weight gain. This was likely caused by an exacerbation of your heart failure possibly from salty foods over the holiday. While you were in the hospital: - we gave you IV diuretics to help remove extra fluid - we checked for pneumonia with a chest x-ray, there was no sign of a pneumonia - we checked for signs on new clots in your legs, there was no new clot Now that you are going home: - continue to take all of your medications as prescribed - monitor your salt intake, this should be no more than 2 grams every day, ask your doctors for help with this if you do not know how to keep track of your salt - continue to weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. - follow-up with your primary care doctor regarding your blood pressure and blood sugar control It was a pleasure taking care of you! Your ___ Inpatient Care Team Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] with history of coronary artery disease c/b ischemic MR [MASKED] DES to LCX [MASKED], TTE [MASKED] with mild regional LV systolic dysfunction), heart failure with preserved ejection fraction (LVEF 50% [MASKED], peripheral vascular disease, chronic kidney disease (stage IV), prior unprovoked DVT c/b severe UGIB while on AC, HTN, dyslipidemia, and T2DM who presents with several days of shortness of breath. Patients says that she first noticed rather acute onset dyspnea starting [MASKED] when trying to walk up the stairs in her home. She had to sit down and catch her breath, whereas just days prior she was able to mount [MASKED] of stairs without difficulty. Patient denies any associated chest pain or palpitations. No dizziness or lightheadedness. Patient further denies any cough, fevers/chills, or pleuritic chest discomfort. She has not experienced any symptoms consistent with orthopnea or PND. No increased [MASKED] swelling, patient notes that she has experienced this in the past. Patient takes her weight nearly every day, 7lbs reported weight gain over the past week (154lbs -> 161lbs), which she attributes to eating more over the [MASKED]. She is currently taking torsemide 40mg qd, no missed doses. No issues with abdominal bloating or constipation. No recent travel. Patient's husband just recovered from a viral URI. In the ED, initial VS were: 97.2 90 186/87 22 100% RA Exam notable for: Obvious bilateral wheezing. No overt volume overload. EKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479, q-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no STEs. Labs showed: CBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97) BMP 142/4.8/105/[MASKED]/2.4/189 Trop <.01 proBNP 4512 VBG 7.33/40 UA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG, blood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG, RBC 1, WBC 1, few bacteria Imaging showed: CXR [MASKED] FINDINGS: Lungs are moderately well-expanded. There is an asymmetric right lower lung opacity, new from [MASKED]. The heart appears mildly enlarged and there is mild pulmonary vascular congestion. No pleural effusion or pneumothorax. IMPRESSION: Right lower lobe opacity could represent pneumonia in the right clinical setting, although atelectasis or asymmetric pulmonary edema could account for this finding. Dedicated PA and lateral views could be helpful for further assessment. Consults: NONE Patient received: [MASKED] 21:45 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:08 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:08 IH Ipratropium Bromide Neb 1 NEB [MASKED] 22:47 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:47 IH Ipratropium Bromide Neb 1 NEB [MASKED] 22:51 IV Azithromycin [MASKED] 22:51 IV CefTRIAXone [MASKED] 22:51 PO PredniSONE 60 mg [MASKED] 22:51 IV Furosemide 80 mg [MASKED] 23:01 IV CefTRIAXone 1 gm [MASKED] 00:13 IV Azithromycin 500 mg [MASKED] 00:23 PO/NG Atorvastatin 80 mg [MASKED] 00:23 PO/NG Carvedilol 25 mg [MASKED] 00:23 PO NIFEdipine (Extended Release) 60 mg [MASKED] 00:23 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 00:23 IH Ipratropium Bromide Neb 1 NEB [MASKED] 00:26 PO/NG Gabapentin 100 mg [MASKED] 00:44 SC Insulin 4 Units Transfer VS were: 98.2 77 141/76 18 100% 2L NC On arrival to the floor, patient recounts the history as above. She says that she feels improved after treatment in the ED, no ongoing SOB. 10-point ROS is otherwise NEGATIVE. Past Medical History: Coronary artery disease Peripheral vascular disease Type II Diabetes Mellitus c/b diabetic retinopathy Obesity Esophageal ring Hypertension Dyslipidemia Bilateral unprovoked posterior tibial DVTs ([MASKED]) off AC given severe UGIB CKD Stage IV iso DM/HTN, secondary hyperparathyroidism Anemia Gout Social History: [MASKED] Family History: Niece had some sort of cancer. Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ============================== ADMISSION PHYSICAL EXAM ============================== VS: 97.5 162/93 78 16 100RA GENERAL: Pleasant female appearing younger than her stated age, taking deep breaths while speaking HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: JVD 10 CM. HEART: RRR, S1/S2, no murmurs, gallops, or rubs. LUNGS: CTAB, no wheezes. ABDOMEN: Obese abdomen, normoactive BS throughout, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. PULSES: 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused, no excoriations or lesions, no rashes. ============================== DISCHARGE PHYSICAL EXAM ============================== VS: Afeb, 144/78, HR 57, 97% RA, RR 12 GEN: Well appearing in NAD Neck: No JVD appreciated CV: RRR no m/r/g, no carotid bruits appreciated PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion EXT: warm well perfused, no pitting edema Pertinent Results: ============================== ADMISSION LABS ============================== [MASKED] 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8* MCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt [MASKED] [MASKED] 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4* Eos-1.8 Baso-0.3 Im [MASKED] AbsNeut-4.49 AbsLymp-1.05* AbsMono-0.26 AbsEos-0.11 AbsBaso-0.02 [MASKED] 06:40AM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142 K-4.8 Cl-105 HCO3-20* AnGap-17 [MASKED] 09:37PM BLOOD proBNP-4512* [MASKED] 09:37PM BLOOD cTropnT-<0.01 [MASKED] 06:40AM BLOOD CK-MB-6 cTropnT-0.05* [MASKED] 02:01PM BLOOD CK-MB-5 cTropnT-0.04* [MASKED] 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3 [MASKED] 09:41PM BLOOD [MASKED] pO2-30* pCO2-40 pH-7.33* calTCO2-22 Base XS--5 ============================== IMAGING ============================== TTE [MASKED]: The left atrial volume index is mildly increased. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal, inferior, inferolateral as well as mid inferior/inferoseptal wall motion abnormalities. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) Mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory. 2) Grade II LV diastolic dysfunction. Compared with the prior study (images reviewed) of [MASKED], LV sytolic function appears mildly less vigorous. Regional wall motion abnormalities encompassess slightly greater territory. CXR PA & LAT [MASKED]: No focal consolidation or pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND [MASKED]: 1. Nonocclusive thrombosis of one of the paired posterior tibial veins in the bilateral lower extremities which appears grossly unchanged compared to bilateral lower extremity ultrasound [MASKED]. No new deep venous thrombosis in either extremity. 2. Right [MASKED] cyst measuring up to 1.8 cm across maximal diameter is unchanged in size compared to [MASKED]. ============================== MICROBIOLOGY ============================== URINE CULTURE [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. BLOOD CULTURE [MASKED]: Blood Culture: PENDING BLOOD CULTURE [MASKED]: Blood Culture: PENDING ============================== DISCHARGE LABS ============================== [MASKED] 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5* MCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147 K-4.0 Cl-105 HCO3-24 AnGap-[MASKED] yo F PMH CAD c/b ischemic MR [MASKED] DES to [MASKED] [MASKED], TTE [MASKED] with mild regional LV systolic dysfunction), HFpEF (LVEF 50% [MASKED], PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC, T2DM presents with subacute SOB, weight gain, c/f acute heart failure exacerbation. She underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. [MASKED] showed no acute DVT, CXR without sign of consolidation. Given her improvement in dyspnea, no supplemental O2 requirement, the patient was discharged w/o medication changes. # Shortness of breath # Hypoxia # acute exacerbation of chronic diastolic heart failure with preserved LVEF (50%) Dry weight per pt 154 lbs. Admission weight above baseline, BNP elevated. Regarding trigger, suspect dietary vs uncontrolled BP. No EKG changes for ACS, trop negative, repeat TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory, as well as Grade II LV diastolic dysfunction and similar to prior [MASKED] TTE. Doubt PNA given CXR and lack of cough/fever, doubt PE given low Wells' score 1.5, and stable repeat [MASKED]. Underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and carvedilol 25mg BID. Was stable on RA prior to discharge. # Hypertension - Patient missed her antiHTN medications earlier day of admission. Continued home carvedilol 25mg BID and nifedipine 60mg BID with holding parameters. Appears that a trial of [MASKED] or spironolactone would be limited by hyperkalemia, so this was deferred. # Urinary frequency/urge incontinence: occurred in setting of diuresis, however UCx ordered in ED did grow enterococci, likely colonization. If symptoms persists would revaluate/treat. CHRONIC STABLE ISSUES # Normocytic anemia (recent baseline Hb 9.4 [MASKED] - Hb was at baseline, no signs of active bleeding. Likely multifactorial, anemia of chronic disease as well as decreased erythropoiten production iso CKD. # Non anion gap metabolic acidosis - Patient has intermittently had a NAGMA in the past. No recent diarrhea. [MASKED] suspect Type IV RTA given advanced age and history of T2DM (both of which can cause hyporeninemia). # Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD iso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na diet. Continued home calcitriol, avoided nephrotoxins and renally dosed all medications. # Coronary artery disease [MASKED] DES to LCX [MASKED]: troponins were trended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was flat. Patient deneied any chest pain. A TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory and similar to prior [MASKED] TTE. Continued home aspirin 81mg qd, home carvedilol 25mg BID with holding parameters, home atorvastatin 80mg qHS. # Type II Diabetes Mellitus (last HbA1C 6.4% [MASKED] - Under excellent control, most recently in the pre-diabetic range. - Continue home 70/30 sliding scale ( t dinner if blood sugar over 130, 10 units 90-130, none if blood sugar under 90) # Dyslipidemia: continued home atorvastatin # Insomnia: continued home gabapentin # Gout: continued home allopurinol ============================== TRANSITIONAL ISSUES ============================== - Discharge weight: 69.2kg - Discharge creatinine: 2.6 - Discharge oral diuretic: torsemide 40mg daily - Transitional issue: consider outpatient epo with renal - Transitional issue: BP goal of 140/90 per accord or even 130/80 per ACC/AHA [MASKED] guidelines however anticipate difficulty in adding additional agents iso CKD (limits use of clonidine) and baseline potassium (would likely limit [MASKED] or spironolactone) - TTE showed prior LV hypokinesis, could consider MIBI or outpatient pharmacological stress test - had some urinary retention/incontinence while undergoing IV diuresis would assess for recurrent symptoms at routine outpatient visits #CODE: Full (confirmed) #CONTACT: [MASKED] (husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.5 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. Gabapentin 100 mg PO QHS 6. NIFEdipine (Extended Release) 60 mg PO BID 7. Torsemide 40 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Allopurinol [MASKED] mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Carvedilol 25 mg PO BID 7. Gabapentin 100 mg PO QHS 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin 9. NIFEdipine (Extended Release) 60 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Torsemide 40 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on chronic diastolic congestive heart failure SECONDARY DIAGNOSES - Hypertension - History of prior DVT - Anemia, NOS - Chronic Kidney Disease stage IV - Coronary Artery Disease [MASKED] drug eluting stent - Diabetes Mellitus Type 2 controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted to the hospital with shortness of breath and weight gain. This was likely caused by an exacerbation of your heart failure possibly from salty foods over the holiday. While you were in the hospital: - we gave you IV diuretics to help remove extra fluid - we checked for pneumonia with a chest x-ray, there was no sign of a pneumonia - we checked for signs on new clots in your legs, there was no new clot Now that you are going home: - continue to take all of your medications as prescribed - monitor your salt intake, this should be no more than 2 grams every day, ask your doctors for help with this if you do not know how to keep track of your salt - continue to weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. - follow-up with your primary care doctor regarding your blood pressure and blood sugar control It was a pleasure taking care of you! Your [MASKED] Inpatient Care Team Followup Instructions: [MASKED]

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fatigue, anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleeding, who was sent to ___ by her physician for anemia (Hgb 6.5). The patient was admitted to ___ in ___ with unprovoked bilateral lower extremity DVTs. She was started on heparin as an inpatient, but anticoagulation was complicated by severely elevated PTT (>150) and upper GI bleed. Endoscopy was notable for significant erythema, superficial ulceration, and gastritis without active bleeding. She was placed on BID PPI prophylaxis. She was eventually bridged to Coumadin for a planned 6 month course. Her INR is managed by her rehab facility, and she is followed by Dr. ___ in ___ clinic. For the last two weeks she has noted increasing fatigue along with shortness of breath, exertional sub-sternal chest pain relieved with rest, and symmetrical lower extremity swelling. During this period she reports that her appetite remained good, and he bowel function was normal. She denies bloody stools or dark stool. On ___ she presented to her PCP office from rehab reporting increasing shortness of breath and fatigue. She was found to have a Hgb of 6.5, with an unconcerning CXR. She was sent to the ___ ED. In the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR: 16 SPO2: 100% RA. Exam was notable for guiac negative stool. Imaging was notable for: "1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst." The patient was transfused with 2 units of pRBCs, with appropriate increase in Hgb to 9.0. Following transfusion, a repeat CXR was notable for pulmonary edema with bilateral pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix in the ED. The decision was made to admit the patient for anemia and flash pulmonary edema. On the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: 76. She reports no acute complaints, and that her shortness of breath has resolved. She denies chest pain, dizziness, lightheadedness. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (hx of MI in ___ BMS to circumflex and POBA ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: ___ Family History: Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: ___ General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Crackles to the mid-lungs bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 2+ pitting edema in dependent areas to the buttocks Skin: no rashes noted Neuro: ___ strength in deltoids, biceps, triceps, wrist extensors, finger extensors, hip flexors, hamstrings, quadriceps, gastrocs, tibialis anterior, bilaterally. Sensation intact bilaterally. PSYCH: Alert and fully oriented; normal mood and affect. sometimes slow to respond and responding with repetitive answers but otherwise appropriate DISCHARGE PHYSICAL EXAM: VS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ pitting edema in shins bilaterally Skin: no rashes noted Pertinent Results: LABORATORY STUDIES ON ADMISSION ============================================= ___ 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6* MCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6* ___ 12:30PM ___ ___ 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* IRON-61 ___ 12:30PM calTIBC-303 FERRITIN-155* TRF-233 ___ 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 ___ 04:50PM LD(___)-247 TOT BILI-0.2 ___ 04:50PM HAPTOGLOB-188 IMAGING: ============================================== LENIs (___) 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. CXR (___): 1. New mild pulmonary edema with persistent small bilateral pleural effusions. 2. Severe cardiomegaly is likely accentuated due to low lung volumes and patient positioning. CXR (___): As compared to ___, the lung volumes have slightly decreased. Signs of mild overinflation and moderate pleural effusions persist. Moderate cardiomegaly. Elongation of the descending aorta. No pneumonia. LABORAROTY STUDIES ON DISCHARGE ============================================== ___ 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0* MCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt ___ ___ 05:45AM BLOOD ___ PTT-30.6 ___ ___ 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 ___ 04:50PM BLOOD LD(LDH)-247 TotBili-0.2 ___ 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7 Brief Hospital Course: Ms. ___ is a ___ year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleed, who was sent to ___ by her physician for anemia. # Anemia: Patient presented with Hgb of 6.5, down from her recent baseline of ~7.5 since her ___ hospitalization. Upon presentation she had a new macrocytic anemia. Hemolysis labs were negative. She received two units of packed red cells with an appropriate rise in her Hgb to 9.0. Stool was guiac negative, with no reports of dark stool or blood in stool. Her hemoglobin remained stable at this level, there was no overt bleeding, and her stool was guiac negative. After transfusion the patient reported significant improvement in her shortness of breath and fatigue. Given her history of gastritis and diverticulosis, a GI bleed was believed responsible for her anemia. Patient should receive an EGD/colonoscopy as an outpatient. # Acute exacerbation of heart failure with preserved ejection fraction: The patient was also found to be slightly volume overloaded, and was treated with 2x40mg IV Lasix, with good urine output and symptomatic improvement. Her pulmonary edema and peripheral edema resolved with diuresis. CHRONIC ISSUES: # Gastic ulceration: Continued on home pantoprazole BID # Hypertension: Continued on home nifedipine, carvadilol, lisinopril. # Stage IV Chronic Kidney Disease: Creatinine remained at baseline (b/l Cr 2.1-2.6) during admission. TRANSITIONAL ISSUES ====================== --Patient's Anemia is thought to be due to slow GI bleed given history of gastritis and diverticulosis. Please schedule EGD/colonoscopy within the next month --Patient continued on Coumadin for bilateral DVTs; please continue to weigh the risks and benefits of anticoagulation given history of bleed. --Discharge weight: 167.7 # CONTACT: ___ ___ # CODE: full, confirmed Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. NIFEdipine CR 30 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 100 mg PO QHS neuropathic pain 11. Pantoprazole 40 mg PO Q12H 12. Senna 8.6 mg PO BID constipation 13. Warfarin 4 mg PO 3X/WEEK (___) 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Furosemide 20 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 18. Warfarin 3 mg PO 4X/WEEK (___) 19. 