Patient presents with glaucoma, characterized by a definitive diagnosis of pigmentary glaucoma. Intraocular pressure measures at 15 mmHg, while the visual field remains normal. Visual acuity is recorded as 20/50. The patient has not undergone prior cataract surgery, but has had LASIK surgery. Additionally, comorbid ocular diseases include macular degeneration.

Patient has been diagnosed with primary open angle glaucoma. The patient's intraocular pressure is a concern and needs monitoring. There is moderate damage observed in the patient's visual field. The visual acuity is recorded at 0.3. The patient has not undergone prior cataract surgery or LASIK surgery. The presence of corneal edema, along with glaucoma, suggests comorbid ocular diseases. The definitive diagnosis is primary open angle glaucoma, and the patient's ocular health requires close attention due to the combination of factors mentioned.

The patient has been diagnosed with glaucoma, specifically primary open-angle glaucoma (POAG). Their intraocular pressure measures at 48 mmHg, indicating elevated pressure within the eye. The patient exhibits advanced glaucomatous field damage in their visual field, and their visual acuity is recorded at 20/150. Notably, the patient has undergone prior cataract surgery. However, they have not had LASIK surgery. In addition to glaucoma, the patient also presents with comorbid ocular diseases, including diabetic retinopathy.

Patient presents with uveitic glaucoma as the definitive diagnosis. Intraocular pressure measures at 28 mmHg. Visual field assessment indicates early field damage. Visual acuity is measured at 20/30. No prior history of cataract surgery or LASIK surgery. Notably, patient also presents with comorbid ocular disease, specifically macular edema.

The individual, aged 39, has been definitively diagnosed with anxiety. They are proficient in English and have reported experiencing significant anxiety symptoms. Their SSASI score is 6, HAM-A score is 20, PHQ-9 score is 7, and HAM-D score is 23, indicating varying levels of anxiety and depressive symptoms. They have also expressed experiencing suicidal ideation. There is no history of dementia. Additional assessment using the GAD-7 and Beck Depression Inventory is ongoing to further understand their condition.

The patient presents with neovascular glaucoma, as evidenced by an intraocular pressure of 22 mmHg. Visual field assessment indicates normal results, and the visual acuity is measured at 0.2. The patient has undergone prior cataract surgery but has not had LASIK surgery. There is no information available about comorbid ocular diseases.

The patient is 25 years old and proficient in English and Swedish. Several anxiety assessment tools have been used to evaluate the patient's condition. The SSASI, HAM-A, PHQ-9, HAM-D, GAD-7, and Beck Depression Inventory scores indicate varying levels of anxiety and depression. The patient reports experiencing suicidal ideation. There is no indication of dementia.

The patient, a 12-year-old individual proficient in English and Spanish, is experiencing symptoms of anxiety. While a definitive diagnosis has not been made, the patient's SSASI score is 12, HAM-A score is 25, HAM-D score is 14, and there are no indications of suicidal ideation or dementia. The patient's condition is being assessed using the PHQ-9, GAD-7, and Beck Depression Inventory scales.

The individual, an adult proficient in English and Dutch, has received a definitive diagnosis of anxiety. Assessments reveal elevated scores on various scales, including HAM-A (18), PHQ-9 (22), HAM-D (24), and GAD-7 (12). Suicidal ideation is present, while dementia is not.

The individual under consideration is a 58-year-old person proficient in English and Turkish languages. A definitive diagnosis of anxiety has been established. Assessments have indicated a SSASI score, a HAM-A score of 12, a HAM-D score of 19, a GAD-7 score of 9, and an 8 on the Beck Depression Inventory. No presence of suicidal ideation has been observed. Additionally, the individual has been diagnosed with dementia.

The patient has a definitive diagnosis of COPD with an FEV1 (Forced Expiratory Volume in 1 second) of 85%. The patient is classified as GOLD stage III. They have experienced three exacerbations in the past year. The prescribed COPD treatments include bronchodilators and steroids. The patient had a smoking history of 5 cigarettes per day until quitting two years ago. They also have a history of interstitial lung disease as a lung comorbidity, and hypertension as another comorbidity.

Patient has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) in stage II according to the GOLD classification. His definitive diagnosis for COPD has been confirmed, and his FEV1 level is measured at 50%. The patient experienced two exacerbations in the past month. Notably, he has never been a smoker. Although he does not currently receive any COPD treatments, he does have a history of asthma as a lung comorbidity. No other comorbidities are present.

The patient, diagnosed with COPD, has a definitive diagnosis and is in Stage IV according to the GOLD classification. Their FEV1 is measured at 65%, indicating impaired lung function. Over the past 12 months, they have experienced 8 exacerbations of their COPD. The patient is undergoing treatment, including using EVB and participating in pulmonary rehabilitation. They have a history of heavy smoking, with a daily consumption of 2 packs of cigarettes. Alongside COPD, the patient has been diagnosed with lung cancer, making it a comorbid condition. No other comorbidities are reported in the medical history.

Patient has a confirmed diagnosis of Chronic Obstructive Pulmonary Disease (COPD) characterized by an FEV1 of 72%, placing him in GOLD stage II. Notably, he experienced his first exacerbation two weeks ago. Current COPD treatments include the administration of steroids. Notably, he has no history of smoking and does not report any lung-related comorbidities. However, he does have a history of glaucoma as an additional comorbidity.

The individual's definitive diagnosis indicates COPD. Their FEV1 value stands at 55%, categorizing them within the early stage of COPD according to the GOLD classification. As of now, there have been no reported exacerbations. Treatment for COPD has not yet been initiated. Furthermore, there is no history of smoking. Additionally, the patient does not have any reported lung comorbidities or other comorbidities.

The patient, diagnosed with breast cancer, has undergone a definitive diagnosis. HER2 status is positive, while information about hormone receptors is not specified. The patient has not received prior chemotherapy or radiotherapy. No prior mastectomy has been performed The patient's performance status is ECOG 1.

The patient's definitive diagnosis is stage III breast cancer. HER2 status is negative, while hormone receptor status is ER+ and PR-. The patient has undergone neoadjuvant chemotherapy and prior stereotactic radiotherapy. A prior mastectomy has been performed. Surgery-related therapy included neoadjuvant chemotherapy. The patient's performance status is ECOG 2.

The patient's breast cancer is at stage 2. The HER2 status is positive, while hormone receptors (PR and ER) are negative. The patient hasn't undergone prior chemotherapy, but has received prior radiotherapy. Mastectomy has not been performed previously. The patient's performance status is Karnofsky 70%.

The patient has been diagnosed with stage IV breast cancer. The cancer is HER2 positive and hormone receptor positive for PR. The patient has undergone prior chemotherapy and radiotherapy treatments. A mastectomy has also been performed previously. The treatment approach included neoadjuvant chemotherapy in relation to surgery. The patient's performance status is ECOG 3, with a Karnofsky score of 50%.

The patient has received a definitive diagnosis of breast cancer. Key details include a negative HER2 status and hormone receptor information. The patient has not undergone prior chemotherapy, radiotherapy, or mastectomy. Their performance status is ECOG 1.

The patient's definitive diagnosis is confirmed through PCR testing. They have shown symptoms such as fever, muscle pain, and shortness of breath. The patient was hospitalized for 5 days, with 2 of those days requiring ventilation. Their vaccination status indicates they have received 1 shot of an mRNA vaccine. The patient's oxygen saturation level is at 95%. They have a history of asthma, a comorbid respiratory disease.

The patient has been diagnosed with COVID-19. The definitive diagnosis was confirmed through PCR testing. The patient exhibited symptoms including fever, headache, and body pains. Due to the severity of the condition, the patient required hospitalization and ventilation support. At the time of assessment, the patient's oxygen saturation level was 96%. The patient had not received any vaccination against COVID-19 prior to this illness. Additionally, the patient had a history of bronchiectasis, a comorbid respiratory disease.

The patient has received a definitive diagnosis of COVID-19 through a PCR test. Their reported symptoms include fever and muscle pain. They have not required hospitalization or ventilation for their condition. The patient's vaccination status indicates that they have received a 2-shot COVID-19 vaccine series along with a booster dose. Their oxygen saturation level is at 97%. There are no comorbid respiratory diseases reported in their medical history.

The patient's definitive diagnosis of COVID-19 is based solely on a positive result from a rapid test. Their reported symptoms include headache and fatigue. They have not required hospitalization or ventilation support. The patient is unvaccinated against COVID-19. Their oxygen saturation level is at 98%. They have a history of asthma as a comorbid respiratory disease.

The individual under consideration has not received a definitive diagnosis for COVID-19. They have experienced symptoms such as headache but have not required hospitalization or ventilation. Their vaccination status indicates that they are unvaccinated. Information regarding their oxygen saturation is not provided. Additionally, there are no reported comorbid respiratory diseases in this case.

The patient has been diagnosed definitively with rheumatoid arthritis and is undergoing active treatment with methotrexate, with no prior DMARD treatment. They are also taking ibuprofen for their condition. The patient has 3 swollen joints and does not have tuberculosis. Comorbidities include hypertension.

The patient's definitive diagnosis is rheumatoid arthritis. Currently, there is no active DMARD treatment, but there was prior treatment with hydroxychloroquine. Prednisone is being used along with other RA medications. The patient has 3 swollen and 2 tender joints. There is no history of tuberculosis. The DAS-28 CRP score is 4. Comorbidities are absent.

The patient has a definitive diagnosis of rheumatoid arthritis. They are currently undergoing active anti-TNF therapy as their DMARD treatment. Prior to this, they were treated with methotrexate. Naproxen is being used as another medication for their rheumatoid arthritis. The patient has 5 swollen joints and 2 tender joints. They have a history of past tuberculosis. There are no comorbidities reported for the patient.

The patient has a definitive diagnosis of rheumatoid arthritis and is currently undergoing active treatment with hydroxychloroquine, without prior DMARD treatment. Additionally, the patient is taking ibuprofen for their condition. They are experiencing symptoms in 6 tender joints and have a DAS-28 CRP score of 5.5. The patient has comorbid diabetes but no history of tuberculosis.

Patient has a definitive diagnosis of rheumatoid arthritis. They are undergoing active anti-TNF therapy as their DMARD treatment, with no prior DMARD treatment or other RA medications. The patient does not have tuberculosis and reports no comorbidities.

The patient's definitive diagnosis is sickle cell anemia (SS genotype). A blood transfusion was administered one week ago. The hemoglobin level is currently 5.8 g/dL. The patient's last vaso-occlusive crisis occurred two months ago. There is no history of stroke.

The individual has been diagnosed with sickle cell anemia (SC), a hereditary blood disorder. Their hemoglobin level is 8.7 g/dl. They have experienced five vaso-occlusive crises in the last 12 months. Additionally, the patient has a history of stroke that occurred 12 years ago. Blood transfusion has never been administered to this patient.

The patient has been diagnosed with sickle cell anemia (SB+). Three weeks ago, the patient received a blood transfusion. Their current hemoglobin level is 10.5. The patient's last vaso-occlusive crisis occurred six months ago, and they have never had a history of stroke.

Patient has been diagnosed with sickle cell anemia. Definitive diagnosis indicates the presence of SS. The patient received a blood transfusion six months ago. Hemoglobin level is recorded at 9.0 g/DL. The patient's most recent vaso-occlusive crisis occurred 2 years ago, while their medical history includes an ischemic stroke that occurred 2 years ago.

This patient, diagnosed with sickle cell anemia, has a hemoglobin level of 7.5 g/dL. They experienced a vaso-occlusive crisis two weeks ago but have no history of stroke. Blood transfusions have not been required in their medical history.

The patient, diagnosed with type 2 diabetes, has a confirmed diagnosis with a definitive assessment. Their HbA1c level stands at 7.2%, indicating their blood glucose control over recent months. Fasting glucose measures 138, while their BMI is 45, signifying their body mass index. The patient is not on insulin therapy nor taking metformin or other anti-diabetic drugs. There are no specific diet restrictions in place. Limited exercise is possible due to being confined to a wheelchair. There is no history of ketoacidosis. The patient has comorbidities including lung cancer, hypertension, and dementia. Recent medical events include a myocardial infarction six months ago.

The individual under consideration exhibits characteristics indicative of type 2 diabetes. The diagnosis is definitive, with a recorded HbA1c level of 4.5 and a glucose level of 95. The patient's BMI is 28, and they do not require insulin treatment. Instead, they are prescribed 5 ml of metformin and a thiazolidinedione as other anti-diabetic medications. The patient adheres to a low-calorie diet and engages in a weekly regimen of walking 2 miles. A history of ketoacidosis is present, along with comorbidities encompassing hypertension and a thyroid disorder. Notably, the patient has not experienced any instances of hospitalization.

The patient is diagnosed with type 2 diabetes. The diagnosis is definitive, indicated by an HbA1c level of 6 and fasting blood sugar of 115. The patient has a BMI of 35. Insulin is being used, along with 8.5 mL of metformin and a sulfonylurea for additional anti-diabetic treatment. Dietary restrictions involve periodic fasting, and the patient engages in 500 meters of daily walking for exercise. There is no history of ketoacidosis, and comorbidities are absent, except for a stroke event in the previous year.

The patient, diagnosed with type 2 diabetes, has received a definitive diagnosis. Their HbA1c level is 5.5, with a glucose level of 100. The patient's BMI is 32. They are not using insulin, but they are taking 5 mL of metformin. No other anti-diabetic drugs are being used. The patient follows a keto diet and engages in regular exercise by jogging 2 miles per day. The patient has a history of ketoacidosis and hypertension. They have never been hospitalized due to their condition.

The patient, diagnosed with type 2 diabetes (HbA1c: 6.3%, fasting blood sugar: 115), has a BMI of 40. Insulin is not currently prescribed, but they are taking 8.5 mL of metformin. No other anti-diabetic drugs are being used. The patient follows a low-calorie diet and does not engage in regular exercise. There's no history of ketoacidosis, but they do have chronic kidney disease as a comorbidity. Hospitalization due to diabetes has not occurred.

