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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: (INTE) MD, 09:54 EDT Authenticated By: (INTE) MD, 20:03 EST Discharge Summary Hospitalist Discharge Summary DATE OF ADMISSION: DATE OF DISCHARGE: ADDENDUM PRIMARY CARE PHYSICIAN: MD CONSULTING PHYSICIANS: None DISCHARGE DIAGNOSES ADDENDUM: Nausea due to Flagyl use. DISPOSITION: Home. DISCHARGE MEDICATIONS: 1. Vancomycin 125 mg p.o. q.6h. x10 days. 2. Claritin 10 mg p.o. q.h.s. 3. Calcium carbonate Tums at bedtime as previously directed. 4. Zantac 150 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: Activity: No restrictions. Diet: Regular. She is to call her physician if she has any questions or concerns or a temperature over 101.5, pain not relieved by medications, nausea, vomiting, diarrhea, difficulty breathing, any signs of infection, chills, night sweats or inability to keep fluids down. She is to follow up with Dr. in one week. Oxygen 2-3 liters via nasal cannula, weaned to 2 liters at night. STUDIES AND PROCEDURE ADDENDUM: None. PERTINENT LABORATORY DATA ADDENDUM: , blood count 5.8, hemoglobin 12.7, hematocrit 38%, platelets 192,000, potassium level 4.9. LFTs notable for an ALT 58, AST of 63 on . Influenza A and B antigens were negative. DATA PENDING AT TIME OF DISCHARGE: None. HISTORY OF PRESENT ILLNESS: Please see the admission history and physical dictated

by Dr. and interim discharge summary dictated by Dr. HOSPITAL COURSE ADDENDUM: I assumed care of the patient on . She generally felt poorly. Her diarrhea waxed and waned. She ultimately was changed to oral vancomycin due to nausea with Flagyl. This seems to have worked well. She also had some bilateral medial forearm discomfort that seemed to be related to potentially thrombophlebitis versus soreness from IV sites. Warm compresses were used but there is no evidence of significant abnormality with regards to this. The patient is set for

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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: (INTE) MD, 09:54 EDT Authenticated By: (INTE) MD, 20:03 EST discharge today. We will make appropriate arrangements. There has been no evidence of acute coronary syndrome, unstable angina or congestive heart failure. The patient did have evidence of pneumonia at admission. She has completed her antibiotic therapy for this. Influenza and pneumococcal vaccinations were declined by the patient. She does not smoke and does not require tobacco cessation counseling. Her physical examination today is unchanged. addendum : called to check on pt and reviewed discharge plan.

MD

DD: 09:54:18 DT: 10:32:28

# cc: MD;

ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 20:03 ELECTRONICALLY SIGNED (INTE) MD, ON: 1 20:03

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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: (INTE) MD, 10:50 EDT Authenticated By: (INTE) MD, 15:31 EDT Discharge Summary Hospitalist Discharge Summary DATE OF ADMISSION: DATE OF DISCHARGE: ADMITTING PHYSICIAN: Dr. PRIMARY CARE PHYSICIAN: Dr. DISCHARGE DIAGNOSES: 1. Community acquired pneumonia, slow to improve. 2. Myotonic dystrophy. 3. Chronic hypoxic respiratory failure, uses home O2 at 2 liters per minute nocturnally. 4. Clostridium difficile colitis. 5. Irritable bowel syndrome. 6. Chronic migraine. 7. Psoriasis. DISCHARGE DIET: Regular. ACTIVITY: As tolerated. CODE STATUS: FULL CODE. ALLERGIES: GUAIFENESIN, THIMEROSAL and Z-PAK. DISCHARGE MEDICATIONS: 1. Flagyl 500 mg p.o. t.i.d. times 13 days, total of 14 days treatment. 2. Calcium carbonate one tablet daily at bedtime 3. Hydrocodone HD oral liquid q.i.d. p.r.n. for cough. 4. Tums two tablets q. h.s. 5. Zantac 150 mg b.i.d. 6. Patient should complete her home Avelox course 400 mg daily, I believe she will have one more dose to be taken on 10/26/2012 p.m. to complete a seven day course. DISPOSITION: Home. Follow up with Dr. in one to two weeks. HOSPITAL COURSE: The patient was admitted to the hospitalist service on with shortness of breath and cough. Please refer Dr. admission H and P for initial presentation. Admitting lab work showed a normal blood cell count. Sodium 142, potassium 3.6, BUN and creatinine of 5 and 0.5, glucose of 127. AST and ALT were mildly elevated at 53 and 72 respectively. Influenza A and B antigens were negative. Urinalysis was unremarkable. Blood cultures from admission were negative. A two view of the chest showed streaky bibasilar opacities, left greater than right, possibly representing atelectasis and/or infiltrate. The patient was admitted to a medical bed, was empirically treated with Levaquin for community acquired pneumonia. She had Rocephin added secondarily because she had been on Avelox as an outpatient. She has had a slow to improve clinical course with