70/30 30 Units Dinner Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6H:PRN Disp #*120 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Gabapentin 100 mg PO QHS neuropathic pain RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 7. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 9. NIFEdipine CR 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp #*10 Tablet Refills:*0 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 13. Senna 8.6 mg PO BID constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*60 Capsule Refills:*0 14. Vitamin D ___ UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Warfarin 4 mg PO 3X/WEEK (___) RX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet Refills:*0 16. Warfarin 3 mg PO 4X/WEEK (___) RX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet Refills:*0 17. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 18. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth EVERY OTHER DAY Disp #*30 Tablet Refills:*0 19. 70/30 30 Units Dinner RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2 Package Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Anemia Congestive heart failure exacerbation Secondary diagnosis: Hypertension DMII on insulin Coronary artery disease Stage IV chronic kidney disease Deep vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, It was a pleasure caring for you. You were admitted to the hospital with fatigue, chest pain, and shortness of breath. You were found to have too few red blood cells (anemia). We gave you blood, and your symptoms improved. Additionally, you were found to have too much fluid in your legs and lungs. We treated you with a diuretic, which helped eliminate the fluid. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your ___ Team Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fatigue, anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleeding, who was sent to [MASKED] by her physician for anemia (Hgb 6.5). The patient was admitted to [MASKED] in [MASKED] with unprovoked bilateral lower extremity DVTs. She was started on heparin as an inpatient, but anticoagulation was complicated by severely elevated PTT (>150) and upper GI bleed. Endoscopy was notable for significant erythema, superficial ulceration, and gastritis without active bleeding. She was placed on BID PPI prophylaxis. She was eventually bridged to Coumadin for a planned 6 month course. Her INR is managed by her rehab facility, and she is followed by Dr. [MASKED] in [MASKED] clinic. For the last two weeks she has noted increasing fatigue along with shortness of breath, exertional sub-sternal chest pain relieved with rest, and symmetrical lower extremity swelling. During this period she reports that her appetite remained good, and he bowel function was normal. She denies bloody stools or dark stool. On [MASKED] she presented to her PCP office from rehab reporting increasing shortness of breath and fatigue. She was found to have a Hgb of 6.5, with an unconcerning CXR. She was sent to the [MASKED] ED. In the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR: 16 SPO2: 100% RA. Exam was notable for guiac negative stool. Imaging was notable for: "1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex [MASKED] cyst." The patient was transfused with 2 units of pRBCs, with appropriate increase in Hgb to 9.0. Following transfusion, a repeat CXR was notable for pulmonary edema with bilateral pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix in the ED. The decision was made to admit the patient for anemia and flash pulmonary edema. On the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: 76. She reports no acute complaints, and that her shortness of breath has resolved. She denies chest pain, dizziness, lightheadedness. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in [MASKED] - CAD (hx of MI in [MASKED] BMS to circumflex and POBA [MASKED] - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: [MASKED] Family History: Niece had some sort of cancer. Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: [MASKED] General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Crackles to the mid-lungs bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 2+ pitting edema in dependent areas to the buttocks Skin: no rashes noted Neuro: [MASKED] strength in deltoids, biceps, triceps, wrist extensors, finger extensors, hip flexors, hamstrings, quadriceps, gastrocs, tibialis anterior, bilaterally. Sensation intact bilaterally. PSYCH: Alert and fully oriented; normal mood and affect. sometimes slow to respond and responding with repetitive answers but otherwise appropriate DISCHARGE PHYSICAL EXAM: VS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ pitting edema in shins bilaterally Skin: no rashes noted Pertinent Results: LABORATORY STUDIES ON ADMISSION ============================================= [MASKED] 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6* MCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6* [MASKED] 12:30PM [MASKED] [MASKED] 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* IRON-61 [MASKED] 12:30PM calTIBC-303 FERRITIN-155* TRF-233 [MASKED] 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 [MASKED] 04:50PM LD([MASKED])-247 TOT BILI-0.2 [MASKED] 04:50PM HAPTOGLOB-188 IMAGING: ============================================== LENIs ([MASKED]) 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex [MASKED] cyst. CXR ([MASKED]): 1. New mild pulmonary edema with persistent small bilateral pleural effusions. 2. Severe cardiomegaly is likely accentuated due to low lung volumes and patient positioning. CXR ([MASKED]): As compared to [MASKED], the lung volumes have slightly decreased. Signs of mild overinflation and moderate pleural effusions persist. Moderate cardiomegaly. Elongation of the descending aorta. No pneumonia. LABORAROTY STUDIES ON DISCHARGE ============================================== [MASKED] 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0* MCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt [MASKED] [MASKED] 05:45AM BLOOD [MASKED] PTT-30.6 [MASKED] [MASKED] 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 [MASKED] 04:50PM BLOOD LD(LDH)-247 TotBili-0.2 [MASKED] 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7 Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleed, who was sent to [MASKED] by her physician for anemia. # Anemia: Patient presented with Hgb of 6.5, down from her recent baseline of ~7.5 since her [MASKED] hospitalization. Upon presentation she had a new macrocytic anemia. Hemolysis labs were negative. She received two units of packed red cells with an appropriate rise in her Hgb to 9.0. Stool was guiac negative, with no reports of dark stool or blood in stool. Her hemoglobin remained stable at this level, there was no overt bleeding, and her stool was guiac negative. After transfusion the patient reported significant improvement in her shortness of breath and fatigue. Given her history of gastritis and diverticulosis, a GI bleed was believed responsible for her anemia. Patient should receive an EGD/colonoscopy as an outpatient. # Acute exacerbation of heart failure with preserved ejection fraction: The patient was also found to be slightly volume overloaded, and was treated with 2x40mg IV Lasix, with good urine output and symptomatic improvement. Her pulmonary edema and peripheral edema resolved with diuresis. CHRONIC ISSUES: # Gastic ulceration: Continued on home pantoprazole BID # Hypertension: Continued on home nifedipine, carvadilol, lisinopril. # Stage IV Chronic Kidney Disease: Creatinine remained at baseline (b/l Cr 2.1-2.6) during admission. TRANSITIONAL ISSUES ====================== --Patient's Anemia is thought to be due to slow GI bleed given history of gastritis and diverticulosis. Please schedule EGD/colonoscopy within the next month --Patient continued on Coumadin for bilateral DVTs; please continue to weigh the risks and benefits of anticoagulation given history of bleed. --Discharge weight: 167.7 # CONTACT: [MASKED] [MASKED] # CODE: full, confirmed Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. NIFEdipine CR 30 mg PO BID 8. Vitamin D [MASKED] UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 100 mg PO QHS neuropathic pain 11. Pantoprazole 40 mg PO Q12H 12. Senna 8.6 mg PO BID constipation 13. Warfarin 4 mg PO 3X/WEEK ([MASKED]) 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Furosemide 20 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 18. Warfarin 3 mg PO 4X/WEEK ([MASKED]) 19. 70/30 30 Units Dinner Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg [MASKED] tablet(s) by mouth Q6H:PRN Disp #*120 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Gabapentin 100 mg PO QHS neuropathic pain RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 7. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 9. NIFEdipine CR 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp #*10 Tablet Refills:*0 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 13. Senna 8.6 mg PO BID constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*60 Capsule Refills:*0 14. Vitamin D [MASKED] UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Warfarin 4 mg PO 3X/WEEK ([MASKED]) RX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet Refills:*0 16. Warfarin 3 mg PO 4X/WEEK ([MASKED]) RX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet Refills:*0 17. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 18. Allopurinol [MASKED] mg PO EVERY OTHER DAY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth EVERY OTHER DAY Disp #*30 Tablet Refills:*0 19. 70/30 30 Units Dinner RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2 Package Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Anemia Congestive heart failure exacerbation Secondary diagnosis: Hypertension DMII on insulin Coronary artery disease Stage IV chronic kidney disease Deep vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], It was a pleasure caring for you. You were admitted to the hospital with fatigue, chest pain, and shortness of breath. You were found to have too few red blood cells (anemia). We gave you blood, and your symptoms improved. Additionally, you were found to have too much fluid in your legs and lungs. We treated you with a diuretic, which helped eliminate the fluid. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of of HTN, CAD s/p DES with ischemic MR and systolic dysfunction, ___ on torsemide, hx of DVT, who presents with 4 days of dyspnea on exertion, leg swelling, and 10 weight gain. Of note, patient was seen in the Heart Failure Clinic with Dr. ___ on ___ where she noted that she has had persistent dyspnea on exertion and PND after a lengthy prior hospitalization for DVT/GIB. At that time she was started on 40mg po torsemide which initially improved her symptoms. Over the holiday she indulged in a high salt diet and developed slow-onset dyspnea on exertion. Denies any medication noncompliance, chest pain, palpitations, palpitations. Describes PND, worsening exercise tolerance (unable to walk >50 feet) and orthopnea. In the ED, patient was found to have 1+ bilateral lower extremity edema, and have bibasilar crackles on exam. Patient underwent CXR, BNP, and was given one dose of IV 40mg Lasix. In the ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to transfer, vitals were 74 188/95 18 100% RA. Patient's labs were remarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN 39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01. Patient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8, Platelet 168, WBC 5.4. Urinalysis still pending upon discharge. EKG: notable for SR 76, with LAD, TWI in the inferior leads which appears unchanged from prior on ___ On the floor she is symptomatically improved since coming to the ED. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (hx of MI in ___ BMS to circumflex and POBA ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: ___ Family History: Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC Admission weight 178lbs GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use, dyspneic at the end of a long sentence. Bibasilar crackles ___ up thorax, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ edema to shins. No femoral bruits. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAMINATION: VS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA weight: 74kg GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. Bibasilar crackles trace, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: dry. No femoral bruits. PULSES: Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS ___ 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8* MCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt ___ ___ 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 Eos-2.4 Baso-0.2 Im ___ AbsNeut-4.38 AbsLymp-0.61* AbsMono-0.27 AbsEos-0.13 AbsBaso-0.01 ___ 12:45PM BLOOD ___ PTT-32.9 ___ ___ 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06 ___ 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* K-5.4* Cl-115* HCO3-19* AnGap-17 ___ 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 ___ ___ 07:38PM BLOOD CK-MB-6 cTropnT-<0.01 ___ 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8 DISCHARGE LABS ===== ___ 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7* MCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt ___ ___ 07:10AM BLOOD ___ ___ 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 K-3.9 Cl-105 HCO3-29 AnGap-14 ___ 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8 IMAGING ===== ___ CXR FINDINGS: There is mild pulmonary edema with superimposed region of more confluent consolidation in the left upper lung. There are possible small bilateral pleural effusions. Moderate cardiomegaly is again seen as well as tortuosity of the descending thoracic aorta. No acute osseous abnormalities. IMPRESSION: Mild pulmonary edema with superimposed left upper lung consolidation, potentially more confluent edema versus superimposed infection. Brief Hospital Course: ___ year-old female with history of hypertension, CAD s/p DES with ischemic MR and systolic dysfunction, ___, hx of DVT, who admitted for CHF exacerbation. # Acute on chronic decompensated heart failure: presented in the setting of high salt diet with dyspnea on exertion, decreased exercise tolerance, ___ edema, crackles on exam, elevated BNP to 10K, 8lbs above dry weight and pulmonary congestion on CXR. Later discovered on pharmacy review that patient had not filled torsemide after last outpatient Cardiology appointment where she was instructed to start taking it. Troponins cycled and negative. On admission, she was placed on a salt and fluid restricted diet. She was diuresed with IV Lasix 80mg for 2 days and then transitioned to po torsemide 40mg with steady weight decline and net negative fluid balance of goal -___ and stable renal function. Electrolytes repleted for goal Mg>2 and K>4. She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. Discharged with close PCP and ___ to monitor weights and blood pressure control. # Hypertension: She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. # Positive U/A: patient asymptomatic but with 32WBCs, ___, +bacteria (although 3 epis). Asymptomatic with no fevers/dysuria/malaise. Urine culture negative. # Left upper lung consolidation: infiltrate per Radiology read on admission CXR. No cough, fevers, leukocytosis. Rereviewed with on-call radiologist who favored pulmonary edema with no need for repeat imaging or PNA treatment unless clinically indicated. Monitored without any significant clinical findings. # DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of thrombus on exam. Daily INR trended and continued on home Coumadin 5mg daily. # Anemia: no signs of external loss, specifically denying any melena. Chronically anemic with baseline ___, presented with Hgb 8. Likely ___ renal disease and ACD however elevated MCV indicates possible reticulocytosis. Altogether low suspicion for GIB so Coumadin was continued. Reticulocytes 2.4 which is inappropriate arguing against acute loss. Trended daily CBC with noted uprising by discharge. # Chronic kidney disease, stage IV- baseline ___, likely ___ HTN and DM. Renally dosed medications and trended Cr with no significant change. # HLD: continued home atorvastatin # DM: held home 25U 70/30. Patient maintained on aspart ISS and glargine qHS with good glycemic control. TRANSITIONAL ISSUES ================== CHF: diuresed with IV lasix, transitioned to po diuretics, discharged home on 40mg po torsemide, to take in the AM and take a banana. Pt complained of unilateral R-sided incomplete hearing loss on day of discharge- was not felt to be related to diuretics but would ___. HTN: increased nifedipine CR to 60mg BID given elevated SBPs. Please f/u at next appointments. Anemia: multiple prior workups showing ACD. Hgb 8s during admission Prior DVT/PE: continued on warfarin, will need continued monitoring DM: stopped home 70/30 while in-house and put on aspart/glargine, discharged on home regimen Discharge weight: 74kg Discharge Cr: 1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS neuropathic pain 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 30 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO BID constipation 14. Vitamin D ___ UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol ___ mg PO EVERY OTHER DAY 17. Torsemide 40 mg PO DAILY 18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner Discharge Medications: 1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner 2. Warfarin 5 mg PO DAILY16 3. Vitamin D ___ UNIT PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Gabapentin 100 mg PO QHS neuropathic pain 10. Lisinopril 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID constipation 15. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 Tablet Refills:*0 16. Pantoprazole 20 mg PO Q12H 17. Carvedilol 25 mg PO BID 18. NIFEdipine CR 60 mg PO BID RX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp #*180 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Acute on chronic decompensated congestive Heart Failure Hypertension Secondary Diagnoses: Anemia Diabetes mellitus Prior deep vein thrombosis Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to ___ for treatment of your congestive heart failure and hypertension. ___ were given IV diuretics with improvement in your symptoms, labs and exam. We increased one of your blood pressure medications and continued your other home medicines. It was a pleasure taking care of ___ during your stay- we wish ___ all the best! - Your ___ Team Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of of HTN, CAD s/p DES with ischemic MR and systolic dysfunction, [MASKED] on torsemide, hx of DVT, who presents with 4 days of dyspnea on exertion, leg swelling, and 10 weight gain. Of note, patient was seen in the Heart Failure Clinic with Dr. [MASKED] on [MASKED] where she noted that she has had persistent dyspnea on exertion and PND after a lengthy prior hospitalization for DVT/GIB. At that time she was started on 40mg po torsemide which initially improved her symptoms. Over the holiday she indulged in a high salt diet and developed slow-onset dyspnea on exertion. Denies any medication noncompliance, chest pain, palpitations, palpitations. Describes PND, worsening exercise tolerance (unable to walk >50 feet) and orthopnea. In the ED, patient was found to have 1+ bilateral lower extremity edema, and have bibasilar crackles on exam. Patient underwent CXR, BNP, and was given one dose of IV 40mg Lasix. In the ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to transfer, vitals were 74 188/95 18 100% RA. Patient's labs were remarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN 39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01. Patient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8, Platelet 168, WBC 5.4. Urinalysis still pending upon discharge. EKG: notable for SR 76, with LAD, TWI in the inferior leads which appears unchanged from prior on [MASKED] On the floor she is symptomatically improved since coming to the ED. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in [MASKED] - CAD (hx of MI in [MASKED] BMS to circumflex and POBA [MASKED] - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: [MASKED] Family History: Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC Admission weight 178lbs GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use, dyspneic at the end of a long sentence. Bibasilar crackles [MASKED] up thorax, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ edema to shins. No femoral bruits. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAMINATION: VS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA weight: 74kg GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. Bibasilar crackles trace, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: dry. No femoral bruits. PULSES: Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS [MASKED] 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8* MCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt [MASKED] [MASKED] 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 Eos-2.4 Baso-0.2 Im [MASKED] AbsNeut-4.38 AbsLymp-0.61* AbsMono-0.27 AbsEos-0.13 AbsBaso-0.01 [MASKED] 12:45PM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06 [MASKED] 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* K-5.4* Cl-115* HCO3-19* AnGap-17 [MASKED] 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 [MASKED] [MASKED] 07:38PM BLOOD CK-MB-6 cTropnT-<0.01 [MASKED] 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8 DISCHARGE LABS ===== [MASKED] 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7* MCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt [MASKED] [MASKED] 07:10AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 K-3.9 Cl-105 HCO3-29 AnGap-14 [MASKED] 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8 IMAGING ===== [MASKED] CXR FINDINGS: There is mild pulmonary edema with superimposed region of more confluent consolidation in the left upper lung. There are possible small bilateral pleural effusions. Moderate cardiomegaly is again seen as well as tortuosity of the descending thoracic aorta. No acute osseous abnormalities. IMPRESSION: Mild pulmonary edema with superimposed left upper lung consolidation, potentially more confluent edema versus superimposed infection. Brief Hospital Course: [MASKED] year-old female with history of hypertension, CAD s/p DES with ischemic MR and systolic dysfunction, [MASKED], hx of DVT, who admitted for CHF exacerbation. # Acute on chronic decompensated heart failure: presented in the setting of high salt diet with dyspnea on exertion, decreased exercise tolerance, [MASKED] edema, crackles on exam, elevated BNP to 10K, 8lbs above dry weight and pulmonary congestion on CXR. Later discovered on pharmacy review that patient had not filled torsemide after last outpatient Cardiology appointment where she was instructed to start taking it. Troponins cycled and negative. On admission, she was placed on a salt and fluid restricted diet. She was diuresed with IV Lasix 80mg for 2 days and then transitioned to po torsemide 40mg with steady weight decline and net negative fluid balance of goal -[MASKED] and stable renal function. Electrolytes repleted for goal Mg>2 and K>4. She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. Discharged with close PCP and [MASKED] to monitor weights and blood pressure control. # Hypertension: She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. # Positive U/A: patient asymptomatic but with 32WBCs, [MASKED], +bacteria (although 3 epis). Asymptomatic with no fevers/dysuria/malaise. Urine culture negative. # Left upper lung consolidation: infiltrate per Radiology read on admission CXR. No cough, fevers, leukocytosis. Rereviewed with on-call radiologist who favored pulmonary edema with no need for repeat imaging or PNA treatment unless clinically indicated. Monitored without any significant clinical findings. # DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of thrombus on exam. Daily INR trended and continued on home Coumadin 5mg daily. # Anemia: no signs of external loss, specifically denying any melena. Chronically anemic with baseline [MASKED], presented with Hgb 8. Likely [MASKED] renal disease and ACD however elevated MCV indicates possible reticulocytosis. Altogether low suspicion for GIB so Coumadin was continued. Reticulocytes 2.4 which is inappropriate arguing against acute loss. Trended daily CBC with noted uprising by discharge. # Chronic kidney disease, stage IV- baseline [MASKED], likely [MASKED] HTN and DM. Renally dosed medications and trended Cr with no significant change. # HLD: continued home atorvastatin # DM: held home 25U 70/30. Patient maintained on aspart ISS and glargine qHS with good glycemic control. TRANSITIONAL ISSUES ================== CHF: diuresed with IV lasix, transitioned to po diuretics, discharged home on 40mg po torsemide, to take in the AM and take a banana. Pt complained of unilateral R-sided incomplete hearing loss on day of discharge- was not felt to be related to diuretics but would [MASKED]. HTN: increased nifedipine CR to 60mg BID given elevated SBPs. Please f/u at next appointments. Anemia: multiple prior workups showing ACD. Hgb 8s during admission Prior DVT/PE: continued on warfarin, will need continued monitoring DM: stopped home 70/30 while in-house and put on aspart/glargine, discharged on home regimen Discharge weight: 74kg Discharge Cr: 1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS neuropathic pain 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 30 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO BID constipation 14. Vitamin D [MASKED] UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol [MASKED] mg PO EVERY OTHER DAY 17. Torsemide 40 mg PO DAILY 18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner Discharge Medications: 1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner 2. Warfarin 5 mg PO DAILY16 3. Vitamin D [MASKED] UNIT PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 5. Allopurinol [MASKED] mg PO EVERY OTHER DAY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Gabapentin 100 mg PO QHS neuropathic pain 10. Lisinopril 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID constipation 15. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 Tablet Refills:*0 16. Pantoprazole 20 mg PO Q12H 17. Carvedilol 25 mg PO BID 18. NIFEdipine CR 60 mg PO BID RX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp #*180 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: Acute on chronic decompensated congestive Heart Failure Hypertension Secondary Diagnoses: Anemia Diabetes mellitus Prior deep vein thrombosis Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. [MASKED], [MASKED] were admitted to [MASKED] for treatment of your congestive heart failure and hypertension. [MASKED] were given IV diuretics with improvement in your symptoms, labs and exam. We increased one of your blood pressure medications and continued your other home medicines. It was a pleasure taking care of [MASKED] during your stay- we wish [MASKED] all the best! - Your [MASKED] Team Followup Instructions: [MASKED]

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

