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history of present illness: the patient is a 76-year-old male who had been hospitalized at the from through of after undergoing a left femoral-at bypass graft and was subsequently discharged to a rehabilitation facility. on , he presented again to the after being found to have a systolic blood pressure in the 70s and n...
history of present illness: the patient is a 47-year-old female with a history of human immunodeficiency virus (last cd4 count 42 and a viral load of 65,000), cirrhosis, diabetes, and hypothyroidism presented with eight days of fevers to 104, chills, shortness of breath, cough, dyspnea on exertion, and fatigue. the pat...
history of present illness: the patient is a 65 year-old woman with end stage renal disease, secondary to malignant hypertension. she was started on dialysis in . she currently was on peritoneal dialysis and appears to be doing well. she has a history of gastric angiectasia which she requires endoscopy. she was admitte...
past medical history: hypertension. admission medications: the patient was on no medications upon admission. allergies: the patient has no known drug allergies. family history: unknown. social history: the patient lives . physical examination on admission: during the five minute examination, the patient became progress...
history of present illness: baby girl is a 1,385 gram, former 30 and week premature baby, born to an 18 year old, gravida i, para 0, now i, mother with prenatal serologies as follows: a positive, antibody negative, rpr nonreactive, hepatitis b surface antigen negative; gbs unknown. pregnancy was complicated by pprom on...
allergies: penicillins attending: chief complaint: cc: major surgical or invasive procedure: stereotactic brain biopsy, neuronavigation guided tumor resection. history of present illness: hpi: 50 year old female presents after having fallen in the bathtub 4 days ago and hitting the back of her head. since then she has ...
history of present illness: mr. is a 72-year-old male with a past medical history significant for pancreatic cancer, ulcerative colitis, hypertension, status post endoscopic retrograde cholangiopancreatography, and status post total abdominal colectomy 20 years ago with an end-ileostomy. the patient underwent an endosc...
history of present illness: this is a 39-year-old woman with diabetes, hypertension, hyperlipidemia and obesity, with a one to two months of chest burning with exertion. for the past six months, she has been participating in a new vigorous exercise program to lose weight. her symptoms do gradually resolve with rest, bu...
see fhp for detailed pmh and allergies s-"how long will surgerry take?" o-a/o/x/3.very cooperative with care. anxious about surgery and asking many questions. anxious to go home soon. given ambien and sleeping well overnight. cv-hemodynamically stable. hr 60s to 80s, nsr with no vea, iabp 1:1 with map 70s to 110s. poor...
allergies: bactrim / ampicillin / remeron attending: chief complaint: chest pressure/cardiac tamponade/ cardiogenic shock major surgical or invasive procedure: emergent sternotomy for pericardial window history of present illness: underwent min. inv. pfo closure in . had emergent admission on for hypotension, pericardi...
allergies: bactrim / ampicillin / remeron attending: chief complaint: history of stroke major surgical or invasive procedure: minimally invasive closure of patent foramen ovale history of present illness: mrs. is a 47 year old female who suffered a cerebellar stroke in . workup at that time revealed a patent foramen ov...
allergies: bactrim attending: addendum: medications on admission: klonopin 3mg po bid lexapro 20mg po daily nortriptyline 50mg po daily crestor 10mg po daily seroquel 50mg po tid trazodone 200mg po qhs:prn insulin, standing and ss medications on discharge: klonopin 3mg po bid lexapro 20mg po daily nortriptyline 50mg po...
allergies: bactrim attending: chief complaint: "i'm just so depressed, i can't do anything" major surgical or invasive procedure: none history of present illness: pt reports 3-4 weeks ago he noticed an increase of stress at work and at home at the same time that he was losing weight to gain better control over his diab...
allergies: bactrim attending: chief complaint: depression major surgical or invasive procedure: none history of present illness: 50 yo m w/ type 2 dm, depression who was admitted to deaconness 4 for major depressive episode and possible . while on 4, the patient was given ativan 1 mg x 1. his klonopin was held. he was ...
history of present illness: the patient is a 65-year-old woman status post coronary artery bypass grafting times three on and discharged home on , who the day prior to admission noted increasing redness of her right lower extremity at the saphenectomy site. she denied fevers, chills or leg pain. she had no shortness of...
history of present illness: this is a 65 year old female with a 20 year history of hypertension and a ten year history of type 2 diabetes who demonstrated a positive exercise stress test in suggestive for possible coronary artery disease. the patient received a stress test as part of a risk stratification workup and at...