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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: (INTE) MD, 10:50 EDT Authenticated By: (INTE) MD, 15:31 EDT continued cough although this is largely nonproductive. I assumed care of Ms. on , was finally able to transition back to oral Avelox as the patient had remained afebrile with a slowly improving clinical course over a period of a couple days. She did develop some loose stools on C. diff toxin returned positive. She was started on oral Flagyl. At this time she is on Avelox and will complete her outpatient course here in the hospital. She also could be treated for two weeks with p.o. Flagyl for her C. diff colitis. The patient will have an influenza vaccine and PNEUMOVAX both ordered to make sure that these are up-to-date prior to her anticipated discharge home on .

MD

DD: 10:50:57 DT: 11:28:37

# ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 15:31 ELECTRONICALLY SIGNED (INTE) MD, ON: 15:31

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Discharge Documentation Document Name: Discharge Note-Nursing Document Status: Signed Performed By: RN, 11:49 EDT Authenticated By: RN, 11:49 EDT RN went over written and verbal instructions with the patient and Dr. They verbalizes understanding and have no further questions at this time. Patient left in a wheelchair escorted out by , NA, her father, and sister. She has all her patient belongings, perscription for Vancomycin, and has no c/o pain and is in NAD at this time.

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 18:10 EDT Authenticated By: (INTE) MD, 23:56 EDT History & Physical Hospitalist History and Physical DATE OF ADMISSION: REQUESTING PHYSICIAN: MD PRIMARY CARE PHYSICIAN: MD ADMITTING HOSPITALIST: MD REASON FOR ADMISSION: Pneumonia. HISTORY OF PRESENT ILLNESS: Briefly, this is a 41-year-old lovely female with a past medical history of myotonic dystrophy, IBS and psoriasis who presents with 2 weeks of progressively worsening cough and shortness of breath. The patient stated approximately 2 weeks ago she started developing a sore throat and cough. The cough has become productive with yellowish sputum. By Tuesday, she went to see her primary care physician with laboratories and chest x-ray and was told that she had left-sided pneumonia and was started on Avelox. She has taken 3 doses; however, today, her pulse ox was 88% and she typically runs 92% to 93% on room air. She also had a fever of 101.3 degrees. The patient denies having any headaches, change in vision or hearing, sinusitis, chest pain, palpitations, orthopnea, PND, lower extremity edema, nausea, vomiting, abdominal pain, or diarrhea. She does have IBS and will have intermittent diarrhea and constipation with antibiotics. Denies having any hemoptysis, hematochezia, melena, bright red blood per rectum, dysuria, urgency, frequency, or hematuria. In the emergency room, she has received a liter of normal saline, O2 supplementation and Levaquin 750 mg IV. PAST MEDICAL HISTORY: 1. Myotonic dystrophy. 2. IBS. 3. Chronic migraines. 4. Psoriasis. PAST SURGICAL HISTORY: 1. Tubal ligation in 2002. 2. Tonsillectomy. HOME MEDICATIONS: 1. TUMS 2 tablets q.h.s. 2. Zantac 150 mg b.i.d. 3. Hydrocodone HD oral liquid q.i.d. p.r.n. for cough and congestion. ALLERGIES: THIMEROSAL and ZITHROMAX. SOCIAL HISTORY: The patient has no history of alcohol or tobacco. FAMILY HISTORY: Mother with myotonic dystrophy.