An elderly female with past medical history of hypertension, severe aortic stenosis, hyperlipidemia, and right hip arthroplasty. Presents after feeling a snap of her right leg and falling to the ground. No head trauma or loss of consciousness.78 M transferred to nursing home for rehab after CABG. Reportedly readmitted with a small NQWMI. Yesterday, he was noted to have a melanotic stool and then today he had approximately 9 loose BM w/ some melena and some frank blood just prior to transfer, unclear quantity.A 75F with a PMHx significant for severe PVD, CAD, DM, and CKD presented after being found down unresponsive at home. She was found to be hypoglycemic to 29 with hypotension and bradycardia.  Her hypotension and confusion improved with hydration. She had a positive UA which eventually grew klebsiella. She had temp 96.3, respiratory rate 22, BP 102/26, a leukocytosis to 18 and a creatinine of 6 (baseline 2).  Pt has blood cultures positive for group A streptococcus.  On the day of transfer her blood pressure dropped to the 60s.  She was anuric throughout the day.  She received 80mg IV solumedrol this morning in the setting of low BPs and rare eos in urine. On arrival to the MICU pt was awake but drowsy.  On ROS, pt denies pain, lightheadedness, headache, neck pain, sore throat, recent illness or sick contacts, cough, shortness of breath, chest discomfort, heartburn, abd pain, n/v, diarrhea, constipation, dysuria.  Is a poor historian regarding how long she has had a rash on her legs.An 87 yo woman with h/o osteoporosis, multiple recent falls, CAD, who presents from nursing home with C2 fracture.  The patient was in her usual state of health at her nursing home until yesterday morning when she sustained a fall when trying to get up to go to the bathroom.  The fall was not witnessed, but the patient reportedly did not lose consciousness.  The patient complained of neck and rib pain. She was taken to OSH, where she was found to have a comminuted fracture of C2.  In the ED, the patient's VS were T 99.1, BP 106/42, P 101, R 24.  She had an ECG which showed sinus tachycardia and ST depressions in V3 and V4.  CT head was negative for ICH.An 82 man with chronic obstructive pulmonary disease, status-post bioprosthetic atrial valve replacement for atrial stenosis, atrial fibrillation with cardioversion, right nephrectomy for renal cell carcinoma, colon cancer status-post colectomy, presents with 9 day history of productive cough, fever and dyspnea.A 94 year old female with hx recent PE/DVT, atrial fibrillation, CAD presents with fever and abdominal pain.  Earlier, she presented with back pain and shortness of breath. She was found to have bilateral PE's and new afib and started on coumadin. Her HCT dropped slightly, requiring blood transfusion, with guaic positive stools. She was discharged and returned with abdominal cramping and black stools. EGD showed a small gastric and duodenal ulcer (healing), esophageal stricture, no active bleeding.  She also had an abdominal CT  demonstrating a distended gallbladder with gallstones and biliary obstruction with several CBD stones.This is a 41-year-old male patient with medical history of alcohol abuse, cholelithiasis, hypertension, obesity who presented to his local hospital with hematemasis.  On Friday evening he had several episodes of vomiting of bright and dark red material.  In the emergency department, initial vs were: T 98.6 P66 BP145/89 R16 O2 sat 98% RA. He was started on a protonix gtt and octreotide gtt given his elevated liver function tests. Lab tests show elevated lipase,  pancytopenia and coagulopathy. He had a right upper abdominal quadrant ultrasound which demonstrated gallstones and sludge and ascites. As such given new ascites and abdominal pain he was given levofloxacin 750mg IV and flagyl 500mg IV reportedly for spontaneous bacterial peritonitis prophylaxis.  On the floor, he reports that he had two episodes of vomiting of dark red emesis.  Per his nurse it was about 75ml and was gastrocult positive.  He has right upper abdominal quadrant pain radiating to his back.  He also reports slow increase in abdominal girth with more acute distention and lower extremity swelling over the two days prior to admission.  The patient denies fever, chills, night sweats, headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. He also denied chest pain or tightness.A G2P0010 26 yo F, now estimated to 10 weeks pregnant, with 4yr hx of IDDM.  Last menstrual period is not known but was sometime three months ago.  Five days ago, the patient began feeling achy and congested. She had received a flu shot about 1 week prior. She continued to feel poorly and developed hyperemesis. She was seen in the ED (but not admitted), where she was given IVF, Reglan and Tylenol and she was found to have a positive pregnancy test. Today, she returned to the ED with worsening of symptoms. She was admitted to the OB service and given IVF and Reglan. Of note, her labwork demonstrates a blood glucose of 160, bicarbonate of 11, beta-hCG of 3373 and ketones in her urine. Her family noted that she was breathing rapidly and was quite somnolent.  She appears to be in respiratory distress.This is a 24 and 2/7 weeks, 678 gm male, born to a 34-year-old G2, P0 to 3 woman. Prenatal screens were O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and GBS unknown.  This was an IVF pregnancy, notable for bleeding in the first trimester. The mother presented to the Hospital on the morning of delivery with premature rupture of membranes.  Betamethasone was given approximately 18 hours prior to delivery.  The mother was also started on ampicillin, gentamycin, and magnesium sulfate. Mother's labor progressed despite magnesium and she developed fever and chills.  Maximum temperature was 101.2 degrees.  Because of progressive labor and concerns for chorioamnionitis, the decision was made to deliver the infants. Delivery was by cesarean section.  The infant was intubated in the Delivery Room and Apgars were 5 at one and 8 at five minutes.  Examination was notable for an extreme pre-term infant, intubated.  Weight was 678 gm.  Chest x-ray shows respiratory immaturity and diffuse bilateral opacities within the lungs, left greater than right, with increased lung volumes.A 55y/o F with sarcoidosis, COPD, idiopathic cardiomyopathy with EF 40% and diastolic dysfunction, varices s/p TIPS and hypothyroidism presenting today with confusion. She was brought to the ED by her husband for evaluation after he noted worsening asterixis.  While in the waiting room the pt became more combative and then unresponsive.  In the ED: VS - Temp 97.9F, HR 115, BP 122/80, R 18, O2-sat 98% 2L NC.  She was unresponsive but able to protect her airway and so not intubated. She vomited x1 and received Zofran as well as 1.5 L NS. Labs were significant for K 5.5, BUN 46, Cr 2.2 (up from baseline of 0.8), and ammonia of 280. Stool was Guaiac negative. A urinalysis and CXR were done and are pending, and a FAST revealed hepatosplenomegaly but no intraperitoneal fluid.A 80yo male with dementia and past history of CABG, two caths this year patent LIMA, totally occluded SVG to RPDA, SVG to OM2, s/p BMS to LCX, presents with increasing chest pain and nausea over the past few days. The patient has history of repeated episodes of recurrent chest pain with relief with morphine.  Pt is on ASA, Statins, Imdur, and Heparin. Last month’s cath showed patent BMS in LCX and no new lesions.  According to the family, the patient has increasing episodes of chest pain with minimal exertion in the last two weeks.66 yo female pedestrian struck by auto. Unconscious and unresponsive at scene. Multiple fractures and complication secondary to the primary injury. S/p embolization of the avulsed second branch of brachial artery, complicated by exp lap secondary to  suspicion of abdominal compartment syndrome. Not much of the response after weaning the sedation with CT of the head showing extensive interparenchymal hemorrhages throughout.A 43 year old woman with history of transverse myelitis leading to paraplegia, depression, frequent pressure ulcers, presenting with chills and reporting she felt "as if dying". Upon presentation, she denied any shortness of breath, nausea, vomiting, but did report diarrhea with two loose bowel movements per day. Patient reported that she had a fallout with her VNA and has not had any professional wound care.  Patient is agitated, with rigors, complaining of feeling cold and back pain. Patient rolled and found to have a stage IV decubitus ulcer on coccyx and buttocks, heels. Admission labs significant for thrombocytosis,  elevated lactate, and prolonged PT.A 52 year-old woman with chronic obstructive pulmonary disease and breast cancer who presented to an outside hospital with shortness of breath and back pain for several weeks. Had been seen by primary  care provider for the back pain and treated with pain medications. Subsequently developed rash that was thought to be zoster. In the last few days, oxygen requirement increased and she had cough, fevers and sore throat. Noted oxygen saturation of 79% with ambulation at home. At outside hospital she was diagnosed with "multi-focal pneumonia." In the process of obtaining a computerized tomography scan, contrast infiltrated her arm with skin blistering and swelling. She was treated with ceftriaxone and transferred to current hospital.A 67 y.o. M with end stage COPD on home oxygen, tracheobronchomalacia s/p Y-stent, h/o RUL resection for squamous cell carcinoma with Cyberknife treatment. Patient had Y-stent placed complicated by cough and copious secretions requiring multiple therapeutic aspirations.  Last bronchoscopy was at OSH, where patient had copious secretions that were aspirated.  Pt reports compliance with Mucomyst nebs and Mucinex.  Patient reports decreaed appetitie, 50 lb wt loss in 6 months.  Decreased activity tolerance.  Smokes 5 cig/day.  PET scan revealed FDG avid soft tissue mass adjacent to lung resection site with some FDG avid nodes concerning for recurrence.  On arrival, vitals were T98.6 HR86 BP106/78 O289. Pt denied chest pain, palpitations, trauma, F/C, N/V/D. Pt. presents with worsening  SOB with R shoulder pain and weakness.A 90+ year old woman who was recently hospitalized for legionella PNA, and has been continuing her recovery at home with her son.  She had been doing fairly well for the last few days except for some waxing and waning confusion, and perhaps intermittent dysarthria.  The son was getting ready for work at 1:15am today, as per his usual routine.  He looked in on the patient at that time; she appeared to be sleeping comfortably in bed, on her back.  Soon thereafter, he heard her walking to the bathroom. At 1:40am, he heard a loud crash coming from the bathroom.  He found the patient on the floor of the bathroom, making non-verbal utterances and with minimal movement of the right side.This is a 76-year-old female with personal history of diastolic congestive heart failure, atrial fibrillation on Coumadin, presenting with low hematocrit and shortness of breath. Her hematocrit dropped from 28 to 16.9 over the past 6 weeks with progressive shortness of breath, worse with exertion over the past two weeks. She reports orthopnea. She denies fevers, chills, chest pain, palpitaitons, cough, abdominal pain, constipation or diahrrea, melena, blood in her stool, dysuria or rash. Her electrocardiogram present no significant change from previous. Her Guaiac was reported as being positive.A 40-year-old woman with a history of alcoholism complicated by Delirium Tremens and seizures 2 years ago, polysubstance abuse ncluding IV heroin, cocaine, crack (last use 2 years ago), heroin inhalation (last use 2 days ago), hep C, presents for voluntary admission for detox. The patient would like to undergo detoxification so she can take care of her children. She also complains of abdominal pain in lower quadrants, radiating to the back since yesterday. She says the pain has worsened since yesterday and is not related to food intake. She also complains of nausea, vomitting (bilious but nonbloody), and diarrhea (no black or red stools).  She stopped her methadone 1 week ago in an effort to quit drug abuse.  She reports dyspnea on exertion, orthopnea. Also describes weight gain. Labs are significant for elevated lipase.78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial fibrillation on coumadin, ischemic stroke, admitted after presenting to cardiology clinic today with confusion and Somnolence. Of note, she was recently discharged after presyncope/falls.  At that time, lasix was stopped and atenolol was switched to metoprolol as there was concern that blunting of tachycardia could be contributing to falls. She was discharged to rehab (previously living at home).  Per report from the ER, patient has had confusion at home for 3 weeks, though no family accompanies her to corroborate this story, and patient denies this. The patient is not sure why she is in the hospital. She saw her cardiologist today, who referred her to the ER after she appeared to be dehydrated, somnolent, and confused.  The patient denies headache, blurry vision, numbness, tingling or weakness. No CP. +SOB, worsening DOE.  No nausea, vomiting.A 87 year old female NH resident with a history of chronic atrial fibrillation, hypertension and hypothyroidism who presents wit abdominal pain.  She had been in her usual state of health until 5 days ago when she suddenly began to have abdominal pain.  Her abdominal pain was initially intermittent lasting for a few hours at at time.  No clear correlation with food.  Yesterday, she noticed that her pain was much more severe and more localized to the right.  This was accompanied by nausea and vomitting.  She vomitted twice, with clear liquid emesis and was sent to a hospital.  At the hospital, she was noted to have elevated amylase/lipase to 538 and 516 with elevated bili to 4.1 and AST/ALT to 198/115 and was given ciprofloxacin, flagyl and 500cc NS and was transferred to the emergency department.  At the emergency department her vital signs were TM 97.9  HR 83  BP 157/92  RR 18 sat 97% RA.94M with CAD s/p 4v-CABG, CHF, CRI presented with vfib arrest. Initial labs significant for K 2.7. EKG showed sinus rhythm, HR 80 with LAD, prolonged PR, TD 0.5 to 1mm in V4-V6. Echo showed Mildly depressed global left ventricular function, mild to moderate aortic regurgitation and mild mitral regurgitation.A 63 yo man with h/o biphenotypic ALL, now Day + 32 from allogeneic SCT, who presents with one week of worsening SOB and two days of a clear productive cough.  The patient states his SOB occured when lying flat, but not with activity.  Also admitted to chest pressure which would come and go in his left chest no related to the SOB.  Sleeps with 3 pillows (no change from baseline), denies PND; admits to a slight increase in lower extremity edema.  Admits to low grade fevers to the 99's and crampy abdominal pain.  Denies chills, night sweats, vomiting, or diarrhea.  Patient also has a history of CMV infection, aspergillus and Leggionare's disease and is on posaconazole.  His CXR showed an opacification of the left basilar lobe and also right upper lobe concerning for pneumonia as well as a small loculated right pleural effusion.85M dementia, colon cancer and recent colectomy with primary reanastomosis  p/w melena. HCT 30 to 23 but hemodynamically stable. NGL negative.  Exam notable for Tm 99 BP 128/50 HR 70 RR 16 with sat 100 on RA. WD man, NAD. Chest clear, JVP 8cm. RR s1s2. Soft abdomen, well healed surgical scar. No edema or cord. Labs notable for WBC 7K, HCT 24, K+ 4.0, Cr 0.7.51 year-old man with multiple sclerosis, quadriparesis, hypertension, restrictive lung disease, chronic constipation and small bowel obstruction after ileostomy, multiple urinary tract infections (also after placement of suprapubic tube), presents with small bowel obstruction and urinary tract infection. Admitted today as his home health aide noticed his urine output was low, 75cc overnight when he usually has about 1 liter overnight. Over the past two weeks he has had mild earaches, a sorethroat as well as some rhinorrhea. He denies any abdominal pain, has not sujectively noticed any change in abdominal distention. In the Emergency Department, he was noted to be severely dehydrated on exam, and creatinine level was 1.4 up from 0.6.The patient is a 79 yoF w/ a h/o CAD s/p RCA stenting, diastolic CHF, 1+ MR, HTN, Hyperlipidemia, previous smoking history, and atrial fibrillation who presents for direct admission from home for progressive shortness of breath. According to Pt, her primary complaint is not shortness of breath, but cough X 1 week which has been rarely productive of white sputum. She denies associated fevers, chills, nausea, vomiting, pleuritic pain, weight gain, or dietary indiscretion. She also reports a sore throat over the past 3 days. She recently underwent thoracentesis for a moderate size pleueral effusion.  Cytology of the effusion was negative for malignant cells. Pt denies recent palpitations, and reports that she has been compliant with all medications. She admits to recent fatigue and 2 pillow orthopnea which has been present for months.  Current etiology considerations include CHF vs intrinsic pulmonary disease (infiltrative) vs embolic disease.  In order to optimize cardic function with atrial kick, pt underwent cardioversion and became hypotensive with a junctional rhythm requiring intubation.  She was placed on dobutamine.  Off of dobutamine, cardiac monitoring demonstrated a long QTc of 700 and an atrial escape rhythm.A 64 yo female with with history of atrial fibrillation, Chronic Obstructive Pulmonary Disease, hypertension, hyperlipidemia, repair of an atrial septum defect which was complicated by sternal wound infection and post-operative atrial fibrillation treated with amiodarone, was initially admitted through the Emergency Department with shortness of breath and back pain, and was noted to have atrial fibrillation with rapid ventricular response. A computed tomography angiography demonstrated diffuse left anterior descending artery and post-obstructive pneumonia concerning for malignancy. For her atrial fibrillation, she was started on diltiazem. For the pneumonia, she was treated with antibiotics. She was then transferred to the floor later that same night on metoprolol 50 mg tid. While on the floor, she had a bronchoscopy performed which showed external compression of her left mainstem bronchus, and she had a biopsy via fine-needle aspiration, which showed large cell carcinoma. She denies chest pain, shortness of breath and tachypnea. She does note some diaphoresis and occasional palpitations.This 84-year-old man with a history of coronary artery disease presents with 2 days of melena and black colored emesis. Stools becoming less dark, but he had increased lethargy and presented to the emergency department today.  Initial systolic blood pressure recorded in the 60s,  but all in 110-120s after that.  In the ED, he had gastric lavage with coffee ground emesis that cleared with 600 cc of flushing. During the lavage he had chest pressure with mild ST depression V3-V5 that resolved spontaneously.  Patient is on ASPIRIN 81 mg Tablet by mouth daily.A 96 y/o female found unresponsive on ground at nursing home.  Pt was in dining room and found by staff.  Unresponsive for 1 min after found.  Pt cannot recollect events preceding fall but with some c/o HA and some neck/shoulder discomfort. NCHCT showed ~9mm L parietal SDH.  C-spine negative.  Imaging: CT head w/o contrast Acute left subdural hematoma measuring 1.5 cm maximal dimensions with leftward subfalcine herniation of 8 mm, downward transtentorial herniation with obliteration of the left suprasellar cistern, and uncal herniation. No fx, destructive infiltrative lesion involving the skull base.85 y/o F with PMHx of HTN, HL, h/o breast CA and 3cm renal pelvis transitional cell tumor who presented for nephrectomy.  Her post op course was complicated by agitation thought due to narcotics.  Today, she was restarted on her home meds and while on telemetry, pt was noted to be bradycardic to 40s.  Pt was triggered for SBP of 70 and HR of 40 during which she remained asymptomatic.  She was given 1L IVF and her HR/BP trended back up to baseline.  However, there was a second event an hour later when she sat up and became bradycardic in the 30s with associated hypotension. Second episode occurred with position change and again, pt developped junctional rhythm in 30s.This is a 54 year old male patient with an idiopathic pulmonary fibrosis, who called today with worsening dyspnea for 3 days. He had been in unusual state of good health at baseline respiratory status (using 4L nasal canula at rest and 6L with exertion) when 3 days prior to admission, he hugged his cousin who has rats for pets and also the heat came up from the basement of his house. He feels that with these two events, his breathing became acutely worse and he is concerned for allergen exposure. He denies any sick contacts, fevers, chills, rhinorrhea. He did receive flu and pneumovax vaccines.  He has had a recent admission last month with progressive dyspnea on exertion. The computed tomography revealed increased ground glass opacity in lower lobes superimposed on pulmonary fibrosis with elevated eosinophils peripherally (12%). A bronchoalveolar lavage was also positive for eosinophils. He was started on high dose steroids (prednisone 60mg) with plan for close outpatient follow up for eosinophilic lung disease. He was discharged on 2-3L nasal canula. He then represented to the emergency department for spontaneous pneumomediastinum of unclear etiology.  On day of current admission, the patient called his pulmonologist complaining of worsening shortness of breath since Saturday. Yesterday he was at pulmonary rehab and desaturated to the 70s on 6L with minimal exertion, and he is currently on 4L nasal canula at rest.  No sick contacts recently. He was asked to go to ED.  In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC.78 M w/ pmh of CABG in early [**Month (only) 3**] at [**Hospital6 4406**]

   (transferred to nursing home for rehab on [**12-8**] after several falls out

   of bed.) He was then readmitted to [**Hospital6 1749**] on

   [**3120-12-11**] after developing acute pulmonary edema/CHF/unresponsiveness?.

   There was a question whether he had a small MI; he reportedly had a

   small NQWMI. He improved with diuresis and was not intubated. 

   .

   Yesterday, he was noted to have a melanotic stool earlier this evening

   and then approximately 9 loose BM w/ some melena and some frank blood

   just prior to transfer, unclear quantity.Ms [**Known patient lastname 241**] is a [**Age over 90 2398**] year old woman with past medical history significant for hypertension, severe aortic stenosis, hyperlipidemia, arthroplasty.

    .

   Per the patient, she was standing and felt a snap of her right leg and fell to the ground. 

   No head trauma or LOC. She was evaluated by orthopedics and transferred to

   medicine for optimization of her cardiac status. 

   Review of systems:

   Ear, Nose, Throat: Dry mouth

   Cardiovascular: Edema, Orthopnea

   Respiratory: Dyspnea

   Flowsheet Data as of [**3294-3-6**] 10:33 PM

   Vital Signs

   Hemodynamic monitoring

   Fluid Balance 24 hours Since [**96**] AM

   Tmax: 37.5 C (99.5)

   Tcurrent: 37.5 C (99.5)

   HR: 102 (93 - 102) bpm

   BP: 117/54(70) {117/54(70) - 117/54(70)} mmHg

   RR: 24 (15 - 24) insp/min

   SpO2: 100%

   Heart rhythm: ST (Sinus Tachycardia)

   .

   -- Clarify She appears comfortable with adequate pain

   control with prn morphine. Given her tight valvular stenosis,

   she is high risk for general anesthesia.

   - would start standing tylenol 1g q8

   - continue morphine IV prn for breakthrough

   - plan for OR tomorrow am per ortho pending optimization of her cardiac

   function, and improvement in renal function

   .

   # CAD: No clear documentation, however given age calcific

   atherosclerosis is highly likely

   -- continue statin

   -- Hold beta blocker for now

   -- hold aspirin in perioperative period

   .

   # ATRIAL FIBRILLATION: In setting of acute pain and peri-op. Will need

 to monitor as pt with high CHADS score, however in periop period would

   not be able to have systemic anticoagulation

   -- Rate control with beta blocker once stable

   -- If unstable, would use esmolol first, cardiovert last option.

   .

   # HTN: Better controlled on floor. Good BP control essential for

   preventing flash pulmonary edema in setting of AS.

   - continue metoprolol, as above

   - continue to monitor BP and consider adding another [**Doctor Last Name **] such

   as amlodipine 5mg daily if BP sustains above SBP 150s

   .

   # Hyperlipidemia

   - continue simvastatin 40mg PO daily

   .

   # FEN/GI: Low sodium diet, replete lytes PRN

   .

   # CODE: Confirmed DNR/DNIPt is a 75F with a PMHx significant for severe PVD, CAD, DM, and CKD

   who presented to [**Hospital1 **]-[**Location (un) 1375**] on [**6-25**] 

   after being found down unresponsive at home. She was found to be hypoglycemic 

   to 29 with hypotension and bradycardia.  

   Her hypotension and confusion improved with hydration.