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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old woman s/p robotic radical cystectomy ___ (with ileal conduit creation) with postop course complicated by bacteremia and abscess, LLE DVT (on prophylactic dosing lovenox) who presents with dyspnea on exertion for past 3 days. Briefly, patient was initially admitted to the Urology service from ___ for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from ___ for ileus requiring NGT decompression, TPN. BCx grew Citrobacter, for which CTX was started. CT showed intra-abdominal, interloop, simple fluid collection and LLQ drain was placed by ___. Patient improved, passing BMs and tolerating PO, and was discharged on cipro/flagyl. She was also discharged on PO Bactrim for presumed UTI, though unclear if she actually took this. During this admission, she was noted to have new bilateral ___ edema. LENIs at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins. She was discharged on Enoxaparin Sodium 40 mg SC daily. She reports that her PCP started PO ___ 20mg daily and since then there has been improvement of the swelling. Per her report, a repeat ___ at the rehab facility (___) was negative for DVT. Patient reports that she recovered well post-operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion. She states that she typically is able to ambulate a block before stopping to catch her breath, however in the past week she has been unable to take more than a few steps. She states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom. When visited by the NP her ambulatory saturation was noted to be in the ___ with associated tachycardia to 110, pallor and diaphoresis. She endorses associated leg swelling left worse than right, and she states that her thighs "feel heavy". She denies any associated chest pain, fever, chills, pain with deep inspiration, abdominal pain, rashes, dizziness, lightheadedness. In the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula ED physical exam was recorded as patient resting comfortably with NC, pursed lip breathing, unable to speak in full sentences before becoming short of breath, urostomy pouch in RLQ, stoma pink, 2+ edema to bilateral lower extremities L>R. ED labs were notable for: Hb 9, Hct 29, plt 479, UA: large ___, >182 WBC, many bact 0 epi. Trop neg x1, proBNP normal CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. EKG showed NSR with frequent PAC Patient was given: ___ 20:26 PO/NG Ciprofloxacin HCl 500 mg ___ 20:26 IV Heparin 6600 UNIT ___ 20:26 IV Heparin Transfer VS were: 98.1 77 145/63 20 99% Nasal Cannula When seen on the floor, she reports significant dyspnea with minimal exertion. Denies chest pain, palpitations, lightheadedness. A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. s/p ___: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: ___ Family History: Negative for bladder CA. Physical Exam: ADMISSION EXAM: Gen: NAD, speaking in 3 word sentences, pursed lip breathing, no accessory muscle use, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with compression stockings in place, no JVD Resp: normal effort, no accessory muscle use, lungs CTA ___ to anterior auscultation. GI: soft, NT, ND, BS+. Urostomy site does not appear infected MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect DISCHARGE EXAM: vitals: 98.3 140/42 90 24 96% 1L Gen: Lying in bed in no apparent distress HEENT: Anicteric, MMM Cardiovascular: RRR normal S1, S2, no right sided heave, ___ systolic murmur Pulmonary: Lung fields clear to auscultation throughout. No crackles or wheezing. GI: Soft, distended, nontender, bowel sounds present, urostomy in place. Extremities: no edema, though left leg appears larger than right leg, warm, well perfused with motor function intact. Her left lower leg is wrapped. Pertinent Results: LABS: ========================== Admission labs: ___ 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20 ___ 02:40PM cTropnT-<0.01 ___ 02:40PM proBNP-567 ___ 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95 MCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1* ___ 02:40PM PLT COUNT-479* ___ 02:40PM ___ PTT-33.4 ___ Discharge labs: ___ 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5* MCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt ___ ___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 K-4.3 Cl-105 HCO3-26 AnGap-14 ___ 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 ___ 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103* ___ 07:15AM BLOOD Iron-18* MICROBIOLOGY ========================== ___ 4:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ENTEROCOCCUS SP.. >100,000 CFU/mL. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S IMAGING ========================== ___ CXR IMPRESSION: Hilar congestion without frank edema. No convincing signs of pneumonia. ___ CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. ___ ___: IMPRESSION: 1. Interval progression of deep vein thrombosis in the left lower extremity, with occlusive thrombus involving the entire femoral vein, previously only involving the mid and distal femoral vein. There is additional nonocclusive thrombus in the deep femoral vein. The left common femoral and popliteal veins are patent. 2. The bilateral calf veins were not visualized due to an overlying dressing. Otherwise no evidence of deep venous thrombosis in the right lower extremity. ___ TTE: Conclusions The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ___ CXR IMPRESSION: Compared to chest radiographs ___ through ___. Heart size top-normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course: Ms. ___ is a ___ woman s/p robotic radical cystectomy ___omplicated by bacteremia and abscess, LLE DVT, currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large PE and progression of DVT. # PE/DVT: Likely due to undertreatment of known LLE DVT with prophylactic dosing of lovenox. Given underdosing of lovenox, this was not thought to be treatment failure and IVC filter was deferred. She had no signs of right heart strain on imaging, EKG, exam. TTE showed no evidence of right heart strain. She was treated with a heparin gtt, then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in CLOT trial. She is quite symptomatic and requires oxygen supplementation, though improved during hospitalization. Please wean oxygen as tolerated. # Pulmonary nodules: Known spiculated masses that were noted on CT in ___, concerning for primary lung malignancy vs mets. Current CT showed stable nodules still concerning for malignancy. She was evaluated by the thoracic team who recommended CT biopsy vs. surveillance. Given her current PE/DVT, the family and the patient decided for surveillance at this time. They will follow up with her primary care provider. # Enterococcal UTI She was noted to have rising WBC in the setting of UCX from urostomy growing Enterococcus. Given her rising leukocytosis, we proceeded with treatment. She was started on IV Ampicillin and transitioned to macrobid, based on sensitivies. Leukocytosis improved on antibiotics. She should complete a 7 day course (day 1: ___, day 7: ___. # Normocytic Anemia: No signs of bleeding, or hemolysis. Hb dropped to nadir of 7.3, stable at discharge at 7.5. Iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low TIBC. Would recommend checking again as outpatient and work-up as needed. # ___ swelling: Likley multifactorial including venous insufficiency, as well as known LLE DVT. She responded quite well with compression stockings. # Hx of bladder cancer: s/p ___ TURBT, high-grade TCC, T1 (no muscle identified). Then in ___, pelvic MRI showed bladder mass invasion, perivesical soft tissue, anterior vaginal wall on right (C/W T4 lesion). In ___, underwent robotic TAH-BSO, lap radical cystectomy and anterior vaginectomy with pathology showing pT2b, node and margins negative. No plan for any further therapy at this time per Dr ___. The patient is safe to discharge today, and >30min were spent on discharge day management services. Transitional issues: - She will need follow up chest CT for pulmonary nodules in 3 months (___) - To complete 7 day course for UTI with macrobid (day 7: ___ - Continue oxygen therapy and wean as tolerated to maintain O2 sat > 92% - Please check CBC on ___ to ensure stability of h/h and demonstrate resolution of leukocytosis - HCP: son, Dr. ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Losartan Potassium 50 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. LORazepam 0.25 mg PO BID:PRN anxiety 9. Senna 8.6 mg PO BID Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Last day: ___. Enoxaparin Sodium 90 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 3. LORazepam 0.25 mg PO QHS:PRN insomnia RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp #*3 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 175 mcg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet Refills:*0 9. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___ it was a pleasure taking care you during your admission to ___. You were admitted for a clot in your lungs and leg. You were treated with a blood thinner. You will need to continue the blood thinner. You were also treated for a urinary tract infection. For your pulmonary nodules, you should follow up with your primary care doctor. Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old woman s/p robotic radical cystectomy [MASKED] (with ileal conduit creation) with postop course complicated by bacteremia and abscess, LLE DVT (on prophylactic dosing lovenox) who presents with dyspnea on exertion for past 3 days. Briefly, patient was initially admitted to the Urology service from [MASKED] for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from [MASKED] for ileus requiring NGT decompression, TPN. BCx grew Citrobacter, for which CTX was started. CT showed intra-abdominal, interloop, simple fluid collection and LLQ drain was placed by [MASKED]. Patient improved, passing BMs and tolerating PO, and was discharged on cipro/flagyl. She was also discharged on PO Bactrim for presumed UTI, though unclear if she actually took this. During this admission, she was noted to have new bilateral [MASKED] edema. LENIs at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins. She was discharged on Enoxaparin Sodium 40 mg SC daily. She reports that her PCP started PO [MASKED] 20mg daily and since then there has been improvement of the swelling. Per her report, a repeat [MASKED] at the rehab facility ([MASKED]) was negative for DVT. Patient reports that she recovered well post-operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion. She states that she typically is able to ambulate a block before stopping to catch her breath, however in the past week she has been unable to take more than a few steps. She states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom. When visited by the NP her ambulatory saturation was noted to be in the [MASKED] with associated tachycardia to 110, pallor and diaphoresis. She endorses associated leg swelling left worse than right, and she states that her thighs "feel heavy". She denies any associated chest pain, fever, chills, pain with deep inspiration, abdominal pain, rashes, dizziness, lightheadedness. In the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula ED physical exam was recorded as patient resting comfortably with NC, pursed lip breathing, unable to speak in full sentences before becoming short of breath, urostomy pouch in RLQ, stoma pink, 2+ edema to bilateral lower extremities L>R. ED labs were notable for: Hb 9, Hct 29, plt 479, UA: large [MASKED], >182 WBC, many bact 0 epi. Trop neg x1, proBNP normal CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. EKG showed NSR with frequent PAC Patient was given: [MASKED] 20:26 PO/NG Ciprofloxacin HCl 500 mg [MASKED] 20:26 IV Heparin 6600 UNIT [MASKED] 20:26 IV Heparin Transfer VS were: 98.1 77 145/63 20 99% Nasal Cannula When seen on the floor, she reports significant dyspnea with minimal exertion. Denies chest pain, palpitations, lightheadedness. A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to [MASKED] years ago, laminectomy of L5-S1 at age [MASKED], two vaginal deliveries. s/p [MASKED]: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: ADMISSION EXAM: Gen: NAD, speaking in 3 word sentences, pursed lip breathing, no accessory muscle use, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with compression stockings in place, no JVD Resp: normal effort, no accessory muscle use, lungs CTA [MASKED] to anterior auscultation. GI: soft, NT, ND, BS+. Urostomy site does not appear infected MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect DISCHARGE EXAM: vitals: 98.3 140/42 90 24 96% 1L Gen: Lying in bed in no apparent distress HEENT: Anicteric, MMM Cardiovascular: RRR normal S1, S2, no right sided heave, [MASKED] systolic murmur Pulmonary: Lung fields clear to auscultation throughout. No crackles or wheezing. GI: Soft, distended, nontender, bowel sounds present, urostomy in place. Extremities: no edema, though left leg appears larger than right leg, warm, well perfused with motor function intact. Her left lower leg is wrapped. Pertinent Results: LABS: ========================== Admission labs: [MASKED] 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20 [MASKED] 02:40PM cTropnT-<0.01 [MASKED] 02:40PM proBNP-567 [MASKED] 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95 MCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1* [MASKED] 02:40PM PLT COUNT-479* [MASKED] 02:40PM [MASKED] PTT-33.4 [MASKED] Discharge labs: [MASKED] 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5* MCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt [MASKED] [MASKED] 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 K-4.3 Cl-105 HCO3-26 AnGap-14 [MASKED] 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 [MASKED] 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103* [MASKED] 07:15AM BLOOD Iron-18* MICROBIOLOGY ========================== [MASKED] 4:30 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ENTEROCOCCUS SP.. >100,000 CFU/mL. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S IMAGING ========================== [MASKED] CXR IMPRESSION: Hilar congestion without frank edema. No convincing signs of pneumonia. [MASKED] CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. [MASKED] [MASKED]: IMPRESSION: 1. Interval progression of deep vein thrombosis in the left lower extremity, with occlusive thrombus involving the entire femoral vein, previously only involving the mid and distal femoral vein. There is additional nonocclusive thrombus in the deep femoral vein. The left common femoral and popliteal veins are patent. 2. The bilateral calf veins were not visualized due to an overlying dressing. Otherwise no evidence of deep venous thrombosis in the right lower extremity. [MASKED] TTE: Conclusions The left atrium is normal in size. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. [MASKED] CXR IMPRESSION: Compared to chest radiographs [MASKED] through [MASKED]. Heart size top-normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman s/p robotic radical cystectomy omplicated by bacteremia and abscess, LLE DVT, currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large PE and progression of DVT. # PE/DVT: Likely due to undertreatment of known LLE DVT with prophylactic dosing of lovenox. Given underdosing of lovenox, this was not thought to be treatment failure and IVC filter was deferred. She had no signs of right heart strain on imaging, EKG, exam. TTE showed no evidence of right heart strain. She was treated with a heparin gtt, then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in CLOT trial. She is quite symptomatic and requires oxygen supplementation, though improved during hospitalization. Please wean oxygen as tolerated. # Pulmonary nodules: Known spiculated masses that were noted on CT in [MASKED], concerning for primary lung malignancy vs mets. Current CT showed stable nodules still concerning for malignancy. She was evaluated by the thoracic team who recommended CT biopsy vs. surveillance. Given her current PE/DVT, the family and the patient decided for surveillance at this time. They will follow up with her primary care provider. # Enterococcal UTI She was noted to have rising WBC in the setting of UCX from urostomy growing Enterococcus. Given her rising leukocytosis, we proceeded with treatment. She was started on IV Ampicillin and transitioned to macrobid, based on sensitivies. Leukocytosis improved on antibiotics. She should complete a 7 day course (day 1: [MASKED], day 7: [MASKED]. # Normocytic Anemia: No signs of bleeding, or hemolysis. Hb dropped to nadir of 7.3, stable at discharge at 7.5. Iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low TIBC. Would recommend checking again as outpatient and work-up as needed. # [MASKED] swelling: Likley multifactorial including venous insufficiency, as well as known LLE DVT. She responded quite well with compression stockings. # Hx of bladder cancer: s/p [MASKED] TURBT, high-grade TCC, T1 (no muscle identified). Then in [MASKED], pelvic MRI showed bladder mass invasion, perivesical soft tissue, anterior vaginal wall on right (C/W T4 lesion). In [MASKED], underwent robotic TAH-BSO, lap radical cystectomy and anterior vaginectomy with pathology showing pT2b, node and margins negative. No plan for any further therapy at this time per Dr [MASKED]. The patient is safe to discharge today, and >30min were spent on discharge day management services. Transitional issues: - She will need follow up chest CT for pulmonary nodules in 3 months ([MASKED]) - To complete 7 day course for UTI with macrobid (day 7: [MASKED] - Continue oxygen therapy and wean as tolerated to maintain O2 sat > 92% - Please check CBC on [MASKED] to ensure stability of h/h and demonstrate resolution of leukocytosis - HCP: son, Dr. [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Losartan Potassium 50 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. LORazepam 0.25 mg PO BID:PRN anxiety 9. Senna 8.6 mg PO BID Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Last day: [MASKED]. Enoxaparin Sodium 90 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 3. LORazepam 0.25 mg PO QHS:PRN insomnia RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp #*3 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 175 mcg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet Refills:*0 9. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [MASKED] it was a pleasure taking care you during your admission to [MASKED]. You were admitted for a clot in your lungs and leg. You were treated with a blood thinner. You will need to continue the blood thinner. You were also treated for a urinary tract infection. For your pulmonary nodules, you should follow up with your primary care doctor. Followup Instructions: [MASKED]