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 18:10 EDT Authenticated By: (INTE) MD, 23:56 EDT REVIEW OF SYSTEMS: As per HPI; otherwise 12-point review of systems negative. PHYSICAL EXAMINATION: VITAL SIGNS: T-max of 36.9 degrees, blood pressure 127/78, heart rate 107, respiratory rate 28, O2 saturation of 88% on 2 liters. GENERAL: The patient is pleasant. She is awake, alert and oriented to person, place and time with evident wet cough. She is able to speak 4-5 word sentences and appears nontoxic. HEENT: Normocephalic and atraumatic. Pupils equal, round and reactive. Oropharynx is clear. Moist mucous membranes. NECK: Supple. PULMONARY: Coarse rales at the bases with a little bit more prominent on the right. No obvious wheezing or rhonchi. CARDIOVASCULAR: Tachycardic. ABDOMEN: Positive bowel sounds, soft, nondistended, and nontender. EXTREMITIES: No cyanosis, clubbing or edema. SKIN: Dry and intact. NEUROLOGIC: She is moving all 4 extremities. No obvious focal deficits are noted. LABORATORY DATA: WBC 5.8, hematocrit 39.4, platelet 202. Differential normal. Chemistry panel shows sodium 142, potassium 3.6, bicarbonate 35, BUN 5, creatinine 0.55, glucose 127, ALT 72, AST 53. Influenza A and B negative. PERTINENT IMAGING: Chest x-ray shows bibasilar opacities, left worse than right. IMPRESSION AND PLAN: Briefly, this is a 41-year-old female with myotonic dystrophy who is coming in with 2 weeks of worsening shortness of breath and productive cough who has had 3 doses of Avelox and is currently 88% on room air, which is less than her baseline of 92% to 93% with low-grade fevers of 101.3 degrees. At this time, the patient has failed outpatient therapy and will require inpatient therapy. 1. Community-acquired pneumonia. We will continue Levaquin 750 mg IV as this is the dose that she has received in the emergency room. Continuous pulse ox. The goal of O2 saturation is 92% to 94%. Nebulizers q.4h. as needed. Tylenol for fevers. Follow up blood cultures. 2. Myotonic dystrophy. Continue pulse ox. Encourage patient to continue immobilization. 3. Irritable bowel syndrome. Continue to monitor and supportive care for now. 4. Chronic migraines. Not an acute issue at this time. 5. Psoriasis. Not evident on skin exam at this time. 6. Gastrointestinal prophylaxis: Continue Zantac and Tums. 7 Deep venous thrombosis prophylaxis with Lovenox 40 mg subcutaneous. CODE STATUS: FULL.

MD

DD: 18:10:25 DT: 19:50:35

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 18:10 EDT Authenticated By: (INTE) MD, 23:56 EDT

cc: MD; ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 23:56 ELECTRONICALLY SIGNED (INTE) MD, ON: 23:56

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Emergency Documentation Document Name: ED Note-Physician Document Status: Signed Performed By: Scanned, Documents 13:33 EDT Authenticated By:

Patient Name: MRN: FIN: Facility: Page Number: 16

Patient Name: MRN: FIN: Facility: Page Number: 17

Emergency Documentation Document Name: ED Note-Physician Document Status: Signed Performed By: (EMER) MD, 18:21 EDT Authenticated By: (EMER) MD, 08:43 EDT ED Note-Physician ED Emergency Room Report DATE OF SERVICE: DATE OF BIRTH: TIME: 5:55 PM HISTORY OF PRESENT ILLNESS: This is a 41-year-old female who presents to the emergency department with a complaint of increasing shortness of breath and some tightness in her chest. The patient has a history of myotonic dystrophy, has had this most of her life. She uses oxygen only at night and usually her oxygen saturations are somewhere between 94-95 during the day. The patient apparently recently 3 days ago, was diagnosed with pneumonia, has had fevers, chills, nonproductive cough and she has had worsening shortness of breath over the past couple of days despite being on a new antibiotic that she cannot recall the name of, and given her worsening symptoms, she was brought to the emergency department. She was found to be somewhat hypoxic, so she remained on oxygen. CHIEF COMPLAINT: Dyspnea, fever, pneumonia with a history of muscular dystrophy. REVIEW OF SYSTEMS: A 10-point review of systems was performed and is all negative except as listed in history of present illness. PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Significant for history of PE, myotonic dystrophy. MEDICATIONS: The patient is no longer on Coumadin or Lovenox; this PE was from birth control pills long ago. ALLERGIES: ZITHROMAX and THIMEROSAL. SOCIAL HISTORY: The patient denies smoking, alcohol, drug use. FAMILY HISTORY: Hypertension. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished female lying in bed in mild to moderate distress. INITIAL VITAL SIGNS: Temperature 36.9, pulse is 77, respirations 20, blood pressure 127/78. Room air pulse oximetry of 88% which is hypoxic. ENT: Oropharynx is clear, no erythema or exudate. There are moist mucous membranes. NECK: Supple. No nuchal rigidity. EYES: Pupils are equal, round and reactive to light and accommodation. EOMI. Sclerae clear. LUNGS: Reveal some decreased breath sounds at the bases. CARDIOVASCULAR: Regular rate and rhythm, clear S1 and S2. No murmurs. ABDOMEN: Soft, nondistended, nontender, positive bowel sounds. No mass, guarding, rebound. MUSCULOSKELETAL: Extremities are warm, pulses 2+, no crepitus, edema, or deformity. SKIN: Warm and dry without lesion, diaphoresis, or rashes. LYMPHATICS: No regional lymphadenopathy or lymphangitis. PLAN: Administer oxygen. She will undergo evaluation with a CBC, blood cultures, chemistries.