   She had a positive UA which eventually grew klebsiella, treated

   initially with levofloxacin. She had a leukocytosis to 18 and a

   creatinine of 6 up from presumed prior baseline of ~2.  On morning of

   transfer, pt had blood cultures result 3/3 bottles positive for GAS,

   her antibiotics were switched to vancomycin which was then changed to

   ceftriaxone.  Her blood pressure dropped to the 60s. She was given a

   bolus of bicarb and transfered to their ICU.  After an additional bolus

   of 500cc she was started on levophed. She was anuric throughout the

   day.  She had a midline placed on right side. She received 80mg IV

   solumedrol this morning in the setting of low BPs and rare eos in

   urine.

   On arrival to the MICU pt was awake but drowsy.  She was receiving

   levophed throughout her transfer. Arrival VS: 96.3 68 102/26 22 97% 2L

   NC on 0.04mcg/kg/min levophed.  On ROS, pt denies pain,

   lightheadedness, headache, neck pain, sore throat, recent illness or

   sick contacts, cough, shortness of breath, chest discomfort, heartburn,

   abd pain, n/v, diarrhea, constipation, dysuria.  Is a poor historian

   regarding how long she has had a rash on her legs. States she has not

   felt ill and she was brought to the hospital because her daughter came

   home and found her sleeping.  Does complain of feeling very thirsty."The patient is an 87 yo woman with h/o osteoporosis, multiple recent

   falls, CAD, who presents from nursing home with C2 fracture and

   evidence of pulmonary emoblus.  The patient was in her usual state of

   health at her nursing home until yesterday morning when she sustained a

   fall when trying to get up to go to the bathroom.  The fall was not

   witnessed, but the patient reportedly did not lose consciousness.  At

   3:30 that afternoon, the patient complained of neck and rib pain. She

   was taken to OSH, where she was found to have a comminuted fracture of

   C2.  She was transferred to [**Hospital1 1**] for further evaluation.  Of note, the

   patient was recently treated for CDiff infection at her nursing

   facility, per discussion with her daughter.

   .

   In the ED, the patient's VS were T 99.1, BP 106/42, P 101, R 24.  She

   had an ECG which showed sinus tachycardia and ST depressions in V3 and

   V4.  CT head was negative for ICH.  She was seen by Trauma surgery, who

   recommended stabalization with a cervical collar for the next six to

   eight weeks, but they deemed that she is not an operable candidate.An 82 M with COPD, s/p bioprosthetic AVR for AS, afib s/p CV, right

   nephrectomy for RCC, colon ca s/p colectomy who presents with 9 day

   hostory of productive cough and fevers.light of stairs baseline.

   dyspnea and productive cough of several weeks. Otherwise patient is

   without any complaints

   In the ED, initial vs were: 80, sbp 100, mid 90s on 6L/NC. Last vital

   signs prior to ER transfer were 98.1, 83, 116/40, 20, 95% on 3L/NC.

   Patient looked comnfortable. 90% room air, INR 8, ABG, ARF, 2 liters

   ivf. guiac + brown, got levo, ceftriaxone.

   Physical Examination

   General Appearance: No acute distress

   Eyes / Conjunctiva: PERRL

   Head, Ears, Nose, Throat: Normocephalic

   Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:

   Systolic)

   Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:

   Present), (Right DP pulse: Present), (Left DP pulse: Present)

   Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :

   RLL, Wheezes : diffuse)

   Abdominal: Soft, Non-tender, Bowel sounds present

   Extremities: Right lower extremity edema: Absent, Left lower extremity

   edema: Absent

   Skin:  Warm

   Neurologic: Attentive, Follows simple commands, Responds to: Verbal

   stimuli, Oriented (to): x3, Movement: Purposeful, Tone: NormalThis is a [**Age over 90 **] year old female with hx recent PE/DVT, atrial

   fibrillation, CAD who is transfered from  [**Hospital3 915**] Hospital for

   ERCP. She has had multiple admissions to [**Hospital3 915**] this past month,

   most recently on [**2963-11-24**]. In early [**Month (only) 776**], she presented with back

   pain and shortness of breath. She was found to have bilateral PE's and

   new afib and started on coumadin. Her HCT dropped slightly, requiring

   blood transfusion, with guaic positive stools. She was discharged and

   returned with abdominal cramping and black stools. She was found to

   have a HCT drop from 32 to 21. She was given vit K, given a blood

   transfusion and started on protonix. She received an IVF filter and

   EGD.  EGD showed a small gastric and duodenal ulcer (healing),

   esophageal stricture, no active bleeding.  She also had an abdominal

   CT  demonstrating a distended gallbladder with gallstones and biliary

   obstruction with several CBD stones.

   Since 12 AM

   Tmax: 38 C (100.4

   Tcurrent: 37.4 C (99.4

   HR: 92 (83 - 94) bpm

   BP: 89/32(54) {89/32(54) - 94/37(60)} mmHg

   RR: 23 (23 - 33) insp/min

   SpO2: 100%

   Heart rhythm: SR (Sinus Rhythm)Ms. [**Known patient lastname **] is a G2P0010 26 yo F, now estimated to 10 weeks pregnant. Pt has 4yr hx of IDDM. LMP is not known but was sometime in [**Month (only) **].

   On [**3243-11-10**], the patient began feeling achy and congested. She

   had received a flu shot about 1 week prior. She continued to

   feel poorly on [**3243-11-11**], and developed hyperemesis. She was seen

   in the ED (but not admitted) at [**Hospital3 **], where she was

   given IVF, Reglan and Tylenol and she was found to have a

   positive pregnancy test. Today, she returned to the ED

   with worsening of symptoms. She was admitted to the OB service

   and given IVF and Reglan. Of note, her labwork 

   demonstrates a blood glucose of 160, bicarbonate of 11, beta-hCG

   of 3373 and ketones in her urine. Her family noted

   that she was breathing rapidly and was quite somnolent. 

   She appears to be in respiratory distress. 

   .

   The falling beta-HCG and trans-abdominal ultrasound indicate

   intra-uterine fetal demise.

   Medications on Admission:

   Lantus 65 units qAM

   Novolog SSI

   Cortef 3mg qAM, 1mg qHS

   .

   Meds on Transfer:

   Levophed

   Dopamine

   Solumedrol 80mg IV

   Amiodarone load

   Insulin in D10Mr. [**Known patient lastname 7952**] is a 41 yo M with PMH ETOH abuse, cholelithiasis, HTN,

   obesity who presented to [**Hospital3 **] with hematemasis.  He reports

   that for the past 6 years he has been drinking [**2-9**] of a 1.7L bottle of

   vodka daily.  On Friday evening he had several episodes of vomiting of

   bright and dark red material for which he presented to [**Hospital1 **].  

   He had an NG tube which reportedly failed to clear with

   lavage and patient self d/c'd the NGT because he was vomiting around

   the tube.  He was given 4mg IV morphine for abdominal pain, ativan 2mg

   IV for withdrawal, protonix 40mg IV, zofran 8mg IV, octreotide 50mcg

   IV, and 1 unit of platelets. 

   In the ED, initial vs were: T 98.6 P66 BP145/89 R16 O2 sat 98% RA. He

   was started on a protonix gtt and octreotide gtt given his elevated

   LFT's.  He was also given a bananna bag.  He had a RUQ ultrasound which

   demonstrated gallstones and sludge and per ED resident report ascites.

   As such given new ascites and abdominal pain he was given levofloxacin

   750mg IV and flagyl 500mg IV reportedly for SBP prophylaxis.  He was

   evaluted by GI in the ED.

   .

   On the floor, he reports that he had two episodes of vomiting of dark

   red emesis.  Per his nurse it was about 75ml and was gastrocult

   positive.  He otherwise endorese RUQ pain radiating to his back.  He

   also reports slow increase in abdominal girth with more acute

   distention and lower extremity swelling over the two days prior to

   admission.

   Physical Examination

   Vitals: BP:153/92 P:64 R: 20 O2: 97% RA

   General: Alert, oriented, no acute distress, no asterixis

   HEENT: Sclera icteric, dry mucous membranes

   Neck: supple, obese, JVP not elevated

   Lungs: bibasilar crackles, no wheezes

   CV: Regular rate and rhythm, [**3-16**] soft nonradiating systolic murmur

   Abdomen:  obese/distended, RUQ and epigastric tenderness to palpation,

   normoactive bowel sounds, no rebound or guarding.

   Ext: warm, well perfused, 1+ pitting edema bilaterally, 2+ pulses

   Labs 

   WBC

                                     2.5

   Hct

                                    36.2

   Plt

                                     28

   Cr

                                     0.5

   Glucose

                                     111

   Other labs: PT / PTT / INR:19.1/31.6/1.7, ALT / AST:37/165, Alk Phos /

   T Bili:130/6.9, Amylase / Lipase:145/288, Albumin:2.5 g/dL, LDH:278

   IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dLInfant is a 24 [**1-31**] week, 678 gm male triplet II who was admitted to the NICU for management of extreme prematurity.

   Infant was born to a 34 y.o. G2P0 now 3 mother. Prenatal screens: O+, antibody negative, HBsAg negative, RPR NR, RI, GBS unknown.  IVF pregnancy notable for bleeding in the first trimester, cerclage placement at 19 weeks, and premature rupture of membranes on [**3435-11-28**] am.

   Mother presented to [**Hospital1 53**]. Betamethasone given [**11-28**] at 0640. Also started on ampicillin, gentamicin, and magnesium sulfate. Mother's labor progressed despite magnesium and she developed chills and a fever (Tm 101.2). Due to progressive labor and concerns for infection, decision made to deliver infants.

   Delivery by Cesarean section. Infant intubated in the Delivery Room and Apgars were 5 at one and 8 at five minutes.

   Infant transported to NICU.

   Exam:

   VS per CareView, of note has required several boluses of NS for low BP.

   Exam notes recorded on newborn examination form.

   Growth measurements: Wt 678 = 25%.

   -- Resp: Infant placed on SIMV. Rec'd 1 dose of surfactant. 

   CXR FINDINGS: There are diffuse bilateral opacities within the lungs, left greater

   than right, with increased lung volumes.  

   No pleural effusion or pneumothorax.  An endotracheal tube is

   seen with tip approximately one vertebral body above the carina.  An umbilical

   vein catheter is seen with tip in the superior vena cava and an umbilical

   artery catheter is seen with tip in the mid-thoracic region.

   The imaged portions of the abdomen show a few [**Last Name (un) 36399**]-filled loops of bowel

   within the left abdomen.  No abnormal soft tissue mass or calcifications.  No

   free interperitoneal air.  The imaged bony structures are unremarkable.The patient is a 55-year-old woman with hepatic sarcoidosis and

   regenerative hyperplasia s/p TIPS [**10/3245**] placed [**1-27**] variceal bleeding

   and portal hypertensive gastropathy s/p TIPS re-do with angioplasty and

   portal vein embolectomy, who was brought to the ED by her husband for

   evaluation after he noted worsening asterixis. While in the waiting room 

   the pt became more combative and then unresponsive. 

   In the ED: VS - Temp 97.9F, HR 115, BP 122/80, R 18, O2-sat 98% 2L NC.

   She was unresponsive but able to protect her airway and so not

   intubated. She vomited x1 and received Zofran as well as 1.5 L NS. Labs

   were significant for K 5.5, BUN 46, Cr 2.2 (up from baseline of 0.8),

   and ammonia of 280. Stool was Guaiac negative. A urinalysis and CXR

   were done and are pending, and a FAST revealed

   hepatosplenomegaly but no intraperitoneal fluid. 

   On arrival to the ICU the pt had another episode of emesis. NGT was

   placed to suction and 1.5L bilious material was drained.

   Allergies:

   Cipro (Oral) (Ciprofloxacin Hcl)

   Hives;

   Doxycycline

   Hives; hallucin

   Paxil (Oral) (Paroxetine Hcl)

   hair loss;

   Quinine

   Rash;

   Compazine (Injection) (Prochlorperazine Edisylate)

   muscle spasm;

   Levaquin (Oral) (Levofloxacin)

   tendinitis of t

   Lithium

   Hives;Mr. [**Name13 (STitle) 5827**] is an 80yo M with dementia, CAD s/p CABG in [**3420**] (LIMA-LAD,

   SVG to OM2, SVG to RPDA), then s/p CABG redo in [**3426**], then s/p 2 caths

   this year with patent LIMA, totally occluded SVG to RPDA, SVG to OM2,

   s/p BMS to LCX on [**1-26**] who presented to [**Hospital3 53**] Hospital

   with increasing chest pain and nausea over the past few days.

   .

   Per report, patient has presented several times since last cathed for

   recurrent angina. Admitted to [**Hospital3 **] on [**3436-4-2**] with recurrent chest  pain. Ruled out for MI. Last episode of chest pressure was the morning of transfer, associated with dry heaves and belching relieved with

   morphine. Pt was continued on ASA, Plavix, Statin, BBker, Imdur and

   placed on Heparin gtt.  Cath last [**Month (only) **] here at [**Hospital1 5**] showed a patent BMS in LCX and no new lesions. According to the

   family he usually has angina once every day or two, but for the past 2

   weeks he has been having angina with any minimal exertion (eg putting

   on his shirt), and waking him several times per night.66 yo female pedestrian struck by auto. Unconscious and unresponsive

   at scene. Multiple fractures and complication secondary to the primary

   injury. S/p embolization of the avulsed second branch of brachial

   artery, complicated by exp lap secondary to  suspicion of abdominal

   compartment syndrome. Not much of the response after weaning the

   sedation but with minimal improvement with CT of the head showing with

   extensive interparenchymal hemorrhages throughout  Tmax: 34.4 C (93.9

   T current: 34.4 C (93.9

   HR: 71 (71 - 88) bpm

   BP: 171/82(120) {158/74(113) - 171/83(122)} mmHg

   RR: 24 (10 - 24) insp/min

   SPO2: 99%

   Heart rhythm: SR (Sinus Rhythm)A 52  year old woman with COPD and breast cancer who presented to an OSH

  with SOB and back pain for several weeks.  Had been seen by PCP for the

  back pain and treated with pain meds.  Subsequently developed rash that

  was thought to be zoster.  In the last few days, increased O2

  requirement (2 liters at baseline --> 4 liters), cough, fevers and sore

  throat.   Noted sat of 79% with ambulation at home.

  At OSH, diagnosed with "multi-focal pneumonia."  In the process of

  obtaining a CT scan, had contrast infiltrate her arm with skin

  blistering and swelling.  Treated with ceftriaxone and transferred to

  [**Hospital1 1**].

  Patient admitted from: Transfer from other hospital

  History obtained from Patient, Medical records

  Physical Examination

  General Appearance: Well nourished, No(t) Anxious, sleepy

  Eyes / Conjunctiva: PERRL, No(t) Sclera edema

  Head, Ears, Nose, Throat: Normocephalic

  Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,

  (Murmur: No(t) Systolic)

  Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:

  Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)

  Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:

  Wheezes :   expiratory, Diminished: ), scoliotic, can feel ribs on the

  back on the right move with breathing

  Abdominal: Soft, Non-tender, Bowel sounds present

  Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, Clubbing

  Musculoskeletal: No(t) Unable to stand

  Skin:  Not assessed, No(t) Jaundice, resolving zoster rash on right

  lateral chest, right arm is wrapped

  Neurologic: Attentive, Follows simple commands, Responds to: Verbal

  stimuli, Oriented (to): person/place/time but sleepy, Movement: Not

  assessed, Tone: Not assessedMs [**Known patient lastname 21112**] is a 43 year old woman with history of transverse

   myelitis leading to paraplegia, depression, frequent pressure

   ulcers, presenting with chills and reporting she felt "as if

   dying". Upon presentation, she denied any shortness of breath,

   nausea, vomiting, but did report diarrhea with two loose bowel

   movements per day. Patient reported that she had a fallout with

   her VNA and has not had any professional wound care since early

   [**Month (only) 51**].

   Patient has a long history of psychiatric and behavioral

   problems. [**Name (NI) **] [**Name2 (NI) **] review, patient was dismissed from the [**Company 110**]

   practice due to abusive behavior against staff. She does not

   have a primary care provider at this time.

   In the ED: Temp 98.9  HR: 90  BP: 109/62  RR: 16  O2 Sat: 97%

   RA. Patient initially thought to be agitated yelling her EMS

   transporters were "white devils". Patient kept in observation

   area, although with rigors, complaining of feeling cold and back

   pain. Patient rolled and found to have a stage IV decubitus

   ulcer on coccyx and buttocks, heels. 

   ==================

     ADMISSION LABS

   ==================

   [**3266-8-26**] 01:50PM BLOOD WBC-10.3 RBC-4.98 Hgb-8.1* Hct-30.7*

   MCV-62* MCH-16.2*# MCHC-26.3* RDW-17.5* Plt Ct-914*

   [**3266-8-26**] 01:50PM BLOOD Neuts-89.0* Bands-0 Lymphs-9.9*

   Monos-0.8* Eos-0.3 Baso-0.1

   [**3266-8-26**] 01:50PM BLOOD PT-15.6* PTT-32.8 INR(PT)-1.4*

   [**3266-8-26**] 01:50PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-135

   K-4.9 Cl-102 HCO3-18* AnGap-20

   [**3266-8-26**] 01:50PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3

   [**3266-8-26**] 04:00PM BLOOD Lipase-17

   [**3266-8-26**] 01:56PM BLOOD Lactate-6.3*

   [**3266-8-26**] 04:12PM BLOOD Lactate-2.9*

   [**3266-8-26**] 06:17PM BLOOD Lactate-1.6Mr. [**Known patient lastname 3887**] is a 67 y.o. M with end stage COPD on home O2 3 L NC,

   tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell

   carcinoma with Cyberknife treatment in [**2764**]. Patient had Y-stent placed

   in [**2769-1-1**] complicated by cough and copious secretions requiring

   multiple therapeutic aspirations.  Last bronchoscopy was [**5-/2769**] at OSH,

   where patient had copious secretions that were aspirated.  Pt reports

   compliance with Mucomyst nebs and Mucinex.  He wears O2 "almost" 24

   hours/day, but always at night. He does not wear his CPAP.  Endorses

   inability to expectorate secretions and having "full feeling" for [**1-7**]

   weeks.  Decreaed appetitie, 50 lb wt loss in 6 months.  Decreased

   activity tolerance.  Smokes 5 cig/day.  PET scan in [**6-12**] revealed FDG

   avid soft tissue mass adjacent to RUL resection site with some FDG avid

   nodes concerning for recurrence.