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, dyspnea major surgical or invasive procedure: cardiac catheterization with placement of three stents and iabp. swan catheter placement. history of present illness: history of present illness: 87 yo m with chronic k...
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from nursing home for fever and elevated white count major surgical or invasive procedure: none history of present illness: 87 yo m with pmh of dm, cad, esrd on hd who was transferred from rehab to ed for eval of feve...
history of present illness: the patient is a 64-year-old female with a history of hypertension, depression, prior suicide attempt by overdose, recently with exacerbated mood disorder status post the death of her husband in , now presented after being found unresponsive. the patient's daughters found her in the morning ...
allergies: morphine attending: chief complaint: seizures major surgical or invasive procedure: : left craniotomy for mass resection history of present illness: mr. is a 75yo rhm with cad s/p cabg, as, htn, hyperlipidemia, now here for resection of parasagittal meningioma. pt first noted symptoms three years ago with di...
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, sob, positive ett major surgical or invasive procedure: four vessel coronary artery bypass grafting(lima to lad, svg to diagonal, svg to om, svg to pda) history of present illness: this is a 71 year old male with k...
allergies: percocet attending: chief complaint: inferior mi major surgical or invasive procedure: cardiac catheterization with 4 overlapping stents to rca history of present illness: 39 yo male with history of gerd woke up w/ sob and lue discomfort 1 day pta. he presented to where he was ruled out for mi by enzymes. he...
allergies:percocet. social hx:single. police officer. etoh-occasional--last drink 4 days ago. wo drug use. crf:smoker-1pk/dat x5yrs. ?elevated cholesterol. +family hx-father w mi early 60's. family hx of dm. present hx:developed sob & lue discomfort/numbness. went to osh-ro w neg ekg/ck's. kept overnight. est-stopped d...
allergies: motrin attending: chief complaint: transferred from osh for dka, r/o mi major surgical or invasive procedure: s/p cardiac catheterization with stenting of left circumflex artery history of present illness: 58 yo male with hx type 1 dm on insulin pump, ?vertigo, no known transferred to ccu for management of p...
history of present illness: patient is a 72-year-old male with coronary artery disease status post myocardial infarction, chf with an ejection fraction of 15% and icd for df/vt. here for possible icd malfunction after he was shocked three times at home the night before admission to an outside hospital. the first shock ...
she was born at 10:16pm this evening as the 3200 gram product of a 39+ week gestation pregnancy to a 34 y.o. g1 p0-1 mother. prenatal laboratory studies included bt o+/ab-, hbsag-, rpr nr, ri, and gbs+. pregnancy reportedly unremarkable. perinatal period was complicated by maternal fever to 102.5, with rom 14 hours ptd...
history of present illness: mr. is a 74-year-old man with known cad, had an mi and 79 and ptca of his lad and rca and . he had a stent to his diagonal in , reports dyspnea on exertion over the past several months accompanied by leg cramps. denies any chest pain, nausea, vomiting, diuresis, syncope. stress echo done rec...
past medical history: 1. coronary artery disease: a) the patient had coronary artery bypass grafting with a saphenous vein graft to the left anterior descending artery, a saphenous vein graft to the first obtuse marginal artery, a saphenous vein graft to the third obtuse marginal artery and a saphenous vein graft to th...
history of present illness: mr. is a 72-year-old gentleman with a history of hodgkin's disease was transferred here from hospital because of intractable seizures and decreased mental status. he was in his usual state of health, active and playing golf, until when he began to become "confused" and developed gait difficu...
allergies: pcn (rash) ros/ neuro: pt awake, oriented x 3. percocet 2 tabs q 4-6 hrs for pain. pt c/o lt leg pain today - medicated w/ percocet with effect. cv: afib rate 80's, no ectopy. bp stable. lle noted to be edematous, painful, positive dopplerable pp ble. awaiting ultrasound lle to r/o dvt. heparin sc 5000u. cou...
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