Patient Name: MRN: FIN: Facility: Page Number: 18

Emergency Documentation Document Name: ED Note-Physician Document Status: Signed Performed By: (EMER) MD, 18:21 EDT Authenticated By: (EMER) MD, 08:43 EDT LABORATORY DATA: Was evaluated by me. It did reveal a CBC that was normal with a count of 5.8, and 61 segs in the differential. Electrolytes were normal as well. Liver function test slightly elevated with an ALT of 72, AST of 53. Flu swab was negative. Chest x-ray did reveal left greater than right infiltrate. MEDICAL DECISION MAKING: This patient presented with shortness of breath and diagnosed pneumonia some 3 days ago, has a history of muscular dystrophy. There was consideration for the possibility of worsening pneumonia, which does indeed appear to be the case. No evidence of influenza, which was also considered. The patient had no pleuritic pain to suggest a pulmonary embolism, but given her findings, she will be admitted. DIAGNOSES: 1. Dyspnea. 2. Hypoxia. 3. Pneumonia. 4. History of muscular dystrophy. 5. Further orders will be per the hospitalist.

MD

DD: 18:21:50 DT: 20:13:13

ELECTRONICALLY REVIEWED AND SIGNED (EMER) MD, ON: 08:43 ELECTRONICALLY SIGNED (EMER) MD, ON: 08:43 Document Name: ED Note-Nursing Document Status: Signed Performed By: RN, 20:04 EDT Authenticated By: RN, 20:04 EDT ED Discharge Assessment Entered On: ED Discharge Assessment Entered On: ED Discharge Assessment Entered On: ED Discharge Assessment Entered On: 20:05 EDT 20:05 EDT 20:05 EDT 20:05 EDT

Performed On: 20:04 EDT by RN, Performed On: 20:04 EDT by RN, Performed On: 20:04 EDT by RN, Performed On: 20:04 EDT by RN, ED Admission/Transfer/Discharge Summary ED Admission/Transfer/Discharge Summary ED Admission/Transfer/Discharge Summary ED Admission/Transfer/Discharge Summary ED Disposition Status : ADMIT - inpatient IV Activity : Assess ED Disposition Condition : Oriented x 3 ED Disposition Comment : Reprot given to RN. Told pt tolerated tray well. Encouraged to call with further questions if at all. No other questions @ this time. ED Plan of Care Met : Met Mode of Discharge : Stretcher

Patient Name: MRN: FIN: Facility: Page Number: 85

Orders Order Date/Time 14:33 EDT Mnemonic Oxygen 2l via NC ED

Action Order

Order Status Completed

Type of Order Patient Care

Ordering Physician (EMER) MD,

Order Placed By RN,

Review Information Nurse Review, Accepted - RN, , 01:15 EDT Order Details

14:32:00 EDT, Stat, once, Walk, None Order Date/Time 14:32 EDT

Home Med List Reviewed ED

Action Order

Order Status Completed

Type of Order Patient Care

Ordering Physician System, Cerner

Order Placed By System, Cerner

Review Information N/A Order Details

14:32:40 EDT 14:32 EDT: Order entered secondary to Home Med Documented No in Triage.

Progress Notes Document Name: Automatic IV to PO Conversion Antibiotic Document Status: Signed Performed By: Rph, 02:11 EDT Authenticated By: Rph, 02:11 EDT AUTOMATIC IV TO PO CONVERSION This patient meets Committee approved criteria for automatic IV to PO conversion of the following medication(s): Levaquin This (these) medication(s) is/are highly bioavailable and should provide an equally efficacious mode of therapy for qualifying patients. Thank you. Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 10:06 EDT Authenticated By: (INTE) MD, 15:51 EDT Subjective Ambulated more yesterday, nausea and diarrhea resolved. feels a little unsteady with ambulation but did well with pt. Assessment/Plan left ue thrombophlebitis: cont warm compresses.

Patient Name: MRN: FIN: Facility: Page Number: 86

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 10:06 EDT Authenticated By: (INTE) MD, 15:51 EDT c diff colitis: continue vancomycin, follow clinically, pt eval, increase mobility, prob d/c tomorrow. dvt / gi prophylaxis: addressed. Physical Exam aox 3, nad left medial forearm swelling seems baseline ctab rrr abd soft, ntnd, +bs ext no c/c/e Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 37.1 90/58 84 18 ---- 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37.1 at 07:04

Intake Output Balance Totals 962.5 0 962.5 Today's Lab Results

05:34 Procedure Units Ref Range Potassium Lvl 4.9 mmol/L 3.5 - 5.1 ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 15:51 ELECTRONICALLY SIGNED (INTE) MD, ON: 15:51 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 16:57 EDT Authenticated By: (INTE) MD, 15:51 EDT Subjective Several loose stools last night, better this am, nausea with flagyl.