   On arrival to [**Hospital1 17**], vitals were T98.6 HR86 BP106/78 O289. Pt denied

   chest pain, palpitations, trauma, F/C, N/V/D. R shoulder full PROM,

   limited abduction on active ROM.The patient is a [**Age over 90 **] year old woman who was recently

   hospitalized for legionella PNA, and has been continuing her

   recovery at home with her son.  She had been doing fairly well

   for the last few days except for some waxing and [**Doctor Last Name 279**]

   confusion, and perhaps intermittent dysarthria.

   The son was getting ready for work at 1:15am today, as per his

   usual routine.  He looked in on the patient at that time; she

   appeared to be sleeping comfortably in bed, on her back.  Soon

   thereafter, he heard her walking to the bathroom. At 1:40am, he

   heard a loud crash coming from the bathroom.  He found the

   patient on the floor of the bathroom, making non-verbal

   utterances and with minimal movement of the right side. The glass

   holder which held the toothbrushes was shattered on the floor.

   The son called EMS.  

   HEENT: Eyes closed, non-responsive to verbal stimuli,

   non-verbal, grimaces on sternal rub

   Cranial Nerves:   Pupils equally round and reactive to light, 3

   to 2 mm

   bilaterally. Eyes closed, left gaze preference, normal doll's,

   corneal intact, R facial weakness, tongue was midline

   Motor: spontaneous movement L side; triple flexion on R side. No

   anti-gravity movement.

   Sensation: Winces to noxious stimuli on the right.  Withdraws to

   noxious stimuli on the left

   Upgoing toe on R

   Coordination: unable to test

   Gait: unable to testThis is a 76-year-old female with pmh of diastolic CHF, atrial

   fibrillation on coumadin, presenting with Hct 16.9 and shortness

   of breath. She had routine labs drawn yesterday at her PCP's office.  Once her hematocrit came she was called and instructed to come to the ED. She is also reporting progressive shortness of breath worse with exertion over the past two weeks. She denies fevers, chills, chest pain, palpitaitons, cough,

   abdominal pain, constipation or diahrrea, melena, blood in her stool, dysuria, rash.  She reports orthopnea.

   In the ED: vitals were 98.4  131/49, 60 24  100% 2L.  ekg with NSR, twi in V1, no significant change from previous. Repeat CBC showed Hct 16.1

   with haptoglobin < 20, and elevated LDH to 315. In addition, her guaiac

   was reported as being positive.  

   Past medical history:

   Hypertension

   Atrial flutter/fibrillation, s/p cardioversion [**2797-1-27**]

   Diastolic heart failure

   Hysterectomy

   Bilateral hip replacements

   Social History:

   Married for 53 years with four children. She is retired

   from the airport. She does not smoke or drink.

   Occupation: retired from airport

   Drugs: denies

   Tobacco: denies any history

   Alcohol: denies40 year old woman with a h/o alcoholism c/b

   DTs/seizures 2 years ago, polysubstance abuse including IV heroin,

   cocaine, crack (last use 2 years ago), heroin inhalation (last use 2

   days ago), hep C, presents for voluntary admission for detox. The

   patient would like to undergo detoxification so she can take care of

   her children. She also complains of abdominal pain, [**12-24**], lower

   quadrants, radiating to the back since yesterday. She cannot describe

   any relationship with food as she has not eaten anything. She says the

   pain has worsened since yesterday. She also complains of nausea,

   vomitting (bilious but nonbloody), and diarrhea (no black or red

   stools). Her last drink was 9am on [**3154-2-15**]. Recently stopped her

   methadone 1 week ago in an effort to quit drug abuse.

   .

   In the ED she was 98.6 101 149/96 20 96. She was [**Doctor Last Name 2062**] 16-25 on CIWA.

   ROS:

   (+)

   Reports DOE, orthopnea. Also describes weight gain since given birth to

   her child 17 months ago, she attributes this to her recent pregnancy.

   She complains of tremors and also complains of a moderate headache

   that's been stable.

   .

   (-)

   Denies CP, fevers, chills, or cough, palpitations, edema, joint pains,

   rashes, AVH, SI, or HI.

   Past Medical History:

   -Alcoholism (drinks baseline 1 pint of liquor/day, past week drinking 1

   liter of vodka/day)

   -Polysubstance abuse - including cocaine, IV heroin, and crack 2 years

   ago, snorting heroin 2 days ago.

   -Hep C, never treated, unknown severity, genotype, etc

   -Infectious endocarditis in her 20s, 6 wks of abx no surgeries

   -No h/o STDs, HIV neg 3 weeks ago

   -Hep B immunized

   Family History:

   Alcoholism in mother, father, and sister. Father also used cocaine and

   sister also used ecstasy.

   Occupation: Formerly worked at Investment Firm Quality Control Dept

   Physical Examination

   Vitals: T: 99.6 BP: 152/96 P: 99 R: 27 O2: 99%RA

   General: Alert, oriented x3, anxious, labile with at times

   inappropriate laughter mixed with anxiety, obese woman.

   HEENT: Sclera anicteric, MMM, oropharynx clear

   Neck: supple, JVP difficult to assess given habitus

   Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi

   CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs,

   gallops

   Abdomen:  soft, diffuse tenderness to palpation, obese, non-distended,

   bowel sounds present, no rebound tenderness or guarding, no

   organomegaly. During the exam she complains of severe tenderness but a

   few minutes later is laughing and sitting comfortably in bed.

   Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema

   Labs 

   PT / PTT / INR:13.7/29.4/1.2, ALT / AST:106/249, Alk Phos /

   T Bili:145/3.0, Amylase / Lipase:135/221, Differential-Neuts:57.3 %,

   Lymph:34.1 %, Mono:7.0 %, Eos:0.8 %, Lactic Acid:1.8 mmol/L,

   Albumin:4.1 g/dL, LDH:329 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.5

   mg/dL78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial

   fibrillation on coumadin, ischemic stroke, admitted after

   presenting to cardiology clinic today with confusion and

   Somnolence. Of note, she was recently discharged at the

   beginning of [**2876-4-14**] after presyncope/falls. At that time,

   lasix was stopped and atenolol was switched to metoprolol as

   there was concern that blunting of tachycardia could be

   contributing to falls. She was discharged to rehab (previously

   living at home).

   Per report from the ER, patient has had confusion at home x 3

   weeks, though no family accompanies her to corroborate this

   story, and patient denies this. The patient is not sure why she

   is in the hospital. She saw her cardiologist today, who

   referred her to the ER after she appeared to be dehydrated,

   somnolent, and confused.

   The patient denies headache, blurry Vision,

   numbness, tingling or weakness. No CP. +SOB, worsening DOE. 

   No nausea, vomiting.

   Physical Exam:

   GENERAL: Intubated, NAD

   HEENT: Normocephalic, atraumatic. No scleral icterus. MMM, OP

   clear.

   CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs

   or [**Last Name (un) 597**].

   LUNGS: CTAB

   ABDOMEN: Soft, NT, ND. +BS

   EXTREMITIES: 1+ edema

   NEUROLOGIC:

   Mental status: Intubated, off sedation, minimal arousal to

   voice/stimulation. Not following commands.

   Cranial nerves: Pupils sluggishly reactive, both post-surgical,

   R 4->3, L 3.5->3. Gaze midline and conjugate, face appears

   symmetric.

   Motor: Withdraws LUE and LLE weakly, no response RUE, triple

   flexion RLE.

   Sensory: withdraws to noxious stimulation weakly as above, L>R

   Coordination: unable to assess

   Gait: unable to assessThis is a 87 year old female NH resident with a history of chronic atrial

   fibrillation, hypertension and hypothyroidism who presents to the 

   [**Hospital Unit Name 10**].  She had been in her usual state of health until 5

   days ago when she suddenly began to have abdominal pain.  Her abdominal

   pain was initially intermittent lasting for a few hours at at time.  No

   clear correlation with food.  Yesterday, she noticed that her pain was

   much more severe, [**3301-9-5**] in severity and more localized to the right.

   This was accompanied by nausea and vomitting.  She vomitted twice, with

   clear liquid emesis and was sent to [**Hospital3 **].  

   At [**Hospital1 **], she was noted to have elevated amylase/lipase to 538 and 516

   with elevated bili to 4.1 and AST/ALT to 198/115 and was given

   ciprofloxacin, flagyl and 500cc NS and was transferred to the [**Hospital1 1**]

   emergency department.

   .

   At [**Hospital1 1**] EDVS 97.9  HR 83  157/92  RR 18  97% RA.  

   Elderly F, oriented X 2, NAD, flat jvp, CTA decreased b/b, s1 s2  

   [**Last Name (un) **], decreased BS, + t at

   ruq, no edemaMr. [**Known patient lastname 4075**] is a 63 yo man with h/o biphenotypic ALL, now Day + 32

   from allogeneic SCT, who presents to clinc with one week of worsening

   SOB and two days of a clear productive cough.  The patient states his

   SOB occured when lying flat, but not with activity.  Also admitted to

   chest pressure which would come and go in his left chest no related to

   the SOB.  Sleeps with 3 pillows (no change from baseline), denies PND;

   admits to a slight increase in lower extremity edema.  Admits to low

   grade fevers to the 99's and crampy abdominal pain.  Denies chills,

   night sweats, vomiting, or diarrhea.

   Assessment and Plan

   Assesment: This is a 63 year-old male with a history of h/o

   biphenotypic ALL, now Day + 32 from allogeneic SCT, who presents with

   hypoxia, one week of worsening SOB, and two days of productive cough.

   Plan:

   # Hypoxia: The patient developed acute onset of hypoxia accompanied by

   fever and a one day cough with sputum production.  Given that the

   patient is about 1 month s/p allogenic SCT the differential is broad

   and would include bacterial pneumonia, viral pneumonia (CMV, flu), and

   opportunistic infections including fungal infections.  Patient also has

   a history of CMV infection, aspergillus and Leggionare's disease and is on

   posaconazole.  His CXR showed an opacification of the left basilar lobe

   and also right upper lobe concerning for pneumonia as well as a small

   loculated right pleural effusion.  Also in the differential is

   noninfectious causes such as PE, CHF, or MI.  US were negative for clot

   and his first set of CE were negative.94 M with CAD s/p 4V-CABG [**3420**] and CRI had been doing well until this

   AM when he was out walking with his wife.  [**Name (NI) **] abruptly syncopized and a bystander started CPR quickly.  The local fire department delivered two shocks without success.  Then EMS came and gave two more shocks and he went back into sinus.  It is unclear whether he regained

   consciousness.  He was intubated then brought to [**Hospital1 5**] ED.

   .

    In the ED, his intial SBP was reported to be 110.  Labs show K 2.7 and

   Hct 25.  He was given 40mEq of KCL.  On repeat labs, his K normalized

   and his Hct was 33 without any blood.  It is unclear whether one of the

   labs was erroneous. 

   the vitals were recorded as: T=34.8, HR 62, 132/74, 18, 100% on AC 18x500, FiO2 100%.   

   EKG: Sinus at 80 BPM with LAD, prolonged PR, TD 0.5 to 1mm in V4-V6

    .

   ECHO:

   The left atrium and right atrium are normal in cavity size. There is

   mild symmetric left ventricular hypertrophy with normal cavity size.

   There is mild global left ventricular hypokinesis (LVEF = 45-50 %). The

   right ventricular free wall is hypertrophied. Right ventricular chamber

   size is normal. with normal free wall contractility. The aortic root is

   mildly dilated at the sinus level. The ascending aorta is moderately

   dilated. The aortic valve leaflets (3) are mildly thickened but aortic

   stenosis is not present. Mild to moderate ([**1-13**]+) aortic regurgitation

   is seen. The mitral valve leaflets are mildly thickened. There is no

   mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The

   tricuspid valve leaflets are mildly thickened. The estimated pulmonary

   artery systolic pressure is normal. There is a trivial/physiologic

   pericardial effusion.

   IMPRESSION: Mildly depressed global left ventricular function. Mild to

   moderate aortic regurgitation. Mild mitral regurgitation.85y/o m w/ hx AD, diverticulosis, recently dx colon ca

   s.p hemicolectomy p/w dark stools and dropping Hct (30

   -->26-->23).

   NG lavage was negative in ED, however, pt with duodenal ulcer

   on EGD [**7-2**]. Possibly recent PUD vs anastomotic site vs [**1-26**] colon ca vs

   diverticulosis.  

   Review of systems:

   Constitutional: No(t) Fever

   Cardiovascular: No(t) Chest pain, No(t) Palpitations

   Respiratory: No(t) Cough, No(t) Dyspnea

   Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,

   No(t) Diarrhea, No(t) Constipation

   Since 12 AM

   Tmax: 37.3 C (99.2

   Tcurrent: 37.3 C (99.2

   HR: 69 (64 - 78) bpm

   BP: 150/73(91) {128/39(65) - 150/99(103)} mmHg

   RR: 16 (16 - 24) insp/min

   SpO2: 100%

   Heart rhythm: SR (Sinus Rhythm)

   O2 Delivery Device: None

   SpO2: 100%

   ABG: ////

   Physical Examination

   General Appearance: No acute distress, Thin

   Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale

   Head, Ears, Nose, Throat: Normocephalic

   Lymphatic: Cervical WNL, Supraclavicular WNL

   Cardiovascular: (S1: Normal), (S2: Normal), RRR

   Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:

   Present), (Right DP pulse: Present), (Left DP pulse: Present)

   Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )

   Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,

   healing colectomy scar, no erythema, tenderness, bleeding, oozing.

   Extremities: Right: Absent, Left: Absent

   Skin:  Not assessed

   Neurologic: Attentive, Follows simple commands, Responds to: Verbal

   stimuli, Oriented (to): only new year and thought he was at [**Hospital1 947**],

   Alzheimer's:  pt with baseline dementia.  Pt oriented to self, but not

   time or place.

   Movement: Purposeful, Tone: Normal

   Labs / Radiology

   WBC

   9.7

   Hct

   24.0

   Plt

   593

   Other labs: PT / PTT / INR:14.4/27.2/1.3"This is a 51 year-old M w/ a h/o MS, quadraparesis, HTN, restrictive

   lung disease, chronic constipation and SBOs s/p ileostomy, multiple

   UTIs (also s/p suprapubic tube) presents with SBO and UTI.  Of note he

   was just recently discharged from the [**Hospital1 52**] on [**10-2**] for an admission

   for a UTI (negative cultures) treated with cipro, shingles treated w/

   acyclovir and SBO evaluated by surgery but managed conservatively.  He

   returns today as his home health aide had noticed his Urine output was

   low, 75cc overnight when he usually has about 1 liter of UOP

   overnight.  His ostomy output has been high.  He has not noticed any

   symptoms.  Over the past two weeks he has had mild earaches, a

   sorethroat as well as some rhinorrhea.  He has not noticed any watery /

   itchy eyes.  He has not sure if he has had a change in his ostomy

   output or suprapubic output.  He has not noticed any visual changes, he

   has not noticed any new neurologic si/sx.  He denies any abdominal

   pain, has not sujectively noticed any change in abdominal distention.

   He denies any pain in regards to his zoster (now or when diagnosed).

   Denies CP, has an occasional cough that is not worsening.

   .

   In the ED, he was noted to be severely dehydrated on exam.   His BP

   nadir was 79/43 and HR peak was 97.  T 99 (he usually "runs low"), new

   ARF 1.4 up from 0.6.A 64 yo F w/PMHx sx for AF, COPD, HTN, hyperlipidemia who initially had

   an open ASD repair c/b sternal wound infection and post-operative AF in

   [**11-15**] treated with amiodarone. On [**2-20**], she was initially admitted

   through the ED with SOB and back pain, and was noted to have atrial

   fibrillation with RVR. A CTA demonstrating diffuse LAD and

   post-obstructive PNA concerning for malignancy. For her atrial

   fibrillation, she was started on diltiazem gtt, for which she was

   transferred to the [**Hospital Unit Name 42**] for monitoring. The atrial fibrillation was

   thought to be in the setting of a post-obstructive pneumonia, for which

   she was treated with antibiotics. She was then transferred to the floor

   later that same night on metoprolol 50 mg tid. While on the floor, she

   had a bronchoscopy performed which showed external compression of her

   left mainstem bronchus, and she had a biopsy/FNA performed, which

   showed large cell carcinoma. She was then readmitted to the [**Hospital Unit Name 42**]

   yesterday with atrial fibrillation with HR 130s, and was started on a

   diltiazem gtt.

   .

   In the [**Hospital Unit Name 42**], she was started on po diltiazem, which was rapidly

   uptitrated to 60 mg qid. She was called out this morning. Tonight, at

   8:30 pm, she was noted to have HR 160s, w/EKG c/w AF with RVR, for

   which she received metoprolol 5 mg IV x2, followed by diltiazem 10 mg

   IV x2 without conversion. She denies chest pain, SOB, tachypnea. She

   does note some diaphoresis and occasional palpitations.Briefly 79 yo F w/ a h/o CAD s/p RCA stenting BMS to mRCA [**3421**] and pLAD

   [**3423**], diastolic CHF (2 pillow orthopnea), 1+ MR, HTN, Hyperlipidemia,

   previous smoking history, and atrial fibrillation initially p/w cough,

   dyspnea.

   .

   Briefly, pt's symptoms began [**Month (only) 760**]. At that time pt was admitted

   with GI bleed, transfused and discharged without resolution of

   symptoms. Furthur workup noted bilateral atrial thrombi and

   anticoagulation was reinitiated. CTA did not show PE but was concern

   for small peripheral emboli as cause of dyspnea. Pt was had multiple

   PFTs, echos, CT scans and CXRs without definitive cause of dyspnea.

   Most recent PFTs on [**3432-12-27**] c/w restrictive ventilatory defect and low

   DLCO suspicious for interstitial pulmonary process (worsening). She has

   been followed by cardiology and pulmonology and is being treated for

   dCHF and reactive airway disease.

   .

   On current admission pt presented with cough, thought to be URI, rather

   than worsening of chronic dyspnea.  Current etiology considerations

   include CHF vs intrinsic pulmonary disease (infiltrative) vs embolic

   disease.

   In order to optimize cardic function with atrial kick, pt was

   pretreated with Sotolol and underwent TEE and cardioversion of afib on

   [**3433-1-11**].  After cardioversion, patient developed junctional HR to 45bpm

   with SBPs in 80s.  She was placed on dobutamine and HR increased to 80s

   (sinus vs antrial escape rhythm).  Off of dobutamine, HR and BP

   decreased with EKG demonstrated QTc of 700.96F found unresponsive on ground at nursing home.  Pt was

   in dining room and found by staff.  Unresponsive for 1 min after

   found.  Pt cannot recollect events preceding fall but with some

   c/o HA and some neck/shoulder discomfort.  Taken to [**Hospital1 1218**]

   where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.

   C-spine negative.  