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, distention, nausea Major Surgical or Invasive Procedure: Interventional radiology placement of abdominal abscess drain History of Present Illness: ___ F with h/o muscle invasive bladder cancer, returning to the ED POD 15 with abdominal pain, nausea, and distension. She has been obstipated for nearly three days. KUB and CT scan notable for dilated loops, air fluids, and tapering small bowel without an obvious transition point. Labwork notable for ___ and leukocytosis. Concerned for small bowel obstruction or an ileus in presence ___ and leukocytosis she was re-admitted for IVF, bowel rest, NGT decompression. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. s/p ___: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: ___ Family History: Negative for bladder CA. Physical Exam: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I Stoma is well perfused; Urine color is yellow Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. Bilateral lower extremities have 2+ pitting edema but no erythema, callor, pain. Pigtail drain has been removed - dressing c/d/i Pertinent Results: ___ 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2* MCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt ___ ___ 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7* MCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt ___ ___ 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0* MCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___ ___ 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0 MCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt ___ ___ 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* Eos-0 Baso-0 ___ Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* AbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00* ___ 01:04PM BLOOD ___ PTT-30.9 ___ ___ 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 K-4.6 Cl-107 HCO3-26 AnGap-8 ___ 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 ___ 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 K-3.6 Cl-107 HCO3-26 AnGap-11 ___ 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 K-5.0 Cl-96 HCO3-21* AnGap-21* ___ 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77 ___ 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2 ___ 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 ___ 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 Iron-23* ___ 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2 ___ 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89* ___ 05:09AM BLOOD Triglyc-106 ___ 08:30AM BLOOD Triglyc-89 ___ 07:06PM BLOOD Lactate-1.5 ___ 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 Lipase-8 ___ 03:00PM OTHER BODY FLUID Creat-0.5 ___ 7:12 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ ___, @14:35 ON ___. ___ 3:00 pm ABSCESS . PELVIC ASPIRATION. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 10:52 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: Ms. ___ was admitted to Dr. ___ service for management of ileus. Upon admission, a nasogastric tube was placed for decompression. On ___, PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On ___, pt started to pass small amount of flatus. ___ CT scan demonstrated improving ileus, but concern for possible urine leak and increased free fluid. On ___, a LLQ drain was placed by interventional radiology. on ___, pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On ___, pt was advanced to a clear liquid diet. Repeat blood cultures were negative and positive blood culture from admission grew citrobacter. Diet was gradually advanced and ensure added. IV medications were gradually converted to PO and she was re-evaluated by physical therapy for rehabilitative services. She was ambulating with walker assistance and prepared for discharge to her ___ facility (___). TPN was continued up until day before discharge. At time of discharge, she was tolerating regular diet, passing flatus regularly and having bowel movements. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 40 mg SC DAILY 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days Last dose ___ 2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days Last dose ___ 3. Senna 8.6 mg PO BID 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 8. Levothyroxine Sodium 175 mcg PO DAILY 9. LORazepam 0.25 mg PO BID:PRN anxiety 10. Losartan Potassium 50 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: bladder cancer, post-operative ileus, bacteremia (CITROBACTER KOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS GROUP) requiring ___ drainage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -___ (acetaminophen) and Ibuprofen for pain control. -Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through ___. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from ALL sources) PER DAY -If you are taking Ibuprofen (Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger -Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -No heavy lifting for 4 weeks (no more than 10 pounds). Do "not" be sedentary. Walk frequently. Light household chores (cooking, folding laundry, washing dishes) are generally “ok” but AGAIN, avoid straining, pulling, twisting (do NOT vacuum). Followup Instructions: ___

Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain, distention, nausea Major Surgical or Invasive Procedure: Interventional radiology placement of abdominal abscess drain History of Present Illness: [MASKED] F with h/o muscle invasive bladder cancer, returning to the ED POD 15 with abdominal pain, nausea, and distension. She has been obstipated for nearly three days. KUB and CT scan notable for dilated loops, air fluids, and tapering small bowel without an obvious transition point. Labwork notable for [MASKED] and leukocytosis. Concerned for small bowel obstruction or an ileus in presence [MASKED] and leukocytosis she was re-admitted for IVF, bowel rest, NGT decompression. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to [MASKED] years ago, laminectomy of L5-S1 at age [MASKED], two vaginal deliveries. s/p [MASKED]: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I Stoma is well perfused; Urine color is yellow Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. Bilateral lower extremities have 2+ pitting edema but no erythema, callor, pain. Pigtail drain has been removed - dressing c/d/i Pertinent Results: [MASKED] 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2* MCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt [MASKED] [MASKED] 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7* MCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt [MASKED] [MASKED] 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0* MCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt [MASKED] [MASKED] 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0 MCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt [MASKED] [MASKED] 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* Eos-0 Baso-0 [MASKED] Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* AbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:04PM BLOOD [MASKED] PTT-30.9 [MASKED] [MASKED] 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 K-4.6 Cl-107 HCO3-26 AnGap-8 [MASKED] 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 [MASKED] 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 K-3.6 Cl-107 HCO3-26 AnGap-11 [MASKED] 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 K-5.0 Cl-96 HCO3-21* AnGap-21* [MASKED] 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77 [MASKED] 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2 [MASKED] 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 [MASKED] 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 Iron-23* [MASKED] 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2 [MASKED] 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89* [MASKED] 05:09AM BLOOD Triglyc-106 [MASKED] 08:30AM BLOOD Triglyc-89 [MASKED] 07:06PM BLOOD Lactate-1.5 [MASKED] 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 Lipase-8 [MASKED] 03:00PM OTHER BODY FLUID Creat-0.5 [MASKED] 7:12 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). Reported to and read back by [MASKED] [MASKED], @14:35 ON [MASKED]. [MASKED] 3:00 pm ABSCESS . PELVIC ASPIRATION. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. [MASKED] 10:52 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: Ms. [MASKED] was admitted to Dr. [MASKED] service for management of ileus. Upon admission, a nasogastric tube was placed for decompression. On [MASKED], PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On [MASKED], pt started to pass small amount of flatus. [MASKED] CT scan demonstrated improving ileus, but concern for possible urine leak and increased free fluid. On [MASKED], a LLQ drain was placed by interventional radiology. on [MASKED], pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On [MASKED], pt was advanced to a clear liquid diet. Repeat blood cultures were negative and positive blood culture from admission grew citrobacter. Diet was gradually advanced and ensure added. IV medications were gradually converted to PO and she was re-evaluated by physical therapy for rehabilitative services. She was ambulating with walker assistance and prepared for discharge to her [MASKED] facility ([MASKED]). TPN was continued up until day before discharge. At time of discharge, she was tolerating regular diet, passing flatus regularly and having bowel movements. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 40 mg SC DAILY 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days Last dose [MASKED] 2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days Last dose [MASKED] 3. Senna 8.6 mg PO BID 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 8. Levothyroxine Sodium 175 mcg PO DAILY 9. LORazepam 0.25 mg PO BID:PRN anxiety 10. Losartan Potassium 50 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: bladder cancer, post-operative ileus, bacteremia (CITROBACTER KOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS GROUP) requiring [MASKED] drainage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -[MASKED] (acetaminophen) and Ibuprofen for pain control. -Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through [MASKED]. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from ALL sources) PER DAY -If you are taking Ibuprofen (Brand names include [MASKED] this should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger -Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -No heavy lifting for 4 weeks (no more than 10 pounds). Do "not" be sedentary. Walk frequently. Light household chores (cooking, folding laundry, washing dishes) are generally “ok” but AGAIN, avoid straining, pulling, twisting (do NOT vacuum). Followup Instructions: [MASKED]

" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: _(...TRUNCATED)

"Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fevers and chills Major Sur(...TRUNCATED)