Patient Name: MRN: FIN: Facility: Page Number: 87

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 16:57 EDT Authenticated By: (INTE) MD, 15:51 EDT Assessment/Plan left ue thrombophlebitis: warm copmpresses tid. c diff colitis: change to vancomycin, follow clinically, pt eval, increase mobility, labs reviewed, check stool studies. dvt / gi prophylaxis: addressed. d/w patient and family Physical Exam aox 3, nad left medial forearm swelling and induration, better, no erythema or drainage ctab rrr abd soft, ntnd, +bs ext no c/c/e Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 37.0 107/61 78 16 94% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37.2 at 08:11

Intake Output Balance Totals 240 0 240 Today's Lab Results

14:08 Procedure Units Ref Range BUN 8 mg/dL 7 - 18 Creatinine 0.66 mg/dL 0.60 - 1.10 Sodium Lvl 144 mmol/L 134 - 145 Potassium Lvl 3.0 L mmol/L 3.5 - 5.1 CO2 35.0 H mmol/L 21.0 - 32.0 Chloride 104 mmol/L 98 - 107 Glucose Lvl 119 H mg/dL 65 - 99 Calcium Lvl 8.3 L mg/dL 8.5 - 10.1 ALT 58 U/L 17 - 65 AST 63 H U/L 3 - 37 Albumin Lvl 2.8 L g/dL 3.4 - 5.0

Patient Name: MRN: FIN: Facility: Page Number: 88

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 16:57 EDT Authenticated By: (INTE) MD, 15:51 EDT Alk Phos 121 U/L 50 - 136 Bili Total 0.3 mg/dL 0.2 - 1.0 Total Protein 5.9 L g/dL 6.4 - 8.2 eGFR - African >60 - * eGFR - African - eGFR calculated by Discern Logic. eGFR - Non-Afri >60 - * eGFR - Non-African - eGFR calculated by Discern Logic. WBC 5.8 k/uL 3.5 - 10.5 RBC 3.92 M/uL 3.90 - 5.03 Hgb 12.7 g/dL 12.0 - 15.5 Hct 37.6 % 35.0 - 44.0 MCV 96.0 fL 82.0 - 98.0 RDW 14.7 % 12.0 - 15.0 Platelet 192 k/uL 150 - 450 ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 15:51 ELECTRONICALLY SIGNED (INTE) MD, ON: 15:51 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 15:08 EDT Authenticated By: (INTE) MD, 08:36 EDT Subjective Events reviewed, patient generall y feels poorly. no diarrhea, no abd pain, cough better, some nausea after avelox. doesn't feel ready for discharge. Assessment/Plan ca p: d/c abx. left ue thrombophlebitis: warm copmpresses tid. c diff colitis: cont flagyl, prob home tomorrow. dvt / gi prophylaxis: addressed. Physical Exam aox 3, nad left medial forearm swelling and induration, no erythema or drainage ctab rrr abd soft, ntnd, +bs ext no c/c/e

Patient Name: MRN: FIN: Facility: Page Number: 89

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 15:08 EDT Authenticated By: (INTE) MD, 08:36 EDT Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 37.1 134/75 87 21 93% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37.1 at 08:07

Intake Output Balance Totals 722.5 0 722.5 No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 08:36 ELECTRONICALLY SIGNED (INTE) MD, ON: 08:36 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:53 EDT Authenticated By: (INTE) MD, 11:45 EDT Subjective

had 2-3 loose stools overnight - no watery per pt, loose cough/did walk twice in hallway yesterday, asks a lot of questions regarding C Diff & contact with her mother who just had C Diff Assessment/Plan 1. Community-acquired pneumonia, Levaquin , CTX , Avelox 2. Myotonic dystrophy. 3. IBS. 4. Chronic migraines. 5. Psoriasis 6. C Diff colitis, Flagyl - reluctant to go home today until she is sure diarrhea will not get worse - tentatively planning d/c on 2 week course of Flagyl, complete Avelox Rx tomorrow night - encouraged continued activity - Lovenox/Pepcid proph

Patient Name: MRN: FIN: Facility: Page Number: 90

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:53 EDT Authenticated By: (INTE) MD, 1 11:45 EDT Dict Time < 30" Physical Exam Chest: R post rhonchi CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS Extremities: L fo rearm thrombophlebitis at prior PIV site Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy AFEB 9 1/59 90 18 95% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37 at 23:42

Intake Output Balance Totals 890.5 1200 -309.5 Today's Lab Results

05:48 Procedure Units Ref Range WBC 6.3 k/uL 3.5 - 10.5 RBC 4.22 M/uL 3.90 - 5.03 Hgb 13.7 g/dL 12.0 - 15.5 Hct 40.6 % 35.0 - 44.0 MCV 96.3 fL 82.0 - 98.0 RDW 15.2 H % 12.0 - 15.0 Platelet 163 k/uL 150 - 450