   Family / Social  history:

    dementia, HTN, afib, CAD

   SURGICAL Hx:  unknown

   .

   SOCIAL Hx:  Daughter serves as HCP; Pt currently DNR/DNI except for

   elective procedure (****SEE CLARIFICATIOIN BELOW****).

   .

   ALLERGIES:  NKDA

   Physical Examination

   General Appearance: No acute distress, Thin

   Eyes / Conjunctiva: PERRL, Conjunctiva pale

   Head, Ears, Nose, Throat: Normocephalic, Poor dentition

   Lymphatic: Cervical WNL, Supraclavicular WNL

   Cardiovascular: (S1: Normal), (S2: Normal)

   Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:

   Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)

   Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :

   bialterally)

   Abdominal: Soft, Non-tender, Bowel sounds present

   Extremities: Right: Absent, Left: Absent

   Skin:  Warm

   Neurologic: Attentive, Follows simple commands, Responds to: Verbal

   stimuli, Oriented (to): A+O x 2, Movement: Not assessed, Tone: Not

   assessed

   Imaging: CT head w/o contrast Acute left subdural hematoma measuring

   1.5 cm maximal dimensions with leftward subfalcine herniation of 8 mm,

   downward transtentorial herniation with obliteration of the left

   suprasellar cistern, and uncal herniation. No fx, destructive

   infiltrative lesion involving the skull base84 year-old man with CAD s/p CABG, DM, HTN, presented with 2 days of

   black stools and coffee ground emesis.  Pt reports of woke up 2am on

   [**10-19**] and had black soft/loose BM, followed by nausea and and vomiting

   blackish liquid.  He felt better but continued to have three more black

   stools over the next two days.  He vomited a total of [**1-20**] times before

   presenting to the hospital.  He has been feeling lethargic and

   lightheaded and called the ambulence at the advice of his son.  His

   stools were lightening in color prior arriving.  He has not been using

   any new medications and has not had a prior GIB.

   .

   In the ED, initial VS: 98.7 88 65/47 98%/RA.  He was BIBEMS with SBPs

   110-120s and has had similarly stable blood pressures since arrival.

   He had an NG lavage with coffee ground emesis that cleared with 600 cc

   of flushing.  During the lavage he had chest pressure and an EKG showed

   STD in V2-4.  He did not have radiation, pain, or diaphoresis.  

   Home medications:

   ALLOPURINOL 300 mg Tablet by mouth daily

   GLIPIZIDE 5 mg Extended Rel by mouth daily

   LOSARTAN [COZAAR]  100 mg by mouth daily

   METFORMIN 500 mg by mouth daily

   METOPROLOL TARTRATE 50 mg by mouth daily

   PIOGLITAZONE [ACTOS] 15 mg by mouth daily

   SIMVASTATIN 80 mg Tablet by mouth daily

   ASPIRIN 81 mg Tablet by mouth daily

   Past medical history:

   Coronary artery disease s/p triple-vessel coronary artery bypass in [**7-/2899**]

   Hypertension

   Peripheral arterial disease

   Hypercholesterolemia

   Diabetes

   Osteoarthritis

   Gout

   Anemia Baseline 32-35 with unrevealing w/u by heme

   Right hernia repair in [**2877**]

   Appendectomy in [**2841**]

   Prostate disease

   N/C

   Occupation: Retired trial lawyer

   Drugs: Denies

   Tobacco: Denies

   Alcohol: Occasional54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had

   been in unusal state of health at baseline resp status (using 4L NC at

   rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who

   has rats for pets and also the heat came up from the basement of his

   house. He feels that with these two events, he breathing became acutely

   worse and is concerned for allergen exposure. He denies any sick

   contacts, fevers, chills, worsening [** 2169**]/productive [** 2169**], rhinorrhea.

   He did receive flu and pneumovax.

   .

   He has had a recent admissions in [**11-26**] with progressive DOE. CT

   revealed increased ground glass opacity in LL superimposed on pulmonary

   fibrosis with elevated eosinophils peripherally (12%). A BAL was also

   positive for eosinophils. He was started on high dose steroids

   (prednisone 60mg) [**2739-2-16**] with plan for close outpatient follow up for

   eosinophilic lung disease. He was discharged on [**2-20**] on 2-3L NC. He then

   represented to [**Hospital1 1**] on [**12-12**] for spontaneous pneumomediastinum of

   unclear etiology.

   .

   On day of admission, Pt called pulmonologist (Dr. [**First Name (STitle) **] c/o worsening

   shortness of breath since Saturday [**3-23**]. Yesterday he was at pulmonary

   rehab and desaturated to the 70s on 6L with minimal exertion, and he is

   currently on 4L NC at rest.  No sick

   contacts recently and [**Name2 (NI) 2169**] has not changed. He was asked to go to ED

   given concern for either acute exacerbation of underlying IPF vs

   superimposed infection vs pneumothorax.

   .

   In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC.85 y/o F with PMHx of HTN, HL, h/o breast CA and 3cm renal pelvis

   transitional cell tumor who presented for nephrectomy on [**2575-8-15**].  Her

   post op course was complicated by agitation thought due to narcotics.

   Today, she was restarted on her home meds and while on telemetry, pt

   was noted to be bradycardic to 40s.  Pt was triggered for SBP of 70 and

   HR of 40 during which she remained asymptomatic.  She was given 1L IVF

   and her HR/BP trended back up to baseline.  However, there was a second

   event an hour later when she sat up and became bradycardic in the 30s

   with associated hypotension. Second episode occurred with position change

   and again, pt developped junctional rhythm in 30s. 

   home meds:

   Verapamil 240mg daily

   Lisinopril 5mg

   Rosuvastatin 10mg

   Meclizine 25 TID PRN

   Imipramine 25 QHS

   Colace 100mg 

   Loratidine 10mg daily

   Physical Examination

   T: 98 BP: 111/47 P: 74 R: 16 O2: 98% on 2L NC

   General: oriented to person only, NAD, comfortable

   HEENT: Sclera anicteric, dry MM, oropharynx clear

   Neck: supple, unable to appreciate JVP due to habitus

   Lungs: poor effort but [**Month (only) 199**] BS at bases and some audible airway

   secretion in upper airways

   CV: Regular rate and rhythm, no m/r/g, diff to auscult [**2-13**] habitus

   Abdomen:  diffusely tender, bowel sounds present, multiple surgical

   incisions, clean dry and intact, abd binder in place

   GU: foley in place

   Ext: cool, no edema, 1+ pulses, pneumoboots in placeA 78 year old male presents with frequent stools and melena.An elderly female with past medical history of right hip arthroplasty presents after feeling a snap of her right leg and falling to the ground.An 87 yo woman with h/o osteoporosis, DM2, dementia, depression, and anxiety presents s/p fall with evidence of C2 fracture, chest pain, tachycardia, tachypnea, and low blood pressure.A 75F found to be hypoglycemic with hypotension and bradycardia. She had  UA positive for klebsiella. She had a leukocytosis to 18 and a creatinine of 6.  Pt has blood cultures positive for group A streptococcus.  On the day of transfer her blood pressure dropped to the 60s.  She was anuric throughout the day, awake but drowsy.  This morning she had temp 96.3, respiratory rate 22, BP 102/26.An 82 man with multiple chronic conditions and previous surgeries presents with 9 day history of productive cough, fever and dyspnea.A 94 year old female with hx recent PE/DVT, atrial fibrillation, CAD presents with fever and abdominal pain.  An abdominal CT  demonstrates a distended gallbladder with gallstones and biliary obstruction with several CBD stones.A 26 year-old diabetic woman, estimated to 10 weeks pregnant, presents with hyperemesis.  Her labwork demonstrates a blood glucose of 160, bicarbonate of 11, beta-hCG of 3373 and ketones in her urine.A 41-year-old male patient with medical history of alcohol abuse, cholelithiasis, hypertension, obesity who presented to his local hospital with hematemasis, abdominal pain radiating to the back and elevated lipase. Signs of ascites, pancytopenia and coagulopathy.Infant with respiratory distress syndrome and extreme prematurity.  Chest x-ray shows diffuse bilateral opacities within the lungs, with increased lung volumes.A 55-year-old woman with sarcoidosis, presenting today with confusion and worsening asterixis.   In the waiting room, the pt became more combative and then unresponsive. Ammonia level 280 on admission.66 yo female pedestrian struck by auto. Unconscious and unresponsive at scene. Multiple fractures and head CT showing extensive interparenchymal hemorrhages.80 yo male with demantia and past medical history of CABG with repeated episodes of chest pain. Admitted for severe chest pain episode.A 43 year old woman with history of transverse myelitis leading to paraplegia, depression, frequent pressure ulcers, presenting with chills, agitation, rigors, and back pain.  Patient has stage IV decubitus ulcers on coccyx and buttocks, heels.  Admission labs significant for thrombocytosis, elevated lactate, and prolonged PT.A 52 year-old woman with history of COPD and breast cancer who presents with SOB, hypoxia, cough, fevers and sore throat for several weeks.67 y.o. male smoker with end stage COPD on home oxygen, tracheobronchomalacia, s/p RUL resection for squamous cell carcinoma. Y-stent placement was complicated by cough and copious secretions requiring multiple therapeutic aspirations. Patient reports decreased appetite, 50 lb wt loss in 6 months.  Decreased activity tolerance.  PET scan revealed some FDG avid nodes concerning for recurrence.  Pt. presents with worsening SOB with R shoulder pain and weakness.A 90+ year old woman who was recently hospitalized for legionella PNA, with confusion and dysarthria the last few days.  Found down in the bathroom this morning, making non-verbal utterances and with minimal movement of the right side.76-year-old female with personal history of diastolic congestive heart failure, atrial fibrillation on Coumadin, presenting with low hematocrit and dyspnea.A 40-year-old woman with a history of alcoholism complicated by Delirium Tremens and seizures 2 years ago, polysubstance abuse, hep C, presents with abdominal pain in lower quadrants, radiating to the back, nausea, vomitting and diarrhea.  Labs are significant for elevated lipase.78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial fibrillation on coumadin, ischemic stroke, admitted after presenting with confusion and somnolence. She was recently discharged after presyncope/falls. Patient has had confusion at home for 3 weeks. The patient denies headache, blurry vision, numbness, tingling or weakness, nausea or vomiting.A 87 yo female reports several days abdominal pain, worse yesterday, severe and more localized to the right, accompanied by nausea and vomitting.  Labs show elevated bilirubin, transaminitis, amylase and lipase.94 M with CAD s/p 4v-CABG, CHF, CRI presented with vfib arrest.A 63 year-old male with biphenotypic ALL, Day +32 after BMT, h/o CMV infection, aspergillus and Leggionare's disease, presents with acute onset of hypoxia accompanied by fever and two days of productive cough.  His CXR showed an opacification of the left basilar lobe and also right upper lobe concerning for pneumonia.85 yo M with PMH of colon CA s/p resection now presenting with black stools and HCT drop.51 years-old male with multiple sclerosis and quadriplegia who presents with small bowel obstruction and low urinary output.An elderly female with history of atrial fibrillation, Chronic Obstructive Pulmonary Disease, hypertension, hyperlipidemia and previous repair of atrial septum defect, presenting with shortness of breath and atrial fibrillation resistant to medication.A 79 year old female wit history of CAD, diastolic CHF, HTN, Hyperlipidemia, previous smoking history, and atrial fibrillation who presents for direct admission from home for progressive shortness of breath. Patient denies recent palpitations, and reports that she has been compliant with all medications. She admits to recent fatigue and 2 pillow orthopnea which has been present for months.  Patient underwent cardioversion and became hypotensive with a junctional rhythm requiring intubation.  She was placed on dobutamine.  Off of dobutamine, cardiac monitoring demonstrated a long QTc and an atrial escape rhythm.A 96 y/o female found unresponsive on ground at nursing home pressents with headache, herniation, and some neck/shoulder discomfort. CT head  shows acute left subdural hematoma.An 84-year-old man with a previous history of coronary artery disease, presenting with 2 days of melena and black colored emesis.This is a 54 year old male patient with an idiopathic pulmonary  fibrosis presenting an acute dyspnea on exertion, secondary to superimposed pneumonia on patient with no pulmonary reserve.  Appears he has been experiencing worsening dyspnea with increased O2 requirement for the last several weeks.An 85 year-old woman on  verapamil  presents with junctional heart rhythm in 30s with associated hypotension.A 47-year-old man comes to the clinic for the follow up of his neuromuscular disease. He experienced gradual, progressive weakness of the left upper extremity over the last year.  Over the last few months, he has also noticed weakness in the right upper extremity.  BP is 120/75, PR is 80 and temperature is 37 C. Reflexes are brisk in the upper extremities, and the plantar responses are extensor.  Mild gait ataxia is present. The patient is under treatment of Riluzole 50 mg BID with the diagnosis of ALS.A 40-year-old woman comes to the clinic complaining of gritty sensation in her eyes. She also has difficulty swallowing dry foods with no pain or heartburn.  The patient is a schoolteacher and must drink water frequently during lectures due to her mouth dryness.  She also reports occasional joint pain.  Medical history is not significant other than the confirmed Sjogren disease with no other rheumatologic disease.  She is sexually active with her husband and has 2 children both delivered by natural vaginal delivery. She has no history of any kind of surgery. Physical examination shows conjunctival erythema and cracking of the lips. The remainder of the examination and history is normal. Her lab result shows elevated ESR (50 mm/h)A 50-year-old woman comes to the clinic with intermittent ear discharge and sense of hearing loss on her left ear.  Past medical history is significant for obesity, hyperlipidemia, and diabetes mellitus.  Her medications include Metformin, Atorvastatin and Vit D supplement. Vital signs are normal. BMI is 37. Otoscopy shows a small perforation in the left tympanic membrane and a pearly mass behind the membrane.  Conduction hearing loss is noted in the left ear.  The remainder of the ear, nose, and throat examination is normal.A 31-year-old woman comes to the office due to 3 days of rash on her left arm.  The lesion is mildly pruritic but not painful.  She is otherwise healthy and occasionally takes ibuprofen during the first few days of her menstrual period.  Temperature is 37 C, blood pressure is 110/75 mm Hg, and pulse is 95/min. The lesion is like a target sign known as erythema migrans. She recently went for an adventure trip in New Hampshire. The patient is diagnosed with Lyme disease.A 57-year-old man comes to the emergency department due to constipation.  His last bowel movement was 2 days ago. He complains of spending about 30 minutes once attempting to defecate. He also has lower back pain.  There is no history of trauma. The pain is not relieved with over-the-counter pain medications.  His vital signs are within normal limits.  Examination shows low back pain that is worse with back flexion and raising of the legs; it radiates into his left leg.  Pinprick in the perianal area does not cause rapid contraction of the anal sphincter.  The rest of the neurologic examination is normal. He is suspected of Cauda Equina syndrome and referred to a spinal MRI.A 30-year-old man who is a computer scientist came to the clinic with the lab result stating azoospermia.  The patient is sexually active with his wife and does not use any contraception methods.  They have been trying to conceive for the past year with no success.  The patient has a past medical history of recurrent pneumonia, shortness of breath, and  persistent cough that produces large amounts of thick sputum. The patient had multiple lung infections during childhood. He does not smoke, use illicit drugs or alcohol.  The patient has no history of other medical conditions including allergies or any kind of surgery.  On physical examination, the digits show clubbing.  An ultrasound shows bilateral absence of the vas deferens, and FEV1 was 75% on the respiratory function test.A 20-year-old man comes to the clinic for his routine checkup. The patient wears glasses for myopia and takes no medications.  Vital signs are normal.  On physical examination, the patient is tall with long upper extremities and fingers.  The face appears narrow with down-slanted palpebral fissures, flattened malar bones, and a small jaw.  The lungs are clear on auscultation.  The abdomen is soft with no organomegaly. The patient is diagnosed with Marfan syndrome, and he is cooperative with his medical appointments. He is working as driver.A 47-year-old woman comes to the clinic complaining of dizziness.  She also has occasional nausea and ringing in her right ear.  The patient also has difficulty hearing while holding her phone to the left ear, although hearing in her right ear is normal.  The dizziness improves spontaneously, and she feels fine between episodes.  Past medical history is notable for hypothyroidism and low vit D level, for which she is using Levothyroxine and Vit D pearl.  She does not use tobacco or drink alcohol. Physical examination shows sensorineural hearing loss in the left ear. She has only one-man sexual partner and menopaused 2 years ago.A 47-year-old man comes to the office due to weight gain and fatigue.  He is not able to lift heavy objects or climb stairs. Family history is positive for DM type 2 and HTN in his father.  Blood pressure is 165/90 mm Hg and pulse is 85/min.  On physical examination, there is symmetric proximal muscle weakness of the upper and lower extremities.  Fasting plasma glucose level is 138 mg/dL and 24-hour urinary cortisol is twice the upper normal limit.  Further evaluation reveals that high-dose, but not low-dose, dexamethasone suppresses serum cortisol levels.  Serum ACTH levels are high-normal. This patient's findings are consistent with endogenous Cushing Syndrome.A 23-year-old female has prolonged oral bleeding immediately after a tooth extraction.  Despite several interventions, the bleeding persists for hours and stops only after desmopressin (DDAVP) administration.  The patient has heavy menstrual cycles each month.  She has no other medical problems and takes no medications.  Her mother and grandmother have also had excessive bleeding during menstrual period.  Review of systems is positive for mild bruising on his legs. Laboratory findings reveal a normal platelet count and an abnormal ristocetin cofactor assay, as well as CB <= 0.30 IU/mL and FVIII:C <= 0.40 IU/mL.A 9-year-old girl is brought to the office for evaluation of short stature and overweight body habitus. The patient's mother and father are 170 cm and 181 cm tall, respectively.  On physical examination, the patient's height is in the 5th percentile of her age.  Other findings include low-set ears, a high arched palate, a webbed neck, and cubitus valgus.  Chromosomal analysis reveals a 45, XO karyotype.A 27-year-old woman comes to the dermatology clinic with skin rash and oral ulcers.  The rashes are mildly itchy. The patient has no other medical conditions and takes no medications.  Vital signs are normal.  On examination, there are pink papules symmetrically distributed over the anterior surfaces of the shins and ankles. There are some white ulcerated papules on her buccal mucosa. She is in relationship with her boyfriend and has only one sexual partner. Her boyfriend uses condoms. She smokes 1 to 2 cigarettes a day and drinks a beer daily. Biopsy reveals prominent hyperkeratosis with a thickened granular layer.  There is an infiltration of mononuclear cells in the superficial dermis that involves the overlying epidermis. The rete ridges have a sawtooth appearance.The patient is a 38-year-old man with cough and body ache that started 3 days ago.  He had fever and chills at the beginning and has low grade fever at the time of visit. He feels tired and sleepy. His body ache and myalgia get better after using Tylenol. The PCR test for Covid is positive. His vital signs are within normal limits with a body temperature of 37.9 C. There is no lymphadenopathy or white exudates in the pharynx.A 41-year-old woman comes to the dermatology clinic complaining of facial redness, especially on her forehead and cheeks. She noticed that the redness gets worse in the summer and after sun exposure. She is otherwise healthy. On physical examination, she has multiple papules and pustules present on her forehead, cheeks, and nose on a background of erythema and telangiectasias. There are no other lesions or nodules. The patient is married and has 2 children who are 5 and 9 years old. She has IUD and doesn't wish to have more kids. She does not smoke or drink alcohol. Her vital signs are normal, and BMI is 21.A 50-year-old woman comes to the clinic complaining of difficulty swallowing both liquids and solid foods, as well as occasional cough while eating.  She also has difficulty lifting her arms above her head and getting up from a chair. The weakness seems to get worse gradually. The patient has no prior medical problems and takes no medications.  Vital signs are normal.  Physical examination shows an erythematous rash on the upper eyelids. There are some red papules over joints of her hands. The rest of the physical examination is unremarkable. Antinuclear antibodies, anti-Jo-1 antibodies and anti-MDA5 antibody are positive.  Muscle biopsy shows perifascicular inflammation and atrophy of the fascicle and surrounding blood vessels.A 19-year-old male came to clinic with some sexual concern.  He recently engaged in a relationship and is worried about the satisfaction of his girlfriend. He has a "baby face" according to his girlfriend's statement and he is not as muscular as his classmates.  On physical examination, there is some pubic hair and poorly developed secondary sexual characteristics. He is unable to detect coffee smell during the examination, but the visual acuity is normal. Ultrasound reveals the testes volume of 1-2 ml. The hormonal evaluation showed serum testosterone level of 65 ng/dL with low levels of GnRH.A 32-year-old woman comes to the hospital with vaginal spotting.  Her last menstrual period was 10 weeks ago. She has regular menses lasting for 6 days and repeating every 29 days. Medical history is significant for appendectomy and several complicated UTIs. She has multiple male partners, and she is inconsistent with using barrier contraceptives. Vital signs are normal.  Serum β-hCG level is 1800 mIU/mL, and a repeat level after 2 days shows an abnormal rise to 2100 mIU/mL.  Pelvic ultrasound reveals a thin endometrium with no gestational sac in the uterus.A 51-year-old man comes to the office complaining of fatigue and some sexual problems including lack of libido. The patient doesn't smoke or use any illicit drug.  Blood pressure is 120/80 mm Hg and pulse is 70/min.  Oxygen saturation is 99% on room air.  BMI is 24 kg/m2.  Skin examination shows increased pigmentation. Genotype testing is consistent with homozygosity for the C282Y mutation. Laboratory study shows transferrin saturation of 55% and serum ferritin of 550 μg/L. He is diagnosed as a case of hemochromatosis.A 61-year-old man comes to the clinic due to nonproductive cough and progressive dyspnea.  The patient's medical conditions include hypertension, hypercholesteremia and peptic ulcer disease.  He smokes 2 packs of cigarettes daily for the past 30 years.  On examination, there are decreased breath sounds and percussive dullness at the base of the left lung.  Other vital signs are normal. Abdomen is soft without tenderness. CT scan shows a left-sided pleural effusion and nodular thickening of the pleura. The plural fluid was bloody on thoracentesis. Biopsy shows proliferation of epithelioid-type cells with very long microvilli.A 7-month-old boy is brought to emergency by his parents due to irritability and inability to defecate for the past 3 days.  The patient has had constipation and discomfort with bowel movements since birth.  His symptoms worsened after eating semi-solid foods.  Vital signs are normal.  Abdominal examination shows distension and tenderness to palpation with presence of bowel sounds.  Xray with barium shows a narrow rectum and rectosigmoid area.  The rest of the colon proximal to this segment is dilated. Digital rectal exam revealed burst of feces out of the anus. The biopsy showed absence of submucosal ganglia in the last segment of the large intestine.A 67-year-old woman comes to the clinic due to recent episode of choking, dysphagia, and cough.  Her other medical problems include hypertension, dyslipidemia, and osteoarthritis.  She does not smoke or use alcohol. She lives with her husband and she is able to do her own daily activities. She used to teach elementary school. Blood pressure is 135/80 mm Hg.  The patient's breath smells bad. Other physical examinations are normal.  A barium swallow study reveals an abnormality in the upper esophagus with an outpouching at the junction of the lower part of the throat and the upper portion of the esophagus.A 47-year-old man comes to the office for routine checkup. He is complaining of chronic cough and occasional but progressive dyspnea.  Other medical conditions include hypertension and osteoarthritis.  The patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs.  He used to be a construction worker. On examination, there are decreased breath sounds and percussive dullness at the base of both lungs.  Chest CT scan reveals a mild bilateral pleural effusion and diffuse thickening of the pleura. The patient's documents show chronic exposure to asbestosis. The specimen of the lungs reveled  pulmonary fibrosis that is most predominant in the lower lobes, characterized  by the presence of asbestos bodies (golden-brown beaded rods with translucent centers).A 24-year-old man comes to the office complaining of infertility.  He and his wife have been trying to conceive for the last 18 months.  Medical records of his wife showed no abnormalities.  The patient doesn't smoke and takes no medications.  Height is 185 cm and weight is 77 kg.  Heart and lung sounds are normal.  There is bilateral gynecomastia and bilateral descended firm testes.  The lower extremities appear abnormally long. His karyotype evaluation shows 47, XXY consistent with Klinefelter syndrome.A 39-year-old woman comes to the clinic complaining of arthralgias and nodules on her legs.  She has no fever or other skin rashes. The prior medical condition is unremarkable, and she takes no medications.  On physical examination, there is moderate hepatomegaly. The lesions on her legs are tender and present predominantly on the anterior surface of the lower extremities. She doesn't smoke and drinks alcohol occasionally. The patient has 2 male sexual partners. Vital signs are normal. Chest x-ray demonstrates enlarged hilar lymph nodes, and laboratory testing reveals an elevated ACE level. Biopsy of the skin lesion shows noncaseating granulomas that stain negative for fungi & acid-fast bacilli.A 2-year-old boy is brought to the office by his parents due to a rash that started 1 week ago.  A similar red, itchy rash on the cheeks, trunk, and arms has occurred intermittently since infancy.  The patient has had a few upper respiratory infections but no major illnesses.  Vaccinations are up to date, and he takes no medications. He is on a balanced diet, and he is healthy in appearance.  Vital signs and milestone examination are within normal limits.  Similar findings are observed on the cheeks and proximal upper extremities.  The diaper area is clear, and no mucosal lesions are present.A 7-year-old girl is brought to the emergency department by her parents for generalized rash.  The mother reports that she was playing outside wearing a skirt and felt a sharp pain in her arm while seating on a mat, plying with her doll.  Her mother suspects that something had stung her.   The patient's blood pressure is 75/55 mm Hg and her heart rate is 122/min.  Physical examination shows erythematous, raised plaques over the trunk, extremities, and face.  Lung auscultation reveals bilateral expiratory wheezes.A 15-year-old boy with mild intellectual disability is brought to the office by his parents for a routine physical examination.  The boy is going to a school for students with learning disabilities.  The patient was adopted, and his immunizations are up to date.  Review of the patient's medical records is notable for cytogenetic studies that showed a small gap near the tip of the long arm of the X chromosome, which is consistent with fragile X syndrome, an X-linked disorder. The defect is an unstable expansion of trinucleotide repeats (CGG) in the fragile X mental retardation 1 (FMR1) gene, located on the long arm of the X chromosome. He is not using any medications and vital signs are within normal levels. His blood chemistry analysis as bellow:

Blood Chemistry Value      Normal Range     Patient Value

Glucose                    90-120 mg/dl     95 mg/dl

BUN (Blood Urea Nitrogen)  7-24 mg/dl       10 mg/dl

Creatinine                 0.7-1.4 mg/dl    0.8 mg/dl

Calcium                    8.5-10.5 mg/dl   9 mg/dl

Sodium                     134-143 mEq/L    135 mEq/L

Potassium                  3.5-4.5 mEq/L    3.7 mEq/L

Chloride                   95-108 mEq/L     98 mEq/L

CO2                        20-30 mEq/L      25 mEq/L

Blood pH                   7.38-7.42        7. 39A 66-year-old woman comes to the office due to joint pain in the hands and periodic morning stiffness that lasts less than 15 minutes.  The pain is moderately severe and worsens with daily activity. The patient used Tylenol with minimal relief.  Past medical history is notable for hypertension and hypercholesteremia.  Physical examination shows firm nodules over the distal interphalangeal joints, bilaterally. The patient has pain in her knees as well. The knees are stiff in the morning for less than 30 minutes and become worse with climbing stairs. She has some sensation of bone friction during activity. X-ray shows narrowing of the joint space, subchondral bone sclerosis and osteophyte formation along the joints.A 23-year-old man comes to the emergency department following an episode of syncope.  He was working out when he felt dizzy and passed out without head injury.  He has had 3 other episodes of light-headedness over the last year, all happening during physical activity. He never had this experience while resting. He has no other medical conditions.  The patient does not use tobacco, alcohol, or illicit drugs.  His father died suddenly at age 35.  Vital signs are within normal limits.  On physical examination, the patient has a harsh systolic murmur.  The lungs are clear with no peripheral edema. Echocardiography shows asymmetric interventricular septal hypertrophy.A 3-year-old girl is brought to the clinic by her parents for assessment of her short stature. Physical examination reveals short limbs and a relatively large head. She has a flat nasal bridge and a small midface. The girl's father exhibits similar physical features; however, her mother looks normal. The genetic testing reveals an autosomal dominant point mutation in the fibroblast growth factor receptor 3 (FGFR3) gene consistent with achondroplasia in both father and the child. The girl has not received any treatment yet, and it is her first visit after immigration to the US. The other mental and developmental examinations are unremarkable.A 19-year-old girl comes to the clinic due to a left wrist mass.  She noticed swelling on the top of her wrist about 4 months ago and came to the clinic due to cosmetic concerns.  Examination shows a nontender, rounded mass on the dorsal wrist that transilluminates with a penlight. Vital signs are normal. The patient needs to type on her computer almost all day. She is left-handed. She does not smoke or use illicit drugs. She is in sexual relationship with two male partners and uses condoms.A 63-year-old man comes to the clinic for recent unintentional weight loss. The patient also has epigastric discomfort after meals. He has no known medical problems and takes no medications. His blood pressure is 130/75 and pulse rate is 88/min. He is not febrile. Upper endoscopy shows a lesion in the stomach that shows typical features of diffuse-type adenocarcinoma presenting with signet ring cells that do not form glands.A 39-year-old man comes to the emergency department with an acute onset of severe left toe pain.  The toe is red and exhibits swelling. The patient is not febrile, and does not remember any recent trauma. Medical history is not significant except for the similar attacks and the diagnosis of gouty arthritis. His medication history includes Allopurinol to prevent gouty attacks. His father has the same medical condition. However, his older brother who is 41 years old is healthy with no history of gouty arthritis. Physical examination shows a swollen, tender first metatarsophalangeal joint.  Aspiration of the joint showed high leukocyte count, negative Gram stain, and numerous needle-shaped crystals, which is compatible with gouty arthritis.An 8-year-old boy is brought to the clinic by his parents because of weakness and difficulty of standing up from a sitting position. The mother is healthy but had a brother who died in his 20th after being disabled and using wheelchairs in the last few years of his life. Physical examination shows 3/5 lower extremity muscle strength and enlarged calf muscles. The other physical examination and vital signs are unremarkable. Muscle biopsy showed absence of dystrophin protein. The patient is diagnosed with DMD.A 67-year-old man comes to the clinic with slowly worsening vision in both eyes.  He is not able to drive at night, as the symptoms are worse at night. His pupils are normal in diameter both in the light and darkness. Other medical history is unremarkable.  Ocular examination shows loss of the red reflex and blurry vision.  Acuity testing shows 50/100 vision in both eyes with normal visual field testing. His blood pressure is 130/70 and pulse is 68/min. the other physical examinations are normal.A 49-year-old man comes to the office because of the bulging in his groin.  Physical examination shows a swelling above the inguinal ligament. When the patient is asked to cough, the size of the bulge increases.  His medical history is significant for mild dyslipidemia, which is under control by lifestyle modifications. He does not smoke, but drinks alcohol occasionally. His vital signs and other physical examinations are unremarkable. He is referred to a surgeon and scheduled to undergo elective laparoscopic hernia repair.A 4-year-old boy comes to the office for the follow up of his confirmed oculocutaneous albinism.  The patient was born at 38 weeks gestation with no complications.  Vital signs are normal.  Weight and height are at the 50th percentile.  On examination, iris transillumination is present, and there are no apparent foveae on funduscopic examination.  Optic nerves are small and gray.  All the hairs including eyebrows and lashes are white.A 33-year-old woman comes to clinic complaining of progressive fatigue, decreased appetite, and 11-lb weight loss in the past 2 months.  She uses levothyroxine because of the previously diagnosed Hashimoto disease. She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows a generalized increase in pigmentation of the skin.  Measurement of serum cortisol before and after administration of exogenous adrenocorticotropic hormone (ACTH) shows no difference in the levels. Stable glucocorticoid replacement therapy starts for her with the diagnosis for primary adrenal insufficiency (Addison disease)A 23-year-old woman comes to the emergency department with a history of nosebleeds lasting for 1 hour. She has a history of heavy menses as well as occasional gum bleeding following dental procedures. Her mother also has a history of menorrhagia. Laboratory tests reveal increased bleeding time and slightly increased partial thromboplastin time. She has no other medical conditions and is otherwise healthy. Her coagulation study shows CB = 0.30 IU/mL and FVIII:C = 0.37 IU/mL. She is not smoking or using any kind of illicit drugs. She uses alcohol occasionally and is in ra elationship with her boyfriend for the past 2 years.A 47-year-old woman comes to the office complaining of pain in the calf and knee when she bends down. The pain limits her activity. Her medical history is significant for osteoarthritis, for which she uses nonsteroidal anti-inflammatory drugs (NSAIDs) for the past two years. She is living with her husband and has 3 children. She doesn't smoke but drinks alcohol occasionally. Her vital signs are normal. On physical examination, there is a small effusion in the right knee. The effusion grew a little larger and she developed a tender swelling in the popliteal fossa and calf. Both the pain and swelling worsened as she bent and straightened her knee.A 25-year-old woman comes to the clinic with her roommate.  The roommate says that the patient has twice fallen asleep while they were talking.  The patient has regularly fallen asleep in the afternoon while reading or watching television but typically feels refreshed after a brief nap.  She also reveals that she sometimes hears a voice prior to falling asleep.  She also complains of some episodes of clumsiness that cause her to drop objects or fall. MSLT showed that the sleep latency was less than 8 min and that the patient enters rapid eye movement (REM) sleep almost immediately.A 17-year-old male comes to the office due to several months of right elbow pain.  The pain is worse with activity and limits his workouts and activities.  He has tried over-the-counter medications with limited relief.  Medical history is notable for eczema, and current medications include a topical hydrocortisone ointment.  He is sexually active with his girlfriend and uses condoms. He does not smoke or drink alcohol. He plays tennis most of the days of the week. The comprehensive evaluation shows pain on the lateral side of the elbow, made worse by pressure applied on the lateral epicondyle of the humerus and when making a fist with the elbow joint straightened. The patient has this pain since last year and had several courses of physical therapy.A 43-year-old woman, gravida 3 para 3, comes to the clinic complaining of recently painful menstrual cycles.  The patient's last menstrual period was 2 weeks ago. Urine β-hCG is negative. Menarche was at age 12, and menstrual periods occur every 28 days and lasts for 5 days.  She is sexually active with her husband and does not have pain with intercourse. BMI is 23 kg/m2 and Vital signs are normal.  On physical examination, the uterus is uniformly enlarged and tender. She is candidate for hysterectomy with the diagnosis of adenomyosis.A 60-year-old man comes to the clinic complaining of hand tremor that started few months ago.  It is most bothering when he wants to drink from a glass or pour from a bottle. He does not smoke, but drinks occasionally. He recently started consuming more alcohol as his tremor subsides somewhat when he drinks small amounts of alcohol.  Family history is significant for similar problems in his mother.  Vital signs are normal and the patient has no other medical conditions.  Neurologic examination shows bilateral tremor in the upper extremities. The diagnosis of essential tremor is confirmed.A 55-year-old white woman comes for a routine checkup.  She has no significant medical history and does not use tobacco, alcohol, or illicit drugs.  The patient's only medication is an over-the-counter multivitamin.  Family history is notable for a hip fracture in her mother.  Blood pressure is 130/80 mm Hg and pulse is 112/min. She has occasional back pain and lives a sedentary lifestyle with the BMI of 24 Kg/m2. Plain X-ray of the spine shows mild compression fracture at the level of T10. X-ray absorptiometry studies demonstrate abnormally low bone density in the lumbar vertebrae and T-score values below -2.5, which confirms the diagnosis of osteoporosis.A 61-year-old man comes to the emergency department complaining of an acute vision disturbance. He had an episode of vision disturbance in the right eye that occurred suddenly and resolved spontaneously in 15 minutes. He also has right jaw pain while chewing.  He also complains of fatigue and hip muscle aches over the last several months.  The patient has a history of mild hyperlipidemia that has been controlled by diet and lifestyle modifications.  On examination, his blood pressure is 130/70 mm Hg and pulse is 66/min.  Neurological examination is unremarkable.  Visual examination is also normal. ESR is 103 mm/h. Temporal artery biopsy shows multinuclear giant cells and internal elastic membrane fragmentation.A 48-year-old man comes to the office complaining of heartburn and acid reflux.  He has taken over-the-counter antacids but sees no relief.  Other medical history is unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  BMI is 31 kg/m2.  Physical examination is  positive for mild tenderness in upper stomach. Chest x-ray shows an air-fluid opacity behind the heart.  A barium swallow study reveals approximately 1/3 of the stomach herniating through the esophageal hiatus.A 15-week-old infant brought to the clinic for the follow up. The infant has flat facies, small ears, a single palmar crease, and upward slanting eyes. He was born on 39th week to a 39-year-old woman who didn't have prenatal care. The medical record confirms the trisomy of chromosome 21 (Down syndrome). The infant is otherwise healthy.A 20-year-old man comes to the emergency due to bleeding after a tooth extraction.  The bleeding has persisted for approximately 30 minutes despite constant direct pressure.  He is a known case of Hemophilia type A treated with FVIII. Blood pressure is 95/60 mm Hg and pulse is 105/min. His weight is 70 Kg. Family history is positive for Hemophilia type A in his maternal uncle. He also has a lipoma on his left arm which he plans to remove surgically. His FVIII activity is 40%.A 70-year-old man comes to the office accompanied by his wife.  The patient has experienced progressive memory loss over the last years.  He needs help with some of his routine activities, such as paying bills.  The patient's wife says, "He used to be such an independent person, but now he needs help with many things, even finding direction to home!"  Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Family history includes Alzheimer disease in his father.  MRI reveals diffuse cortical and hippocampal atrophy. The diagnosis of AD is made using the National Institute on Aging and the Alzheimer's Association (NIA-AA) criteria.Patient is a 45-year-old man with a history of anaplastic astrocytoma of the spine complicated by severe lower extremity weakness and urinary retention s/p Foley catheter, high-dose steroids, hypertension, and chronic pain. The tumor is located in the T-L spine, unresectable anaplastic astrocytoma s/p radiation. Complicated by progressive lower extremity weakness and urinary retention. Patient initially presented with RLE weakness where his right knee gave out with difficulty walking and right anterior thigh numbness. MRI showed a spinal cord conus mass which was biopsied and found to be anaplastic astrocytoma. Therapy included field radiation t10-l1 followed by 11 cycles of temozolomide 7 days on and 7 days off. This was followed by CPT-11 Weekly x4 with Avastin Q2 weeks/ 2 weeks rest and repeat cycle.48 M with a h/o HTN hyperlipidemia, bicuspid aortic valve, and tobacco abuse who presented to his cardiologist on [**2148-10-1**] with progressive SOB and LE edema. TTE revealed severe aortic stenosis with worsening LV function. EF was 25%. RV pressure was 41 and had biatrial enlargement. Noted to have 2+ aortic insufficiency with mild MR. He was sent home from cardiology clinic with Lasix and BB (which he did not tolerate), continued to have worsening SOB and LE edema and finally presented here for evaluation.