C Diff (+) ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 11:45 ELECTRONICALLY SIGNED (INTE) MD, ON: 11:45

Patient Name: MRN: FIN: Facility: Page Number: 91

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:53 EDT Authenticated By: (INTE) MD, 11:57 EDT Subjective

Slept better last night, still having loose non-productive cough, didn't walk yesterday as didn't feel real good - plans to walk some today, good PO intake/nausea better Assessment/Plan 1. Community-acquired pneumonia, Levaquin 10/19-, CTX 10/20- 1. Myotonic dystrophy. 2. IBS. 3. Chronic migraines. 4. Psoriasis. - slow to improve but remains afebrile, SaO2 okay on 3 lpm (uses 2 lpm nocturnally at home) - will d/c IV Abx today ---> has brought Avelox from home in, will resume - encouraged activity - she could likely go home if not this pm then by tomorrow, suspect she will have a slowly resolving course over a period of weeks, could consider adding PO Prednisone to help curtail inflammatory response to infection, on Alb nebs Q6hrs - Lovenox/Pepcid proph Physical Exam Chest: R post rhonchi CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS Extremities: No clubbing, cyanosis or edema Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy AFEB 10 7/68 88 18 94% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37.2 at 23:51

Intake Output Balance Totals 840.5 1050 -209.5

Patient Name: MRN: FIN: Facility: Page Number: 92

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:53 EDT Authenticated By: (INTE) MD, 11:57 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 11:57 ELECTRONICALLY SIGNED (INTE) MD, ON: 11:57 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:58 EDT Authenticated By: (INTE) MD, 13:00 EDT Subjective

persistent cough but looser per pt, ambulated in halls with some dyspnea, PO intake good, no nausea Assessment/Plan 1. Probable community-acquired pneumonia, Levaquin -, CTX 1. Myotonic dystrophy. 2. IBS. 3. Chronic migraines. 4. Psoriasis. - cont IV Abx x 1 more day, if remains afebrile will likely switch to PO - has home O2 so could d/c home with outpt f/u - Lovenox/Pepcid proph Physical Exam Chest: R basi lar rhonchi CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS Extremities: No clubbing, cyanosis or edema Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy AFEB 1 07/62 84 20 93% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 37.0 at 19:55

Patient Name: MRN: FIN: Facility: Page Number: 93

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 06:58 EDT Authenticated By: (INTE) MD, 13:00 EDT

Intake Output Balance Totals 1085 200 885 No 24 Hour Lab Data

BC NTD ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 13:00 ELECTRONICALLY SIGNED (INTE) MD, ON: 13:00 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 07:34 EDT Authenticated By: (INTE) MD, 13:07 EDT Subjective

Non-productive coughing spells continue, feels tired after going to bathroom, no chest pain, some nausea last pm with Levaquin administration Assessment/Plan 1. Probable community-acquired pneumonia, Levaquin -/CTX 1. Myotonic dystrophy. 2. IBS. 3. Chronic migraines. 4. Psoriasis. - cont Abx x 2, plan to transition back to PO Avelox once family brings in to hospital - Proventil MDI Q6hr - Lovenox proph - ambulate, IS Q1hr w/a - Humabid BID Physical Exam Chest: R post rhonchi CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS

Patient Name: MRN: FIN: Facility: Page Number: 94

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 07:34 EDT Authenticated By: (INTE) MD, 13:07 EDT Extremities: No clubbing, cyanosis or edema Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy AFEB 11 6/67 78 20 95% 2.0 L/m NASAL CANNULA 24 Hr Tmax: 36.9 at 23:41

Intake Output Balance Totals 1085 200 885 No 24 Hour Lab Data

BC NTD ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 13:07 ELECTRONICALLY SIGNED (INTE) MD, ON: 13:07 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 09:17 EDT Authenticated By: MD, 09:17 EDT Subjective She feels about the same as yesterday. no pain. no productive cough. PAST MEDICAL HISTORY: 1. Myotonic dystrophy. 2. IBS. 3. Chronic migraines. 4. Psoriasis. Assessment/Plan Probable pneumonia (bacterial, CAP) -continue levaquin and rocephin -add IS and acapella

Patient Name: MRN: FIN: Facility: Page Number: 95

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 09:17 EDT Authenticated By: MD, 09:17 EDT -continue nebs, O2, ambulate -if not better tomorrow, consider steroids DVt px - on lovenox Physical Exam Chest: sig nificant rhonchi and wheezing still present CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS Extremities: No clubbing, cyanosis or edema Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.8 109/71 82 20 96% 3.0 L/m NASAL CANNULA 24 Hr Tmax: 36.8 at 07:45

Intake Output Balance Totals 1182 2 1180 No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 09:17 ELECTRONICALLY SIGNED MD, ON: 09:17 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 10:18 EDT Authenticated By: MD, 10:18 EDT Subjective She feels somewhat better. no cp. no sig sob. chest congestion and cough about the same. PAST MEDICAL HISTORY: 1. Myotonic dystrophy.

Patient Name: MRN: FIN: Facility: Page Number: 96

Progress Notes Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 10:18 EDT Authenticated By: MD, 10:18 EDT 2. IBS. 3. Chronic migraines. 4. Psoriasis. Assessment/Plan Probably pneumonia (bacterial, CAP) -continue levaquin -add rocephin (since she got worse with quinolone as outpt) -continue nebs, O2 DVt px - on lovenox Physical Exam Chest: bi basilar crackles, scattered wheezing CV: RRR, No rubs, murmurs or gallops Abdomen: Soft, nontender, nondistended, NABS Extremities: No clubbing, cyanosis or edema Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 37.0 124/67 74 20 95% ----------- 24 Hr Tmax: 37.0 at 07:46

Intake Output Balance Totals 1507 0 1507 Today's Lab Results

06:14 Procedure Units Ref Range Potassium Lvl 4.2 mmol/L 3.5 - 5.1 ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 10:18 ELECTRONICALLY SIGNED MD, ON: 10:18

Patient Name: MRN: FIN: Facility: Page Number: 97

Progress Notes Document Name: Progress Note-Nurse Document Status: Signed Performed By: RN, 02:24 EDT Authenticated By: RN, 02:24 EDT Pt A&Ox3, O2 sats 95% on 3L NC, non-momitored. No complaints of pain or nausea. Pt ambulates independently to bathroom. Instructed pt to call if SOB or needs assisance OOB, verbalized understanding. Pt in no distress with callbell and telephone at bedside. Document Name: Progress Note-Nurse Document Status: Signed Performed By: RN, 22:29 EDT Authenticated By: RN, 22:29 EDT c'diff report called to hospitalist. Document Name: Progress Note-Nurse Document Status: Signed Performed By: RN, 11:47 EDT Authenticated By: RN, 11:47 EDT The RN walked with the patient down the hallway and back on 3L nasal cannula. The patient c/o of shortness of breath her oxygen level went from 94% on 3L nasal cannula to 86% on 3L nasal cannula. The RN ambulated with the patient back to her room. It took her 2 minutes to recover to her baseline of 94% on 3L nasal cannula. The patient is left in bed has no c/o SOB and/or pain. She is left in bed with the call bell within reach and is told to call if she needs anything. The patient verbalizes understanding. PA is at bedside visiting with the patient at this time.

Patient Name: MRN: FIN: Facility: Page Number: 98

Hematology General Hematology Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

WBC k/uL

[3.5-10.5]

RBC M/uL

[3.90-5.03]

Hgb g/dL

[12.0-15.5]

Hct %

[35.0-44.0]

Platelet k/uL

[150-450]

RDW %

[12.0-15.0]

MCV fL

[82.0-98.0] 14:08 EDT 5.8 3.92 12.7 37.6 192 14.7 96.0 05:48 EDT 6.3 4.22 13.7 40.6 163 15.2 H 96.3 16:02 EDT 5.8 4.06 13.4 39.4 202 15.5 H 97.1

Differential Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

Neutro %

[42-78]

Lymph %

[16-52]

Mono %

[1-11]

Eos %

[0-7]

Basophil %

[0-4]

Neutro Abs k/uL

[2.10-6.30] 16:02 EDT 61 29 6 3 1 3.54

Chemistry General Chemistry Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

Sodium Lvl mmol/L

[134-145]

Potassium Lvl mmol/L [3.5-5.1]

Chloride mmol/L [98-107]

CO2 mmol/L

[21.0-32.0]

BUN mg/dL [7-18]

Creatinine * mg/dL

[0.60-1.10] 05:34 EDT 4.9 14:08 EDT 144 3.0 L 104 35.0 H 8 0.66 06:14 EDT 4.2 16:02 EDT 142 3.6 102 35.0 H 5 L 0.55 L

16:02 EDT Creatinine:

* This creatinine method is traceable to a GC-IDMS method and NIST standard reference material. Procedure

Units Ref Range

eGFR - African

eGFR - Non-African *

Glucose Lvl mg/dL [65-99]

Calcium Lvl mg/dL

[8.5-10.1]

Alk Phos U/L

[50-136]

Bili Total mg/dL

[0.2-1.0] 14:08 EDT >60 f >60 f 119 H 8.3 L 121 0.3 16:02 EDT >60 f >60 f 127 H 8.4 L 126 0.3

16:02 EDT eGFR - Non-African:

The eGFR is calculated using the four parameter MDRD equation for IDMS-traceable creatinine. eGFR < 60 indicates chronic kidney disease, eGFR < 15 indicates kidney failure.