During this admission repeat echo confirmed critical aortic stenosis showing left ventricular hypertrophy with cavity dilation and severe global hypokinesis, severe aortic valve stenosis with underlying bicuspid aortic valve, dilated ascending aorta, mild pulmonary artery systolic hypertension. The patient underwent a preop workup for valvular replacement with preop chest CT scan and carotid US (showing moderate heterogeneous plaque with bilateral 1-39% ICA stenosis). He also underwent a cardiac cath with right heart cath to evaluate his pulm art pressures which showed no angiographically apparent flow-limiting coronary artery disease.A 32 yo woman who presents following a severe 'exploding' headache. She and her husband report that yesterday she was in the kitchen and stood up and hit her head on the corner of a cabinet. The next morning she developed a sudden 'exploding' headache. She came to the hospital where head CT showed a significant amount of blood in her right ventricle. NSGY evaluated her for spontaneous intraventricular hemorrhage with a concern for an underlying vascular malformation. Cerebral angiogram was done which showed abnormal vasculature with a draining vein from L temporal lobe penetrating deep white matter consistent with AVM. The patient did continue to have a headaches but they were improving with pain medication. The patient refused PT evaluation but was ambulating independently without difficulty. She was discharged to home with her husband on [**2155-12-6**].This is a 44 year old female with PMH of PCOS, Obesity, HTN who presented with symptoms of cholecystitis and was found incidentally to have a large pericardial effusion. A pericardiocentesis was performed and the fluid analysis was consistent with Burkitt's lymphoma. Pericardial fluid was kappa light chain restricted CD10 positive monotypic B cells expressing FMC-7, CD19, CD20, and myc rearrangement consistent with Burkitt's Lymphoma. A subsequent lumbar puncture and bone marrow biopsy were negative for any involvement which made this a primary cardiac lymphoma. A cardiac MRI showed a mass that was 3cm x 1cm on the lateral wall of the right atrium adjacent to the AV junction.

Past Medical History:

1. Rare migraines

2. HTN

3. Obesity

4. PCOS/infertility

5. Viral encephalitis/meningitis-->ICH-->seizure/stroke ([**2137**]) =- from severe sinus infxn, caused mild non-focal residual deficits

6. CSF leak w/ meningitis s/p lumbar drain placement

7. R LE DVT s/p IVC filter placement

8. Knee surgery74M hx of CAD s/p CABG, EF 60% prior CVA (no residual deficits), HTN, HL, DMII, Moderate to Severe PVD was referred to cardiology for evaluation of PVD, and on examination patient was found to have carotid bruits. Upon further review of symptoms the pt reports + Occasional dizziness, no prior syncope occasional HA, Denies CP/SOB. No sensory or motor defects. He recalls that he might have had a stroke 10-15 years ago without any residual deficit. Prior to CABG he only had diaphoresis.

Further review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. He underwent Carotid U/S that showed significant bilateral carotid stenosis, L>R. Angiography revealed an 80% stenosis of the R ICA and a 90% L ICA stenosis. Cerebral angiography further revealed patent right ACA and MCA and patent left ACA and left MCA.

Past Medical History:

CAD s/p CABG in [**2154**] ([**Hospital1 112**])

Prior CVA

Bilateral carotid artery disease

Anemia

PVD

Hypertension

Diabetes c/b retinopathy and peripheral neuropathy

Cataracts s/p surgery

Thyroid nodule

Colon polyps s/p resection

Intermittent Lower back pain

Proteinuria

s/p right elbow fracture as a child

ArthritisPatient is a 55yo woman with h/o ESRD on HD and peritoneal dialysis who presented with watery, non bloody diarrhea and weakness. She has a history of 2 prior C diff infections, the most recent just 1 month ago. Recent antibx use in the last month on prior admission. Was also txd for Cdiff at that time for 14 d. course with po vanco. Pt was initially admitted to the ICU and was septic on pressors (levophed) until the morning of [**8-26**] with leukocytosis but no fever. C diff assay positive on admission, and pt had leukocytosis consistent with C diff. Patient was placed on Vanco po, Flagyl IV and Flagyl po initially, and when patient improved she was transitioned to Vanco oral and Flagyl oral on [**8-29**]. Patient was treated with Vanco for an extended course of 6 weeks given her recurrent C diff. Pt was also encouraged to take probiotics and to bleach her home when she was discharged.60 yo M with Hep C cirrhosis, grade II esophageal varices, recent admission for UGIB [**2-9**] NSAID gastritis, referred for admission throught the ED by hepatology clinic for new slurred speech and tangential thought process. Patient also describes new imbalance leading to a fall during which he may have hit his head on. Per last liver clinic note has been off ETOH for a year (corroborated with pt), utox was negative for alocohol. CT was within normal limits, and neuro evaluation determined this was not ischemic infart. Patient was given a presumptive diagnosis of hepatic encephalopathy and started on lactulose. Liver function tests showed a striking increase in his total and direct bilirubin since last visit. Another worrisome feature was the increase in the patient's AFP. This could be progression of cirrhosis as he failed interferon twice. He is to follow-up as an outpatient to work this up.

Past Medical History:

HCV Cirrhosis (tx with interferon x2 with no response)

Portal Gastropathy

Grade II Esophageal varices

HTN

Recent admission [**4-/2150**]: UGIB [**2-9**] non-steroidal induced

gastritisThis is a 57-year-old gentleman with CLL and large cell transformation. He presented with his disease back in [**10/2119**] with an elevated white count and LDH. He was without any splenomegaly or any cytopenias at that time. He did have some bulky lymphadenopathy. He then completed four cycles of FCR therapy, which he completed back in 09/[**2119**]. He had an excellent response to therapy and was monitored off treatment for approximately two years. He then presented in [**7-/2122**] with a rising white count, approximately 50% lymphocytes, and a mildly elevated LDH. He also had some mild worsening palpable lymphadenopathy. He then received four cycles of PCR, but did not have much in the way of response and his treatment regimen was switched to R-CVP of which he received two cycles. He did again not have a significant response, though continued to have an excellent performance status, and he was ultimately switched to Campath therapy. He did have resolution of his lymphocytosis, and his white count has come down nicely, but did not have much in the way of response in terms of reducing his bulky lymphadenopathy. He then eventually had developed an enlarging left cervical node which was biopsied and was found to have Richter's transformation.41 year old man with history of severe intellectual disability, CHF, epilepsy presenting with facial twitching on the right and generalized shaking in at his NH which required 20 mg valium to cease seizure activity. Per outside medical patient was felt to have focal epilepsy with secondary generalization, likely due to anoxic brain injury at birth, and probably related to the atrophic changes seen on MRI, particularly in the left temporal lobe.

The patient first developed seizures at age 13 found by family to have a generalized convulsion. He had a second seizure two years after his first episode. He was maintained on Dilantin and phenobarbital. The patient went 20 years without another seizure. He was recently tapered off Dilantin, and it was felt that perhaps this medication was necessary to maintain him seizure free. The patient had no further events during the hospital course and was back at his baseline at the time of discharge. Full EEG reports are pending at the time of dictation.

Past Medical History:

Epilepsy as above, CHF, depressionPt is a 22yo F otherwise healthy with a 5 yr history of the systemic mastocytosis, with flares normally 3/year, presenting with flushing and tachycardia concerning for another flare. This is patient's 3rd flare in 2 months, while still on steroid taper which is new for her. She responded well to 125 mg IV steroids q 8 hrs and IV diphenydramine in addition to her continuing home regimen. CBC was at her baseline, w/normal differential. Serum tryptase revealed a high value at 84. The patient failed aspirin challenge due to adverse reaction. She was stabilized on IV steroids and IV benadryl and transferred back to the medical floor. She continued on her home histamine receptor blockers and was transitioned from IV to PO steroids and benadryl and observed overnight and was discharged on her home meds, prednisone taper, GI prophylaxis with PPI, Calcium and vitamin D, and SS bactrim for PCP.A 75 yo M w/ metastatic papillary thyroid cancer s/p XRT 19 sessions who presented with 2 days of worsening dysphagia for solids, poor oral intake, weight loss 20 pounds over last several weeks and some lethargy.

Papillary thyroid cancer dx w/ right neck mass

--s/p neck mass resection; unable to perform thyroidectomy

--high bleed risk, proximity to trachea and recurrent laryngeal nerve and large tumor size

--s/p XRT to neck 

--s/p RAI ablation

--Metastatic to lymph nodes and adrenal glands

* s/p hernia repair

* s/p tonsillectomy34 year old woman with Marfan's syndrome and known severe mitral valve prolapse with regurgitation, who was planned for a MV repair but was lost to follow-up. She remains symptomatic and is now prepared to undergo mitral valve repair/replacement surgery. EF of 65% on TTE. 

Past Medical History:

Marfans Syndrome

MVP with severe mitral regurgitation

Gastric reflux disease

History of gestational diabetes mellitus

Hypertension with pregnancy

Obesity

c-section x 2

laser eye surgery

cataract surgery

foot surgery (shorten bone length)70 y/o with COPD on 2.5-3.5L O2 at baseline, OSA and obesity hypoventilation syndrome, dCHF, discharged [**2132-8-24**] now presents with agitation and altered mental status with hypoxia and O2 sats 70s on BipAp with 5L. Pt agitated then somnolent at initial presentation. Daughter reported increased agitation and altered mental status x 2-3 days with O2 sats 60s-70s at home. Daughter has also noted increased LE edema and weight gain which prompted a phone call to her PCP and increased lasix dose from 80daily to 100mg daily with some mild improvement in edema. She has had decreased appetite, PO intake, energy level at home with difficulty with ADLs. No recent history of fever, cough, chills, sputum production, CP, abd pain, or other complaints other than chronic right thigh pain last 1-2 months. Daughter also reports med compliance and compliance with BiPap at night.

Past Medical History:

- CAD; s/p 4 vessel CABG in [**2119**]

- CHF; EF 55%, mild AS

- obesity hypoventilation syndrome

- obstructive sleep apnea

- DM2

- ventricular tachycardia; s/p ICD in [**2127**]

- hypothyroidism

- schizophrenia

- COPD

- Pneumona treated in [**4-7**] at [**Hospital1 **]62 yo male with hx of CVA, neurogenic bladder with indwelling suprapubic catheter with multiple prior admissions for UTIs, altered mental status, and urosepsis presents to the hospital in urosepsis now resolved after treatment with vanc/meropenem. Per CT there is a non-obstructing stone in the L ureter, no evidence of urethral strictures. Significant leaking around suprapubic cath site. Started on ditropan changed over to detrol. Urologist not concerned with leaking and will f/u with pt next week.

s/p CVA

Neurogenic bladder s/p suprapubic cath

Recurrent UTIs with Klebsiella/Pseudomonas

Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03

(s/p R-CHOP x 6 cycles)

Bells Palsy

BPH

Hypertension

Partial Bowel obstruction s/p colostomy

Hepatitis C

Cryoglobulinemia

SLE with transverse myelitis, anti-dsDNA Ab+

Insulin Dependant Diabetic

Fungal Esophagitis Stage IV?

Urinary Tract Infections-pseudomonas & enterococcus70 year-old woman with a history of CAD recently noted abdominal mass who presents with fevers/rigors and bandemia. Over the last few weeks leading up to admission, she has been experiencing mid-abdominal pain, radiating to the left flank. It lasts throughout the day is not increased by eating though there is associated vomiting and is worsened with coughing. CT abdomen without contrast was then performed on [**4-20**] showing a large 9.5 x 7.5 x 6.0-cm heterogeneous left upper abdominal mass. Patient underwent a EUS with biopsy. The results of the biopsy were consistent with pancreatic adenocarcinoma at the head of pancreas. Splenic flecture/pancreatic tail mass was also seen on CT, likely diverticular abscess given the patients recent likely history of diverticulitis this was thought to be an infected fluid collection or abscess. She was treated with IV antibiotics (Zosyn, then ceftriaxone and flagyl) and will continue on them until seen by ID as an outpatient.

Past Medical History:

1. Coronary artery disease with history of angioplasty in [**State 108**] one year ago

2. Mitral valve prolapse

3. Atrial fibrillation

4. Hyperlipemia

5. Hypertension

6. Chronic kidney disease (SCr 2.1 in [**3-17**])

7. Hypothyroidism? (TSH 10 in [**3-17**])

8. Anemia (HCT 30.7 in [**3-17**])79 yo F with multifactorial chronic hypoxemia and dyspnea thought due to diastolic CHF, pulmonary hypertension thought secondary to a chronic ASD and COPD on 5L home oxygen admitted with complaints of worsening shortness of breath. Cardiology consult recommended a right heart cath for evaluation of response to sildenafil but the patient refused. Pulmonary consult recommended an empiric, compassionate sildenafil trial due to severe dyspneic symptomology preventing outpatient living, and the patient tolerated an inpatient trial without hypotension. Patient to f/u with pulmonology to start sildenifil chronically as outpatient as prior authorization is obtained.

Past Medical History:

- Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement.

- Diastolic CHF, estimated dry weight of 94kg

- Pulm HTN (RSVP 75 in [**11-24**]) thought secondary to longstanding ASD

- COPD on home O2 (5L NC) with baseline saturation high 80's to low 90's on this therapy.

- OSA, not CPAP compliant

- Mild mitral regurgitation

- Microcytic anemia

- Hypothyroidism

- S/p APPY, s/p CCY ('[**33**])

- Gallstone pancreatitis s/p ERCP, sphincterotomy

- Elevated alk phos secondary to amiodarone64yo woman with multiple myeloma, s/p allogeneic transplant with recurrent disease and with systemic amyloidosis (involvement of lungs, tongue, bladder, heart), on hemodialysis for ESRD who represents for malaise, weakness, and generalized body aching x 2 days. She was admitted last week with hypercalcemia and treated with pamidronate 30mg, calcitonin, and dialysis. Patient was Initially treated with melphalan and prednisone, followed by VAD regimen, and autologous stem cell transplant. With relapse of her myeloma, she received thalidomide velcade and thalidomide, which were eventually also held due to worsening edema and kidney function.This is a 78 year-old male with h/o BPH s/p multiple urological procedures, including s/p Suprapubic prostatectomy. He was noted to have low urine output and bladder scan showed 360cc residual. It was impossible for staff to pass a foley. Urology was consulted, performed a flexible cystoscopy in the ICU and found severe 2cm bulbar urethral stricture. They were able to pass small catheter through and left in place. The patient leaked around the catheter, the catheter eventually came out but he continued to have good urine output and post-void bladder scans were performed q4h to ensure he did not have high residual volume. Urology suggested that when patient is stable he will have to be taken to the OR to have the stricture surgically fixed.65 yo man with history of CAD and prior MI, HLD, HTN, ventricular tachycardia, and syncope was admitted earlier today evaluation of syncope and ventricular arrhythmias. He was recently discharged after a negative work-up for syncope which included the implantation of a cardiac monitoring device. It was interrogated at the OSH and per report the monitor read from yesterday: 40 seconds of VT and then bradycardia with a rate of 39 shortly thereafter corresponding with his symptoms. Overnight, the patient went into monomorphic VT on telemetry. The patient was found to be unresponsive. CPR was initiated, unclear if the patient had a pulse. Within one minute the patient returned to sinus rhythm. The patient does not report any symptoms prior to this episode. Currently, the patient feels presyncope and nausea, but denies chest pain. Patient is to be transferred to the CCU for catheterization and EPS.A 35-year-old woman presents with history of acne and mild hirsutism. The primary evaluation revealed elevated testosterone levels. She recently noticed gradual enlargement of her hands and feet and recognized that her ring is getting small for her finger. There is some irregularity in her menstrual cycle as well as some nipple discharge. She also has positive history for snoring and headache. The physical examination revealed subtle facial features of acromegaly and prognathism. Visual fields are normal by confrontation. Hirsutism, soft tissue thickening and diaphoresis of the hands and feet are noted.  Laboratory evaluation in the fasting state reveals IGF-1 of 968 ng/mL and random GH of 19.7 ng/mL. MRI reveals a macroadenoma with no invasion. She is on stable doses of octreotide LAR since her diagnosis was confirmed. She is married and has 2 children. She is using IUD as her contraceptive method.The patient is a 57-year-old man with abdominal pain and vomiting. The pain started gradually about 20 hours ago in the epigastric and periumbilical regions, radiating to his back. He drinks around 60 units of alcohol per week and smokes 22 cigarettes per day. He is healthy with no history of allergies or using any medications. His family history is positive for type 2 diabetes (his father and sister). He lives alone and has no children. The abdomen is tender and soft. His bowel sounds are normal. His heart rate is 115/min and blood pressure 110/75 mmHg. The lab results are remarkable for leukocytosis (19.5), urea of 8.5, high CRP (145), high amylase (1200) and Glc level of 15. Cross-sectional imaging was negative for obstructive pancreatitis.The patient is a 31-year-old woman complaining of abdominal pain. The pain started last night as diffuse abdominal discomfort. She had poor appetite as well as malaise. The pain worsened in intensity and became sharp in the morning. The pain became localized to the right lower quadrant in the morning. The temperature is within the normal limits with normal vital signs. Focal tenderness and guarding were observed during palpation of the right lower quadrant. Palpation of the left lower quadrant causes pain on the right. Her lab work is remarkable for leukocytosis.

Computed Tomography of the abdomen with contrast shows the presence of a distended appendix with thickened appendiceal wall without perforation, abscess or gangrene.

She is a candidate for laparoscopic appendectomy under general anesthesia.A 39-year-old man came to the clinic with cough and shortness of breath that was not relieved by  his inhaler. He had these symptoms for 5 days during the past 2 weeks. He doubled his oral corticosteroids in the past week. He is a chef with a  history of asthma for 3 years, suffering from frequent cough, wheezing, and shortness of breath and chest tightness. The symptoms become more bothersome within 1-2 hours of starting work every day and worsen throughout the work week. His symptoms improve within 1-2 hours outside the workplace. Spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 63% of the predicted. His past medical history is significant for seasonal allergic rhinitis in the summer. He doesn't smoke or use illicit drugs. His family history is significant for asthma in his father and sister.  He currently uses inhaled corticosteroid (ICS) and fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily.The patient is a 55 year old man visiting his primary care physician for lower urinary tract symptoms including frequency, urgency, weak stream, incomplete emptying and intermittent flow for the past 9 months. Further evaluation revealed:

IPSS score : 15

Post-void residual: 70 mL

Prostate volume (TRUS): 60 mL

Prostate-specific antigen (PSA) level: 3.2 ng/mL

10 mL/sec of maximum flow rate when urine volume was 130 mL

He is otherwise healthy only using Vit D 1000 units daily. His recent blood chemistry (3 days ago) was normal: 

Hgb: 13.5 g/dl

WBC: 135000 /mm3

Plt: 350000 /ml

PT: 11 second

PTT: 35 second

INR: 0.9

Creatinine: 0.5 mg/dl

BUN: 10 mg/dl

U/A:

Color: yellow

Appearance: cloudy

PH: 5.3

Specific gravity: 1.010

Glc: 100

Nitrite: negative

Ketone: none

Leukocyte esterase: negative

RBC: negative

WBC: 2 WBCs/hpf

U/C: negativeThe patient is a 42 year-old postmenopausal woman who had a screening sonogram which revealed an abnormality in the right breast. She had no palpable masses on breast exam. Core biopsy was done and revealed a 1.8 cm infiltrating ductal breast carcinoma in the left upper outer quadrant. Lumpectomy was done and the surgical margins were clear. The tumor was HER2-positive and ER/PR negative. Axillary sampling revealed 1 positive lymph node out of 12 sampled. CXR was unremarkable. She is using “well women” multivitamins daily and no other medication. She smokes frequently and consumes alcohol occasionally. She is in a relation with only one partner and has a history of 3 pregnancies and live births. She breastfed all three children.A 45-year-old woman was referred to the emergency department with abdominal pain lasting about 4 days accompanied by nausea and 2 episodes of vomiting. The pain is localized to the epigastric region and radiates to the right upper quadrant. The pain is worsening after eating fatty food. The patient experienced similar pain twice in the past year. Her past medical history is remarkable for hypercholesterolemia and two C/sections. She has 2 children, and she is menopausal. She doesn't smoke, drink alcohol, or use illicit drugs. She is mildly febrile. Her BP is 150/85, HR 115, RR 15, T 38.2, SpO2 98% on RA. On palpation, she experiences epigastric tenderness  and  tenderness in the right upper quadrant without rebound. Bowel sounds are normal. Laboratory analysis is remarkable for elevated ESR and leukocytosis with a left shift. The ultrasound revealed several gallstones and biliary sludge. The largest gallstone is 0.7cm. Surgery consultation recommends elective cholecystectomy.A 53-year-old man presents with chronic HCV infection for the past 2 years. His past medical history is only significant for inguinal hernia surgery when he was 20 years old. He is on IFN (100 mg/week) plus RBV (400 mg/day) combination therapy for the past 9 months. Direct antiviral drugs were added to his treatment 6 months ago. His medical record shows previous positive HCV RNA tests as well as positive enzyme immunoassay for anti-HCV-antibodies. The recent biopsy was negative for hepatocellular carcinoma and was only remarkable for chronic inflammation compatible with a chronic viral hepatitis. There is no evidence of alcoholic liver disease, bleeding from esophageal varices, hemochromatosis, autoimmune hepatitis or metabolic liver disease. He is an alert male with no acute distress. His BP: 130/75, HR: 90/min and BMI: 27. His abdomen is soft with no ascites or tenderness. The lower extremities are normal with no edema.The patient is a 60-year-old Spanish man presenting with shortness of breath about a day before. The symptoms began acutely and progressively worsened. He is a known case of COPD since 2 years ago. The spirometry revealed post-bronchodilator FEV1/FVC = 60% of predicted values. He smokes 20 cigarette per day. His past medical history is remarkable for BPH and he is using Flomax for that. His family history is positive for HTN in his brother. His medication includes Duo-Neb inhaled q4 hr PRN, Vit D3 1000 units per day and Flomax for his PBH. He is an obese man who is acutely ill but oriented and conscious. The vital signs are as bellow:

BP: 135/80

RR: 25/min

HR: 75 bpm

BMI: 40

O2sat: 90%The patient is a 24-year-old man who has had type 1 diabetes for 11 years. He presents to the emergency room with hyperglycemia and concern for possible diabetic ketoacidosis after not taking his insulin for 3 days. The patient reports that he is currently homeless and has lost his supply of insulin, syringes, glucometer, and glucose testing supplies. The patient states that at the time of his initial diagnosis with type 1 diabetes he was hospitalized with a glucose value >1000 mg/dL. At the time, he was experiencing polyuria, polydipsia, and polyphagia. He reports that he has been on insulin since the time of his diagnosis, and he has never been prescribed oral agents for diabetes management. Most recently, he has been using insulin glargine 55 units once daily, and insulin aspart sliding scale 3 times daily. The patient has had previous episodes of diabetic ketoacidosis, for which he was hospitalized. With this episode of hyperglycemia, he is not experiencing any nausea, vomiting, or abdominal discomfort, and he appears well. His lab studies showed:

A1c: 11.3%

Creatinine: 0.9 mg/dL with eGFR >60 mL/min

Aspartate aminotransferase (AST): 17 U/L

Alanine aminotransferase (ALT): 14 U/L

Beta-hydroxybutyrate: 0.1 mmol/L

Bicarbonate: 25 mEq/L

Anion Gap: 14 mEq/LThe patient is a 33-year-old woman complained of fatigue, weight gain and abnormal spotting between menses. No hirsutism or nipple discharge was detected. Her BMI was 34. Her lab results were remarkable for high TSH level (13 mU/L) and low free T4 level (0.2 ng/dl). Her anti-TPO levels were extremely high (120 IU/ml). She was diagnosed with Hashimoto's thyroiditis. Her aunt, brother and mother have the same disease. After  starting 250 mcg Levothyroxine per day, her symptoms improved significantly and her periods are normal. She is still overweight with BMI of 31. Her most recent thyroid profile revealed all results except for anti-TPO within the normal range:

TSH: 2.35 mU/L

Free T4: 2.7 ng/dl

Anti-TPO: 75 IU/mlThe patient is a 37-year-old woman who came to the clinic for a routine Pap smear. The test revealed stage 1B of cervical cancer. The patient tested positive for HPV 16. She has three sexual partners and   four children. She underwent tubal ligation. She smokes 30 packs/year and drinks alcohol frequently. She is otherwise healthy. She was offered a radical hysterectomy.The patient is a 47-year-old Asian woman complaining of persistent feelings of sadness. She lost interest in activities she used to enjoy. She states that her mood is mostly depressed for the past 3 weeks. She also lost her appetite , which led to about 5kg weight loss. She complains of loss of energy and feelings of worthlessness nearly every day. She is not using any drugs and she does not smoke. She doesn't drink alcohol. She used to exercise every day for at least 30 min. But she doesn't have enough energy to do so for the past 3 weeks. She also has some digestive issues recently. She is married and has 4 children. She is menopausal. Her husband was recently diagnosed with colon cancer and he is starting his chemotherapy. There is nothing remarkable in her past medical history and her drug history is only positive for Vit D3 1000 units daily. Her family history is negative for any psychologic problems. Her HAM-D score is 20.The patient is a 32-year-old obese woman who came to the clinic with weight concerns. She is 165 cm tall and her weight is 113 kg.  She is complaining of sleep apnea, PCO and dissatisfaction with her body shape. She is a high-school teacher married for 5 years. She doesn't use any contraceptive methods for the past 4 months and she had no prior pregnancies. She doesn't smoke or use any drugs. She likes to try diets and exercise to lose weight. She completed the four square step test in 14 seconds. Her BP: 130/80, HR: 195/min and her BMI is: 41.54. Her labs:

FBS: 98 mg/dl

TG: 150 mg/dl

Cholesterol: 180 mg/dl

LDL: 90 mg/dl

HDL: 35 mg/dl

Her cardiac assessment is normal. Her joints and ROM are within  normal.The patient is a 35-year-old woman with myasthenia gravis, class IIa. She complains of diplopia and fatigue and weakness that affects mainly her upper limbs. She had a positive anti-AChR antibody test, and her single fiber electromyography (SFEMG) was positive. She takes pyridostigmine 60 mg three times a day. But she still has some symptoms that interfere with her job. She is a research coordinator and has 3 children. Her 70-year-old father has hypertension.  She does not smoke or use illicit drugs. She drinks alcohol occasionally at social events. Her physical exam and lab studies were not remarkable for any other abnormalities.

BP: 110/75

Hgb: 11 g/dl

WBC: 8000 /mm3

Plt: 300000 /ml

Creatinine: 0.5 mg/dl

BUN: 10 mg/dl

Beta hcg: negative for pregnancyA 3-day-old Asian female infant presents with jaundice that started a day ago. She was born at 38w3d of gestation, after an uncomplicated pregnancy. The family history is unremarkable. The baby is breastfed.

Vital signs are reported as: axillary temperature: 36.3°C, heart rate: 154 beats/min, respiratory rate: 37 breaths/min, and blood pressure: 65/33 mm Hg. Her weight is 3.2 kg, length is 53 cm, and head circumference 36 cm. Her sclera are yellow and her body is icteric. No murmurs or any other abnormalities are  detected in the heart and lung auscultation. Her liver and spleen are normal on palpation.

Laboratory results are as follows: 

Serum total bilirubin: 21.02 mg/dL

Direct bilirubin of 2.04 mg/dL

AST: 37 U/L

ALT: 20 U/L

GGT: 745 U/L

Alkaline phosphatase: 531 U/L

Creatinine: 0.3 mg/dL

Urea: 29 mg/dL

Na: 147 mEq/L

K: 4.5 mEq/L

CRP: 3 mg/L

Complete blood cell count within the normal range.

She is diagnosed with uncomplicated neonatal jaundice that may require phototherapy.A 57-year old farmer was diagnosed with Parkinson's disease a year ago. He experiences slowness of movement and tremors. His past medical history is significant for hypertension and hypercholesterolemia. He lives with his wife. They have three children. He used to be active with planting and taking care of their farm animals before his diagnosis. The patient complains of shaking and slow movement. He had difficulty entering through a door, as he was frozen and needed guidance to step in. His handwriting is getting smaller. He is on Levodopa and Trihexyphenidyl. He stated his medications help with shaking and slow movement. But he still has difficulty initiating movements, stiffness and slowness in general. He is an alert and cooperative man who doesn't have any signs of dementia. He doesn't smoke or use any illicit drugs.The patient is a 14-year-old boy complaining of scoliosis and back pain. He has no other medical condition. He used to be able to play routine activities such as basketball and soccer, however, he recently has problem doing them. The pain is in his leg and back and aggravated by physical activities. He prefer lying down most of the time. He is not happy with his body gesture and complaints of shoulder imbalance and shifting his head to right. Patient is a well-dressed and well-nourished adolescent who is alert and cooperative. The left shoulder is slightly higher than the right shoulder. The scoliotic curve is measured as 45 degree. The patients is candidate for scoliosis surgery according to perioperative MEP monitoringPatient A is a 30-year-old male who was admitted to the hospital after 10 days of cough, profuse nocturnal sweating and loss of appetite. He had traveled to India 1 months ago and has not any positive history of TB vaccination. He is a previously healthy man, working as an engineer in a high tech company. He doesn't smoke o use any illicit drugs. He was febrile (38 c) with heart rate of 115 b/min, respiratory rate of 22, BP of 125/75 mmHg and O2 sat of 97%. Chest X-ray showed infiltrate in the middle of left lung with diameter of 1.8 cm with signs of cavitation. The sputum smear revealed positive sputum culture for Mycobacterium tuberculosis which are sensitive of the first-line TB drugs (isoniazid, streptomycin, rifampicin and ethambutol). Lab study is reported bellow:

Hgb: 13 g/dl

WBC: 14000 /mm3

Plt: 300000 /ml

AST: 13 U/L

ALT: 15 U/L

Alk P: 53 U/L

Bill total: 0.6 mg/dl

Na: 137 mEq/l

K: 4 mEq/l

Creatinine: 0.5 mg/dl

BUN: 10 mg/dl

ESR: 120 mm/hrA 62-year-old African-American man presented with left upper and lower extremity weakness, associated with dark visual spot in right eye, right facial numbness, facial drop and slurred speech. He denied dyspnea, headache, palpitations, chest pain, fever, dizziness, bowel or urinary incontinence, loss of consciousness. His medical history was significant for hypertension, hyperlipidemia and hypothyroidism. He smokes cigarette 1 pack per day for 40 years and alcohol consumption of 5 to 6 beers per week. He is not aware about his family history. He is using Levothyroxine, Atorvastatin and HTCZ. His vital signs were stable in the primary evaluation. Left-sided facial droop, dysarthria, and left-sided hemiplegia were seen in the physical exam. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. Intravenous recombinant tissue plasminogen activator (t-PA) was administered as well as high-dose statin therapy. The patient was admitted to the intensive care unit to be monitored for 24 hours. MRI of the head revealed an acute 1.7-cm infarct of the right periventricular white matter and posterior right basal ganglia.A 12 year old girl came to the clinic with her mother, complaining of short stature, delayed in puberty and developmental delay. Her karyotype study revealed 45X and confirmed the diagnosis of Turner syndrome. She is treating with GH since 6 months ago without estrogen therapy to avoid menarche and reach the ideal height. She is an obese, mentally retarded girl in the physical exam. Her breast bulb were in stage 1 with no course hair in the pubic or axillary. Her TSH was 3 and FBS was 75 in the latest lab study.A 34 year old man comes to the clinic complaining of dizziness and severe diarrhea since yesterday. He has returned from an international trip few days ago and was living in a camp in Sudan for a month. He developed abdominal pain followed by bloating and nausea as well as loose bowel movements. Soon he was having profuse watery diarrhea without odor. The stool is watery and white but the patient has no fever. Blood pressure is 95/62 lying down and drops to 75/40 standing. The skin turgor has reduced. HR is 110 and he looks ill with dry mucosa. V. cholerae was seen in dark-field microscopy of a fresh stool specimen. The lab study is as bellow:

Sodium                           137 meq/L

Potassium                      2 meq/L

Chloride                         94meq/L

CO2                                 15 meq/L

Fecal leukocytes           None seen

Fecal occult blood        NegativeA 57-year-old man was admitted to the clinic because of weight loss and persistent dry cough 4 months ago. Chest computed topography showed bilateral multiple infiltrates in the upper lobes and thickened bronchial walls. There is a documented positive serum MPO-ANCA in his medical record. Transbronchial biopsy revealed necrotic granulomas with multinucleated giant cells and the Wegener's granulomatosis was diagnosed for him. He is treating with corticosteroid and cyclophosphamides since 4 months ago. His Birmingham Vasculitis Activity Score (BVAS) is above 4 since the beginning of his disease. His last physical exam and lab study was performed yesterday and showed the results bellow:

A wellbeing, well-nourished man, non-icteric, cooperative and alert

Weight: 73 kg

Height: 177

BP: 120/80

HR: 90/min

RR: 22/min

Hgb: 13 g/dl

WBC: 8000 /mm3 (Neutrophil: 2700/mm3)

Plt: 300000 /ml

AST: 40 U/L

ALT: 56 U/L

Alk P: 147 U/L

Bill total: 1.2 mg/dl

ESR: 120 mm/hr

MPO-ANCA: 153 EUThe patient is a 41-year-old man and a known case of Acromegaly who underwent transsphenoidal surgery 4 months ago. He came to the clinic for the follow up lab studies after his primary resection surgery. His lab study shows the IGF-1 level of 4.5 ULN adjusted by sex and age. His random GH level is 4 ug/L. The recent brain MRI confirmed the residual pituitary tumor. His past medical history is only significant for acromegaly due to pituitary adenoma and the recent surgery. After his surgery he takes only vitamin D and multivitamins.The patient is a 17-year-old boy complaining of severe migratory pain in the right lower quadrant of his abdomen that started four days ago. The pain is accompanied by nausea and vomiting. He was febrile with tenderness, rebound tenderness and guarding on palpation. His WBC was elevated with dominant neutrophils. CT scan showed evidence of acute perforated appendicitis with free fluid in the pelvis. Diagnostic laparoscopy revealed phlegmon with no other abdominal abnormalities. He is now a candidate for emergent laparoscopic appendectomy under general anesthesia.A 17 year old boy  complains of vomiting, non-bloody diarrhea, abdominal pain, fever, chills and loss of appetite for the past 3 days. He ate a salad at a restaurant prior to his diarrhea onset. Physical exam was remarkable for pallor, jaundice, and diffuse abdominal tenderness. Lab results were as follows:

Hemoglobin: 9.7 g/dL

Platelet: 110,000 /cu.mm

Creatinine: 3.6 mg/dL

blood urea nitrogen (BUN): 73 mg/dL

direct bilirubin: 2.4 mg/dL