14:08 EDT eGFR - African: eGFR calculated by Discern Logic.

16:02 EDT eGFR - African: eGRF calculated by Discern Logic.

14:08 EDT eGFR - Non-African: eGFR calculated by Discern Logic.

16:02 EDT eGFR - Non-African: eGRF calculated by Discern Logic.

Patient Name: MRN: FIN: Facility: Page Number: 99

Chemistry General Chemistry Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

Albumin Lvl g/dL

[3.4-5.0]

Total Protein g/dL

[6.4-8.2]

ALT U/L

[17-65]

AST U/L

[3-37] 14:08 EDT 2.8 L 5.9 L 58 63 H 16:02 EDT 2.9 L 6.6 72 H 53 H

Immunology/Serology/Molecular Testing

Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes

Procedure Units

Ref Range

Influenza A Ag *

[Neg]

Influenza B Ag

[Neg]

C.Diff-Rapid PCR *

[NEGATIVE]

C.Diff-NAP1

18:34 EDT POSITIVE A See Below 16:02 EDT Neg Neg

18:34 EDT C.Diff-NAP1

027-NAP1-BI PRESUMPTIVE NEGATIVE

16:02 EDT Influenza A Ag: * Detection of the current strain of H1N1 "swine" flu virus in humans by this method has not been established. A positive result for influenza A does not distinguish seasonal influenza A from H1N1 type influenza A. A negative result does not exclude the possibility of either seasonal or H1N1 strains of influenza A.

18:34 EDT C.Diff-Rapid PCR: *Repeat testing following a positive test is not recommended since patients may carry toxigenic C. difficile for months after clinical cure unless the patient improves with therapy and relapses after the completion of a treatment regimen. For negative tests,repeat testing is not needed due to the high sensitivity of PCR tests.

Urinalysis

Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes

Procedure Units

Ref Range

UA Color

UA Clarity

UA Spec Grav

[1.005-1.030]

UA pH

[5.0-8.0]

UA Protein *

[Neg]

UA Glucose

[Neg] 18:59 EDT Yellow Clear 1.007 6.0 Neg Neg

18:59 EDT UA Protein:

INTERPRETATION OF NUMERIC VALUES FOR URINALYSIS Protein Glucose Ketone TR = Trace TR = 100 mg/dL TR = 5 mg/dL 1+ = 30 mg/dL 1+ = 250 mg/dL 1+ = 15 mg/dL 2+ = 100 mg/dL 2+ = 500 mg/dL 2+ = 40 mg/dL 3+ = 300 mg/dL 3+ = 1000 mgdL 3+ = >80 mg/dL

Patient Name: MRN: FIN: Facility: Page Number: 100

Urinalysis

Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes

Procedure Units

Ref Range

UA Ketones

[Neg]

UA Bili

[Neg]

UA Blood

[Neg]

UA Nitrite

[Neg]

UA Leuk Est

[Neg]

UA WBC /HPF [0-2]

UA RBC /HPF [0-3]

18:59 EDT Neg Neg Neg Neg Neg 1 1 Procedure

Units Ref Range

UA Bacteria

[None Seen]

UA Hyal Cast /LPF [0-0]

Urine Collection Type

18:59 EDT None Seen 1 H Urine, Midstr

Microbiology - Blood Cultures PROCEDURE: Blood Culture SOURCE: Venous COLLECTED: 16:02 EDT STARTED: 16:17 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified: 22:01 EDT No growth. __________________________________________________________ PROCEDURE: Blood Culture SOURCE: Venous COLLECTED: 16:02 EDT STARTED: 16:17 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified: 22:01 EDT No growth. __________________________________________________________

Diagnostic Radiology Accession Number Exam Exam Date/Time Ordering Physician

DR Chest 2 Views 16:22 EDT (EMER) MD, CPT4 Codes 71020 (DR Chest 2 Views)

Patient Name: MRN: FIN: Facility: Page Number: 101

Diagnostic Radiology Accession Number Exam Exam Date/Time Ordering Physician

DR Chest 2 Views 16:22 EDT (EMER) MD, CDM Codes 25564 (DR Chest 2 Views) Reason For Exam Fever Report CHEST 2 VIEWS INDICATION: Cough, fever, dyspnea TECHNIQUE: Two views compare FINDINGS: Cardiac size normal. Patient has achieved a shallow inspiration. There streaky basilar opacities, atelectasis versus infiltrate left worse than right. No evidence for failure. There is no effusion or adenopathy. Bones unremarkable. IMPRESSION: Shallow inspiration with streaky basilar opacities left worse than right, atelectasis versus infiltrate ***** Final ***** (RAD) MD, Signed (Electronic Signature): 4:24 pm Signed by: (RAD) MD, Transcribed by: