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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ y/o M w/ PMHx of recurrent DVT/PE ___ years ago, ___, on life-long anticoagulation), presented with left leg and chest pain. Patient has not taken coumadin for ___ weeks ___ visiting his sister in the hospital. Per office records, last therapeutic INR in ___, was on 5mg coumadin. Patient reports left calf pain/tightness 5 days ago, similar to what he experienced with prior DVT. On DOA, patient experienced sharp, ___, non-radiating substernal chest pain suddenly. Associated with dyspnea, and fatigue. Chest pain worse with cough and deep inspiration. No recent travel, no h/o malignancy, no h/o GI, GU, intracranial bleed. In the ED, initial VS. 99.0 103 127/83 16 99%. CTA showing b/l subsegmental PE. EKG showing new RBBB and S1Q3T3 pattern. Given 100mg Lovenox, 5mg Morphine IV and full dose ASA. Currently, patient c/o ___ substernal pain. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. <PAST MEDICAL HISTORY> COPD DVT/PE in ___ and ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Cancer (mom and GM, uterine and colon) <PHYSICAL EXAM> ADMISSION EXAM: VS - 97; 114/80; 1028; 100RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - tachycardic, regular, no MRG, nl S1-S2, no parasternal heave ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) + ___ sign on L. calve, tenderness on palpation SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait DISCHARGE EXAM: VS - 98.5; 117/75; 80; 20; 95%RA Exam otherwise unchanged since admission <PERTINENT RESULTS> ADMISSION LABS: ___ 10: 13AM BLOOD WBC-10.8 RBC-4.46* Hgb-13.5* Hct-41.4 MCV-93 MCH-30.2 MCHC-32.6 RDW-12.0 Plt ___ ___ 10: 13AM BLOOD ___ PTT-28.9 ___ ___ 10: 13AM BLOOD Glucose-81 UreaN-13 Creat-1.0 Na-138 K-3.8 Cl-100 HCO3-29 AnGap-13 ___ 10: 13AM BLOOD proBNP-36 ___ 10: 13AM BLOOD cTropnT-<0.01 DISCHARGE LABS: ___ 07: 45AM BLOOD Hct-38.2* INR: ___ 10: 13AM ___ ___ 07: 50AM ___ ___: 50AM ___ ___ 07: 45AM ___ IMAGING: CXR ___: PA and lateral views of the chest were obtained. Lung volumes are low with bibasilar plate-like atelectasis, left greater than right. No definite signs of pneumonia or CHF. No large pleural effusion or pneumothorax is seen. Heart size is difficult to assess though appears grossly stable. Mediastinal contour is normal. Bony structures appear intact. IMPRESSION: Bibasilar plate-like atelectasis, left greater than right. Please refer to subsequent CTA chest for further details. CTA chest ___: There are bilateral subsegmental and lingular pulmonary emboli. Consolidations in the bases may be atelectasis, however, lack of enhancement is suggestive of early infarct. In addition, seen anterior to the heart is a consolidation which is likely an infarct from a lingular pulmonary embolus. There is no evidence of right heart strain. There is no axillary, mediastinal or hilar lymphadenopathy. No pulmonary nodules or masses are seen. There is no pneumothorax. The bones are unremarkable. Although this study was not tailored to evaluate the subdiaphragmatic contents, a right adrenal adenomyolipoma is seen but not fully imaged. The imaged portion of the spleen, liver and left adrenal gland is normal. IMPRESSION: Bilateral subsegmental and lingular pulmonary emboli with probable early infarction. <MEDICATIONS ON ADMISSION> Coumadin ___ daily (last took ___ weeks ago) Celexa 40mg daily Albuterol inhaler prn tiotropium inhaler prn <DISCHARGE MEDICATIONS> 1. enoxaparin 120 mg/0.8 mL Syringe Sig: One ___ (110) mg Subcutaneous Q12H (every 12 hours): as directed. Disp: *14 syringes* Refills: *0* 2. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. Disp: *14 Tablet(s)* Refills: *0* 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. Disp: *10 Tablet(s)* Refills: *0* 7. Outpatient Lab Work ___ ___ <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> PRIMARY: Pulmonary Emboli <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Mr ___, It was a pleasure participating in your care at ___. You were admitted because you had chest and leg pain. We found that you have blood clot in your lungs. We are treating you with Lovenox (injection blood thinner). You will continue to take Lovenox until your coumadin level builds up in your blood. We made the following changes to your medications: STARTED Lovenox (you will stop once your coumadin level is at goal) RESTARTED Coumadin STARTED Oxycodone as needed for pain
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[REDACTED] y/o M with PMHx of DVT, recently off coumadin, presenting with left leg pain, chest pain, CTA c/w b/l subsegmental PE. # PE/Chest pain: Patient presented with chest pain and leg pain. CTA showing bilateral subsegmental PEs. EKG with S1Q3T3. Patient with h/o recurrent DVT/PE x2, on life-long anticoagulation. These DVT/PEs did not seem provoked. Unclear whether he had hypercoagulable workup as outpatient. Per outpt records, last time INR within goal was [REDACTED], on coumadin 5mg daily. Patient with med non-compliance due to social reasons. Will continue to require lifelong anticoagulation given this is his third episode. On admission, patient mildly tachycardic, but not hypotension and had no O2 requirement. Chest/leg pain controlled with oxycodone 5mg BID prn. Will likely be able to wean off as PE/DVT resolves. Started Lovenox [REDACTED] bid (1mg/kg bid) and coumadin 5mg daiy on [REDACTED]. INR on [REDACTED] was 1.1. Patient will go to [REDACTED] for Lovenox/coumadin bridging and continued monitoring. Once INR [REDACTED], can discontinue lovenox. Please arrange follow up and INR monitoring with patient's PCP- [REDACTED]. # COPD: Patient only with [REDACTED] year smoking history, but recently diagnosed with COPD. Uses rescue inhalers every few days. Continue tiotropium and albuterol prn. # Depression: Continued celexa daily. # Transitional issues: - code status: full code - pending labs: none - follow up issues: INR check, Lovenox- coumadin bridging; Please arrange follow up and INR monitoring with patient's PCP- [REDACTED] prior to discharge from [REDACTED]
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Left lower lobe lung nodules <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p left VATS and left lower lobe wedge resection X2 <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ with a h/o uterine cancer ___ with lung mets s/p LUL wedge resection ___. She has been followed for lung nodules since. On her most recent chest CT ___ it was noted 12 x 11 mm solid subpleural nodule in the left lung base that was 5 x 5 mm in ___. A new 6 x 4 mm solid subpleural nodule in the left lung base was also noted. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> 1. Right adrenal adenoma 8 mm. 2. IPMN, pancreatic tail. 3. Hypercholesterolemia. 4. Hypertension. 5. Osteopenia. 6. Colonic polyps. 7. Obesity, BMI 30.5. Past Surgical History: 1. Total abdominal hysterectomy, bilateral salpingo- oophorectomy, and omentectomy in ___ for endometrial carcinoma, status post chemo and radiation. 2. Left upper lung lobe wedge resection and mediastinal lymph node dissection for metastatic endometrial adenocarcinoma in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history is significant for heart disease only. Mother with an MI at ___. Father was killed at age ___ during the ___. Paternal grandmother with CAD and her brother has CAD. None known history of malignancy in the family. <PHYSICAL EXAM> Discharge Exam Gen: NAD, A and OX3 CV: RRR, no murmur Pulm: CTAB, no wheezing, CT site and incisions C/D/I, no erythema Abd: Soft, NT/ND, no rebound/guarding Ext: WWP, no cyanosis <MEDICATIONS ON ADMISSION> Oxybutynin chloride 5', Simvastatin 10', Calcium 600 w Vitamin D3 600 mg (1,500 mg)-400 unit capsule", MVI <DISCHARGE MEDICATIONS> Home meds plus: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills: *0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 capsule by mouth every 4 hours Disp #*40 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p left VATS and left lower lobe wedge resection X2 <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Lung Surgery * You were admitted to the hospital for lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol ___ mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you.
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[REDACTED] y/o female presents for surgical excision of 2 left lower lobe lung nodules suspicious for metastatic endometrial cancer. She was taken to the operating room on [REDACTED] and underwent an uncomplicated left VATS wedge excision X2. For full details please see the operative report. She tolerated the procedure well and was transferred to the PACU in stable condition with one chest tube. A PACU CXR showed a tiny apical PNX. On POD#1 her diet was advanced from clears to regular. Her CT had no air leak and was removed. Post removal CXR showed no interval change or PNX. Her pain was well controlled on oral pain medication and she was moving her bowels and bladder independently. She understood the follow up plan.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ POD3 from lap-assisted R hemicolectomy for suspected CRC of mid-ascending colon discharged morning of ___ presenting to ED with dyspnea and new supplemental O2 requirement here. Hospital course notable for URI documented on admission and intermittent SOB/wheezing treated with albuterol nebs. SaO2 on discharge 94ra with inspiratory crackles R>L noted on exam, now 90ra on presentation improving to 96%4lnc. Pt notes new pedal edema this morning. Hx AF on coumadin, held for operation, plan to restart ___. HSQ administered t.i.d. during post-operative course with sequential compression devices and ambulation POD 1. Last TTE ___ LVEF 55%, mild biatrial dilatation. At time of consultation, pt with son and daughter, reporting subjective SOB without chest pain. Denies productive cough, fevers, chills, nausea, vomiting, abdominal pain or distention, PO intolerance, diarrhea, constipation, dysuria. <PAST MEDICAL HISTORY> Hypertension, hyperlipidemia, Afib on coumadin, invasive adenocarcinoma of mid-ascending colon PSH: Lap-assisted R hemicolectomy ___ ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of colon cancer or heart disease. <PHYSICAL EXAM> VS: T 97.5, HR 80, BP 158/90, RR 20, SaO2 97%ra GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: irregularly irregular, +S1S2 w no M/R/G PULM: inspiratory crackles R lung field base>apex, no respiratory distress, no accessory muscle use BACK: no vertebral tenderness, no CVAT ABD: well-healing laparoscopic and hand-port sites. no erythema, drainage, fluctuance. soft, NT, ND, no mass, no hernia. PELVIS: deferred EXT: WWP, no CCE, no tenderness, 2+ B/L ___ NEURO: A&Ox3, no focal neurologic deficits WOUND: skin dehiscence at umbilical port incision site, packed with dry gauze, no erythema/induration PSYCH: normal judgment/insight, normal memory, normal mood/affect <PERTINENT RESULTS> ___ 07: 00PM BLOOD WBC-9.7 RBC-3.88* Hgb-11.0* Hct-32.2* MCV-83 MCH-28.3 MCHC-34.1 RDW-13.0 Plt ___ ___ 05: 25AM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-138 K-3.7 Cl-101 HCO3-26 AnGap-15 ___ 05: 25AM BLOOD ___ PTT-45.4* ___ . CHEST (PA & LAT) Study Date of ___ 8: 11 ___ Interstitial edema with trace fissural fluid. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___ 9: 14 ___ Right upper lobe pneumonia. Bilateral small pleural effusions with adjacent atelectasis. Small filling defect in the subsegmental right middle lobe artery concerning for small subsegmental pulmonary embolus of uncertain chronicity. . BILAT LOWER EXT VEINS Study Date of ___ 10: 59 AM No DVT in right or left lower extremities. <MEDICATIONS ON ADMISSION> Finasteride 5, Olmesartan/HCTZ 40/12.5, Simvastatin 20, Terazosin 10, Warfarin 5 ___ MTRSa <DISCHARGE MEDICATIONS> 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous Q12H (every 12 hours). Disp: *20 mg* Refills: *1* 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. Disp: *30 Tablet(s)* Refills: *0* 6. olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp: *7 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> pulmonary embolism pneumonia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for shortness of breath and found to have a small pulmonary embolism as well as a pneumonia. You were started on coumadin and heparin for your pulmonary embolism, and you will take coumadin as well as lovenox injections at home. You may stop taking the lovenox once your INR is between 2.0 and 3.0. You should also continue taking antibiotics for 10 days to treat your pneumonia. Your umbilical incision is open and has been packed with dry gauze. Please continue to change this gauze daily until the wound heals. Call your doctor or return to the ED if you experience shortness of breath, chest pain, increasing redness, drainage, or pus from your wound, fevers, or any other symptoms that concern you.
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Patient is a [REDACTED] who was readmitted on the day of discharge [REDACTED] s/p R hemicolectomy for adenocarcinoma with shortness of breath. He was found to have a right upper lobe pneumonia and a small subsegmental right middle lobe pulmonary embolism. He was admitted for IV antibiotics ceftriaxone and azithromycin, and systemic anticoagulation with a heparin drip. He also received bilateral duplex ultrasound of his lower extremities, which showed no DVT. On the floor, he remained stable with no dyspnea or chest pain, and maintained good oxygen saturations on room air. He was discharged on HD#3 on therapeutic lovenox bridge plus coumadin, and his antibiotics were switched to PO levofloxacin. Of note, on HD#3 he developed a superficial dehiscence of his umbilical port incision with intact fascia; a small dry gauze was placed into the wound, and he will continue to change this dressing at home daily. He was tolerating a regular diet, ambulating, and voiding at the time of discharge, and received appropriate teaching regarding his lovenox and wound care. He was also inspected by medicine consult per request of his PCP, [REDACTED]. Medicine consult agreed with our treatment plan. Patient was given specific instructions to follow up with INR checks at [REDACTED] which would be called into his PCP and to continue his lovenox until theraputic. However, the issue of his anticoagulation will be monitored by his PCP as an outpatient.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Vancomycin / Morphine / Remicade / Compazine <ATTENDING> ___. <CHIEF COMPLAINT> Failed ileoanal pouch <MAJOR SURGICAL OR INVASIVE PROCEDURE> Removal of ileoanal pouch <HISTORY OF PRESENT ILLNESS> ___ yoM with long history of ulcerative colitis, well known to Dr. ___ ___ to medical service for continued pouch pain, and ___ pain, as well as 13 pound weight loss over past month. Patient denies fevers or chills. No nausea or vomiting. Reports leakage from anus and severe spasms requiring quick trips to bathroom. Leakage is described as beige in color, liquid with some blood in it. Ileostomy output has not hcanged, but pain increases in the area when he has high volume output or when his is on liquid diet. On cipro and flagyl without any symptomatic improvement. <PAST MEDICAL HISTORY> 1. Ulcerative colitis: dx'ed ___. Initially used prednisone and Asacol, but not effective. He tried Remicade, but due to reaction, Remicade was D/C. He failed Cyclosporin. Pt had Humira 4 times. He also reported he failed with ___. He tried Canasa supp that was not working. 2. Depression 3. ADD 4. Serotonin syndrome 5. Polyarthropathy 6. Avascular necrosis of R distal femur and proximal tibia 7. H/o narcotic abuse - previously on Suboxone, followed by Dr. ___ (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Sister with recently diagnosed UC. Father - colonic polyps. Grandfather - colon cancer. Mother - Type 2 ___ Mellitus. <PHYSICAL EXAM> Vitals: 97.6, 112/72, 77, 16, 99RA Gen: NAD, AOX3 HEENT: PERRL, EOMI, MMM, sclera anicteric, not injected Neck: no LAD, no JVD Cardiovascular: RRR normal s1, s2, no murmurs appreciated Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: ostomy bag in place, normoactive bowel sounds, soft, diffusely TTP but worse periumbilical, non distended Extremities: No edema, 2+ DP pulses, no erythema/edema/tenderness of knees bilaterally NEURO: PERRL, EOMI, face symmetric, no tongue deviation Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious <PERTINENT RESULTS> Admission labs: ___ 07: 30PM WBC-8.6 RBC-4.64 HGB-13.6* HCT-40.4 MCV-87 MCH-29.3 MCHC-33.6 RDW-13.7 ___ 07: 30PM NEUTS-70.0 ___ MONOS-3.6 EOS-3.1 BASOS-1.1 ___ 07: 30PM PLT COUNT-351# ___ 07: 30PM GLUCOSE-84 UREA N-13 CREAT-0.9 SODIUM-139 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-33* ANION GAP-13 ___ 07: 30PM ALBUMIN-4.9 CALCIUM-10.8* ___ 07: 30PM ALT(SGPT)-23 AST(SGOT)-22 ALK PHOS-99 TOT BILI-0.3 ___ 07: 30PM LIPASE-25 ACUTE ABD SERIES ___ VIEWS OF ABD & SGL CHEST VIEW) Study Date of ___ IMPRESSION: 1. Relative paucity of bowel gas with few small foci gas seen distally in the pelvis. No large air-fluid level. While no definite evidence of high-grade bowel obstruction, dilated fluid-filled loops of bowel would be difficult to exclude. 2. No evidence of free air. 3. Clear lungs. Colonoscopy, ___ Findings: Mucosa: Diffuse discontinuous granularity, friability and erythema with contact bleeding were noted in the stoma. These findings are compatible with ileitis. Cold forceps biopsies were performed for histology at the stoma. Diffuse continuous erythema, congestion, ulceration and proctitis with contact bleeding were noted in the rectal pouch. These findings are compatible with pouchitis. Cold forceps biopsies were performed for histology at the rectal pouch. Impression: Granularity, friability and erythema in the stoma compatible with ileitis (biopsy) Erythema, congestion, ulceration and proctitis in the rectal pouch compatible with pouchitis (biopsy) Otherwise normal colonoscopy to stoma <MEDICATIONS ON ADMISSION> 1. mirtazapine 30 mg PO HS 2. hydrocortisone acetate 10 % Rectal BID 3. pantoprazole 40 mg PO Q12H 4. clonazepam 0.5 mg PO QID as needed for anxiety. 5. fentanyl 25 mcg/hr Patch 72 hr 6. promethazine 25 mg PO Q6H as needed for nausea. 7. ferrous sulfate 300 mg once a day. 8. hydromorphone 2 mg PO BID 9. Cipro 250 mg PO BID 10. Flagyl 500 mg PO three times a day for 1 months. <DISCHARGE MEDICATIONS> 1. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. hydrocortisone acetate 10 % (80 mg) Foam Sig: One (1) Appl Rectal BID (2 times a day). 3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for rash/pruritis. 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *80 Tablet(s)* Refills: *0* 8. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp: *1 Patch 72 hr(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ulcerative colitis Ileitis Pouchitis Chronic abdominal pain Depression Anxiety <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Follow-up with both your GI and surgical doctors for further ___ as well as your pain clinic doctors for further ___ of the pain.
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Mr. [REDACTED] was transferred to the General Surgery service on [REDACTED] to undergo removal of ileoanal pouch for recurent pouchitis. The patient tolerated the procedure well (the reader is referred to the operative note for details) and after a brief, uneventful stay in the PACU was transferred to the floor in stable conditions, NPO with IVF, a foley catheter in place, Dilaudid PCA for pain control. On POD1 diet was advanced to clear liquids and tolerated. He was transitioned to PO pain meds and the dilaudid PCA was discontinued. His regular home medication were re-started as well. On POD2 the foley catheter was discontinued and he voided without difficulties. Diet was advanced to full liquids with supplements at lunch and dinner time per nutrition recommendations with return of bowel function. At the time of discharge the patient was afebrile, vital signs were stable and he was tolerating a full liquid diet, ambulating and voiding without assistance and pain was well controlled with a fentanyl patch (which the patient had before his admission to the hospital with good results) and PO dilaudid for breaktrough pain. He received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Bactrim / Epinephrine <ATTENDING> ___. <CHIEF COMPLAINT> UTI <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with metastatic neuroendocrine carcinoma and a UTI see for fatigue and hypoxia. She was due for blood transfusion today but had saturation of 77% on RA initially. Improved with oxygen but still was 90% on RA. She was sent to the ED for eval re: presumptive UTI, and to r/o for potential other infectious etiology. Her urine culture in clinic showed Klebseilla which was intermediate senstive to Macrobid. In the ED, gave one dose of ceftriaxone, CT chest doen with no PE and small bilateral pleural effusions. H/H stable. Given Morphine 2mg IVP and Zofran 4mg IVP for nausea and pain w/ good effect. On arrival to the floor, patient was feeling mildly nauseous but was conversant and in no physical distress. Denied fevers, chills, abdominal pain or chest pain. REVIEW OF SYSTEMS: Per HPI <PAST MEDICAL HISTORY> PAST ONCOLOGIC HISTORY: She had biopsy on ___ which showed neuroendocrine tumor. CEA 33 (high), ___ 33 (wnl), AFP 1.3 (wnl). She has been receiving chemotherapy with etoposide/cisplatin. Had port placed on ___. Now continues with outpatient etoposide/cisplain (C2D15 on admission). PAST MEDICAL HISTORY: 1. Bilateral breast cancer diagnosed ___ years and ___ years ago. She is status post bilateral mastectomy. 2. Spinal stenosis. 3. Diabetes mellitus. 4. ?Arrhythmia 5. Hypertension PRIOR SURGICAL HISTORY 1. Status post mastectomy as described above. 2. Status post cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> No liver cancer <PHYSICAL EXAM> ADMISSION PHYSICAL EXAMINATION: VS: Reviewed in OMR; stable GENERAL: Elderly woman in no distress. HEENT: Moist mucous membranes. No oropharyngeal lesions. NECK: No cervical, supraclavicular or axillary adenopathy. CARDIOVASCULAR: Regular rate, normal S1, S2. She has ___ holosystolic murmur loudest at the apex. PULMONARY: Clear to auscultation bilaterally with scant bibasilar crackles. ABDOMEN: Bowel sounds are present. The abdomen is soft. The liver is palpable below the costal margin, although limited by body habitus. EXTREMITIES: Limbs: No tremors, clubbing, edema or asterixis. SKIN: No rashes or skin breakdown. NEUROLOGIC: Grossly nonfocal. DISCHARGE VS - 97.8 120/40 81 18 95%RA Gen - sitting up in bed, comfortable, thin Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg; JVD to clavicle at 30 degrees, unchanged from day prior Lungs - CTA bilaterally Abd - soft nontender, normoactive bowel sounds Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses; port c/d/i Neuro - AOx3, moving all extremities Psych - appropriate <PERTINENT RESULTS> ADMISSION ___ 02: 10PM BLOOD WBC-11.7* RBC-2.26* Hgb-8.0* Hct-23.9* MCV-106* MCH-35.4* MCHC-33.5 RDW-26.2* RDWSD-96.2* Plt ___ ___ 02: 10PM BLOOD Neuts-83.4* Lymphs-7.6* Monos-7.0 Eos-0.9* Baso-0.3 Im ___ AbsNeut-9.79*# AbsLymp-0.89* AbsMono-0.82* AbsEos-0.11 AbsBaso-0.03 ___ 08: 00PM BLOOD Neuts-83.7* Lymphs-9.2* Monos-5.5 Eos-0.8* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-8.39* AbsLymp-0.92* AbsMono-0.55 AbsEos-0.08 AbsBaso-0.01 ___ 02: 10PM BLOOD Plt Smr-LOW Plt ___ ___ 08: 00PM BLOOD Glucose-147* UreaN-23* Creat-0.8 Na-133 K-4.8 Cl-99 HCO3-24 AnGap-15 ___ 05: 22AM BLOOD proBNP-2267* ___ 08: 00PM BLOOD Calcium-8.3* Mg-2.1 ___ 08: 14PM BLOOD Lactate-0.8 DISCHARGE ___ 05: 34AM BLOOD WBC-4.4 RBC-2.40* Hgb-8.2* Hct-24.8* MCV-103* MCH-34.2* MCHC-33.1 RDW-23.8* RDWSD-85.2* Plt ___ ___ 05: 34AM BLOOD Glucose-149* UreaN-22* Creat-0.8 Na-135 K-4.4 Cl-99 HCO3-30 AnGap-10 Micro: ___ 2: 00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING ___ - CT Head - No acute intracranial process. ___ - CTA Chest - 1. No evidence of pulmonary embolism or aortic abnormality. 2. Small bilateral pleural effusions, right greater than left, slightly enlarged since prior exam. 3. Diffuse interstitial thickening of the lungs bilaterally may be secondary to volume overload. 4. Main pulmonary artery is mildly enlarged, unchanged since ___. 5. Thickening along the minor fissure, unchanged since ___. 6. Diffuse sclerotic foci throughout the bones concerning for diffuse metastatic disease. TTE The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. <DISCHARGE INSTRUCTIONS> Ms. ___: It was a pleasure caring for you at ___. You were admitted with confusion and found to have a urinary tract infection. You were treated with antibiotics and you improved. Of note, during your hospital stay you were also found to have fluid in your lungs. You were treated with a medication to remove the fluid and you improved. We spoke to your oncologist who recommended that you should have an echocardiogram (an ultrasound of your heart) as an outpatient. We discussed this with you and your daughter, and you agreed. You are now ready for discharge
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This is a [REDACTED] year old female with past medical history of breast cancer status post bilateral mastectomy, on chemotherapy for metastatic pancreatic versus ampullary neuroendocrine carcinoma, admitted [REDACTED] with confusion, found to have a UTI, course notable hypoxia thought to relate to new diagnosis of heart failure, empirically diuresed and returning to baseline # Acute metabolic encephalopathy / Urinary tract infection - presented with acute confusion; labs were notable for UA and urine culture concerning for UTI; remainder of infectious and metabolic workup was unremarkable, with the exception of hypoxia as below. CT Chest and CT head without acute processes. Patient treated empirically with ceftriaxone. Urinary culture subsequently grew klebsiella. Patient completed 5 days of ceftriaxone during her inpatient stay with resolution of mental status to baseline. Of note, given initial encephalopathy, her Oxycontin (recently uptitrated to q8hours at assisted living) was downtitrated to q12hours without any subsequent worsening in her pain symptoms. # Acute Diastolic CHF / Hypoxia - Patient presented with O2 sat in the [REDACTED] on room air. CTA chest did not show acute pulmonary embolism or infection, but there was radiographic evidence of pulmonary edema and clinical evidence of volume overload. BNP was elevated at [REDACTED]. She was treated with two doses of Lasix 10mg IV with normalization of her oxygen saturation. Patient underwent TTE that showed normal regional/global systolic function (LVEF >55%). Clinical picture felt to be most consistent with diastolic CHF. Patient subsequently stable off of diuretics, without need for diuretic at discharge. Discharge weight 52.57kg (115.9 lb) # Neuroendocrine carcinoma / chronic cancer pain - continued allopurinol; modified pain regimen of oxycontin with prn Oxycodone as above; continued lidocaine patch # Peripheral neuropathy - continued gabapentin # Depression - continued mirtazapine # GERD - continued PPI # Hypertension - continued propranolol # Depression - Continued citalopram, mirtazapine # Diabetes type 2 - Continued glipiZIDE Transitional Issues - DNR/DNI per MOLST - HCP/Contact: [REDACTED] [REDACTED] - New diagnosis of Diastolic CHF, discharge weight 52.57kg (115.9 lb) - Completed 5d ceftriaxone during admission, no further antibiotics needed at discharge - Scheduled for follow-up with oncologist Dr. [REDACTED] [REDACTED] on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Gabapentin 100 mg PO QHS 4. Mirtazapine 15 mg PO QHS 5. Simethicone 40-80 mg PO QID:PRN bloating 6. Allopurinol [REDACTED] mg PO DAILY 7. Prochlorperazine 5 mg PO Q6H:PRN nausea 8. Docusate Sodium 100 mg PO BID 9. Senna 8.6 mg PO BID:PRN constipation 10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 11. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H 12. Omeprazole 40 mg PO DAILY 13. Citalopram 30 mg PO DAILY 14. GlipiZIDE 2.5 mg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. Vitamin D 1000 UNIT PO DAILY 17. Propranolol LA 120 mg PO DAILY Discharge Medications: 1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Allopurinol [REDACTED] mg PO DAILY 4. Citalopram 30 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS 7. GlipiZIDE 2.5 mg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Mirtazapine 15 mg PO QHS 10. Omeprazole 40 mg PO DAILY 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 13. Prochlorperazine 5 mg PO Q6H:PRN nausea 14. Propranolol LA 120 mg PO DAILY 15. Senna 8.6 mg PO BID:PRN constipation 16. Simethicone 40-80 mg PO QID:PRN bloating 17. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [REDACTED] Discharge Diagnosis: # Acute bacterial UTI secondary to klebsiella # Acute CHF of uncertain etiology # Neuroendocrine carcinoma / chronic cancer pain # Peripheral neuropathy # Depression # GERD # Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: [REDACTED]
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> "I don't know what happened. They just showed up at the door." <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> The patient is BIBA after her mother called ___. The patient states that two days ago she stopped taking her medications, and that "I don't know why." Yesterday she cut her L wrist to try to kill herself, following her command AH. She also reported that she was planning on taking all her medications and cutting her throat, but her mom came by and ___ her. Today, her mother called ___ out of concern for the patient's continuing SI. The patient states that she has been hearing AH, which are "evil" and which are commanding her to hurt herself. She says that she always has the AH, and that she always has thoughts of killing herself. She also endorses VH of hairy monsters with horns that are the devil. <PAST MEDICAL HISTORY> PSYCHIATRIC HISTORY: -diagnoses: reported depression -prior hospitalizations: confirms, but will not elaborate -outpatient treaters: psychiatrist Dr. ___ in ___ SA: patient confirms, but will not elaborate -SI/HI/assaultive behavior: patient endorses past SI, denies HI -last seen by BEST ___ at ___ urgent ___ PAST MEDICAL HISTORY: -asthma -?HTN <SOCIAL HISTORY> SUBSTANCE ABUSE HISTORY: -patient denies EtOH, illicits, tobacco SOCIAL HISTORY: ___ <FAMILY HISTORY> FAMILY PSYCHIATRIC HISTORY: -her mother suffers from depression <PHYSICAL EXAM> VS: T 97.3, HR 59, BP 138/90, RR 16, Pox 97% RA PE: medically stable and safe for admission. MSE: Mildly obese Hispanic woman, well groomed, in hospital gown, sitting up in bed. Wearing several black bracelets on each wrist. Shows me her left wrist which has a 6 cm long horizontal superficial cut. Patient is cooperative, but appears to be internally stimulated, as she is often staring out into the ED hallway and needs frequent redirection, and even then she demonstrates paucity of speech. Demonstrates psychomotor retardation. Mood- "I am fine." Affect- severely blunted. TF- appears to be internally stimluated, difficult to assess as patient shows paucity of speech and content. TC- endorses SI and command AH to kill herself, denies HI, endorses VH of "monster." I/J- impaired. COGNITIVE ASSESSMENT: SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert ORIENTATION: oriented x 3 ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): dowb intact, but very slow with pauses between each day MEMORY (SHORT- AND LONG-TERM): ___ registration, ___ recall, ___ recall with prompt CALCULATIONS: $1.25 = 5 quarters FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): ___, ___ PROVERB INTERPRETATION: SIMILARITIES/ANALOGIES: apple/orange = round <PERTINENT RESULTS> ___ 06: 05PM GLUCOSE-84 UREA N-6 CREAT-0.9 SODIUM-138 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17 ___ 06: 05PM CALCIUM-9.6 PHOSPHATE-4.2 MAGNESIUM-1.8 ___ 06: 05PM ALT(SGPT)-55* AST(SGOT)-34 ALK PHOS-75 TOT BILI-0.5 ___ 06: 05PM VIT B12-934* ___ 06: 05PM TSH-1.1 ___ 06: 05PM HCG-<5 ___ 06: 05PM WBC-9.6 RBC-4.04* HGB-13.3 HCT-37.9 MCV-94 MCH-32.9* MCHC-35.1* RDW-12.6 ___ 06: 05PM PLT COUNT-381 ___ 06: 05PM NEUTS-68.9 ___ MONOS-4.7 EOS-0.6 BASOS-0.4 ___ 06: 05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07: 00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 07: 00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07: 00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07: 00PM URINE ___ BACTERIA-FEW YEAST-NONE ___ 07: 00PM URINE UCG-NEGATIVE <MEDICATIONS ON ADMISSION> -Haldol 5mg PO QHS -Trazodone 150mg PO QHS -Prazosin 1mg daily -Citalopram 20mg daily -Lorazepam 1mg PO TID PRN -Flovent 220 q puffs INH BID -ProAir 90mcg INH 1 puff Q4h PRN SOB -Nortrel (OCP) <DISCHARGE MEDICATIONS> 1. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *0* 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp: *60 Tablet(s)* Refills: *0* 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp: *90 Tablet(s)* Refills: *0* 4. Prazosin 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp: *30 Capsule(s)* Refills: *0* 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. Disp: *30 Tablet(s)* Refills: *0* 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 8. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home with Service <DISCHARGE DIAGNOSIS> Axis I: Schizoaffective disorder Axis II: deferred Axis III: asthma, HTN Axis IV: financial, unemployed, chronic mental illness Axis V: 45 <DISCHARGE CONDITION> VS: 98.3 ___ 16 99%RA Medically stable and safe for discharge. MSE: alert, attentive; well-groomed; good eye contact; speech is accented with appropriate volume; mood "good"; affect is generally bright with periods of anxiety; mild derailment; denies current AVH/HI/SI; I/J: moderate <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -Please take medications as prescribed. -Please follow up with outpatient appointments as scheduled. -Please call ___ or return to your nearest ER if having thoughts of hurting yourself or others.
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1. LEGAL Patient refused to sign a CV on admission and was admitted on a [REDACTED] on [REDACTED]. The patient agreed to sign a CV section 10 & 11 on [REDACTED]. 2. PSYCHIATRIC On admission the patient's Haldol was increased to 5mg PO BID with PRN doses as needed throughout the day. The patient was continued on Celexa 20mg as she took at home. The patient continued to show sx of depressed mood and thought blocking and disorganization. Her Haldol was increased to 5mg TID and Celexa was increased to 40mg daily. She developed daytime sedation on the increased Haldol, and in consequence her Haldol was decreased back to 5mg daily, and Geodon was started at 60mg BID and titrated up to 80mg BID. She showed significant clinical improvement with more organized thoughts, improved mood, and less thought blocking. She tolerated Geodon well without side effects. The patient attended few groups without much participation. She was not active in the milieu initially secondary to her anxiety and active psychosis. 3. MEDICAL The patient was continued on fluticasone and albuterol inhalers on admission. She did not have any acute medical issues during her hospital stay. She confirmed that she does not take the oral contraceptive pill. 4. PSYCHOSOCIAL The patient's D[REDACTED] caseworker was contacted by social work, and visited the patient during her hospitalization. Her D[REDACTED] caseworker has agreed to provide her transportation to the partial hospital program. 5. DISPO She was discharged home with plans to attend the [REDACTED] [REDACTED] program. She will also follow up with her psychiatrist.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Subdural hematoma and hyponatremia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> This is a ___ year old gentleman with PMH significant for HTN, hemochromatosis, prostate cancer s/p resection, who experienced an unwitnessed syncopal episode one week prior, transferred from ___ for further management of bilateral SDH and hyponatremia. . Patient was in his usual state of health until 1 week prior, when he had an unwitnessed syncope episode. Denies any chest pain, palpitations, shortness of breath, diaphoresis, nausea, vomiting, or seizure like activity prior to episode. Denies postictal confusion, incontinence following incident. He experienced temporary loss of consciousness but did not seek medical attention at that time. He does not recall the fall but reports that he was unconscious for only seconds. He denies any prior syncopal episodes. Patient denies any difficulty with speech, neurologic deficits, muscle weakness, sensation changes, blurry vision, headaches, incontinence, confusion. . He went to his PCP earlier today and found to have profound sodium of 121. Referred to ___ for CT head which demonstrated bilateral chronic frontal subdural hematomas. Transferred to ___ for further management. . Of note, patient reports that he drinks 6 beers/day. CAGE questions negative. Reports that he generally skips breakfast and eats a small lunch with a large dinner. . In the ED initial VS were: T: 99.4, BP: 161/74, HR: 96, RR: 16, O2sat: 99% RA. Patient given 60 meq KCL X 1 and 1L NS. Laboratory data remarkable for K of 3.1 and Na of 121. Neurosurgery consulted who reviewed CT films and recommended q2h neurologic checks with no need for any intervention. . Upon reaching the floor, patient reports only mild soreness on right side of his face. . ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. <PAST MEDICAL HISTORY> - prostate cancer s/p resection - history of gastritis - HTN - hemochromatosis, diagnosed ___ years prior <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. No family history of CAD or sudden cardiac death or seizures. <PHYSICAL EXAM> VS: T: 96.3, P: 80, R: 18, BP: 157/83, O2sat: 100% RA. Gen: NAD, pleasant, alert and oriented to person, place, time HEENT: EOMI, PERRL, ecchymosis noted on face, dry mucous membranes Neck: supple, no JVD CV: distant heart sounds with RRR, nl S1 S2. No R/G/M. Pulm: CTA B with no w/r/r. Abd: soft, nontender, nondistended, normoactive bowel sounds Ext: no edema, pulses 2+ bilaterally Neuro: CNII-XII intact, moving all extremities, no focal deficits, ___ strength in all extremities, intact sensation in all extremities. Able to perform serial 7's and months of the year backwards. <PERTINENT RESULTS> ___ 07: 50PM BLOOD WBC-5.9 RBC-3.64* Hgb-11.7* Hct-33.7* MCV-93 MCH-32.2* MCHC-34.8 RDW-13.4 Plt ___ ___ 05: 56AM BLOOD WBC-4.1 RBC-3.37* Hgb-11.0* Hct-31.0* MCV-92 MCH-32.7* MCHC-35.6* RDW-13.8 Plt ___ ___ 06: 10AM BLOOD WBC-4.1 RBC-3.36* Hgb-11.0* Hct-31.8* MCV-95 MCH-32.6* MCHC-34.5 RDW-13.5 Plt ___ . . ___ 06: 10AM BLOOD ___ PTT-29.5 ___ . . ___ 07: 50PM BLOOD Glucose-85 UreaN-20 Creat-1.3* Na-121* K-3.1* Cl-85* HCO3-20* AnGap-19 ___ 05: 56AM BLOOD Glucose-87 UreaN-18 Creat-1.3* Na-123* K-3.5 Cl-87* HCO3-25 AnGap-15 ___ 01: 10PM BLOOD Glucose-114* UreaN-18 Creat-1.4* Na-123* K-4.1 Cl-89* HCO3-23 AnGap-15 . . ___ 09: 10PM BLOOD Na-127* K-3.7 Cl-93* ___ 06: 10AM BLOOD Glucose-88 UreaN-17 Creat-1.2 Na-128* K-3.4 Cl-91* HCO3-26 AnGap-14 ___ 01: 55PM BLOOD Na-130* K-3.6 Cl-94* . . ___ 05: 56AM BLOOD TSH-1.6 . . Echocardiogram ___: Conclusion: The left atrium is normal in size. The estimated right atrial pressure is ___. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: dilated borderline hypocontractile right ventricle <MEDICATIONS ON ADMISSION> - metoprolol 25mg PO daily - omeprazole 20mg PO daily - HCTZ 50mg PO daily <DISCHARGE MEDICATIONS> 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Subdural hematoma Syndrome of inappropriate antidiuretic hormone hypersecretion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <DISCHARGE INSTRUCTIONS> You were admitted to the hospital one week after a fall with momentary loss of consciousness. You were discovered to have a stable head bleed (subdural hematoma) and low blood sodium. You were evaluated and treated by the medicine service and your blood sodium improved. You were also evauated by the neurosurgery service and were found to be stable from a neurosurgical standpoint. An echocardiogram was performed to evaluate your heart function, which was normal. You should take you home medication as prescribed in this discharge document and keep you outpatient appointments. You should also continue to limit you fluid intake to no more than 1500 mL of fluid daily, which is the equavalent of three 500mL water bottles. You have been scheduled to have a blood draw on ___ at 9: 30AM at Dr. ___ and a follow up appointment with Dr. ___ on ___ at 3: 30PM. You have also been scheduled for a ___ clinic follow up appointment on ___ at 2: 00PM The following changes have been made to your medications: 1.) Your Hydrochlorothiazide has been STOPPED please review this medication with you PCP ___: ___
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Mr. [REDACTED] is a [REDACTED] year old gentleman with PMH significant for HTN, hemochromatosis, prostate cancer s/p resection, who experienced an unwitnessed syncopal episode one week prior to presentation who was transferred from [REDACTED] for further management of bilateral SDH and hyponatremia. . # Subdural hematoma: Mr. [REDACTED] had a CT scan that identified a subdural hematoma that appears chronic in nature and was likely secondary to prior head trauma. His head CT films were reviewed by neurosurgery team in the ED. The neurosurgery service determined that there was no need for an acute intervention at this time. Since presentation and throughout admission he was free of focal neurologic deficits. The neurosurgery service recommended outpatient follow up in 4 weeks in [REDACTED] clinic with a surveillance CT scan to be arranged at that time. Additionally, no seizure prophylaxis was recommenced at time of discharge by neurosurgery. He remained hemodynamically stable throughout admission. . # Syncope: The etiology of his syncopal episode was quite unclear and the differential included orthostatic hypotension, neurocardiogenic, arrhythmia or mechanical cardiovascular etiology, seizure, stroke, and hypoglycemia. Due to unwitnessed nature of event and his inability to provide accurate history, it was difficult to determine a clear cause. Hypoglycemia in setting of poor AM PO intake was a possibility, although is blood glucose remained normal throughout admission. Additionally, no prodromal symptoms, seizure like activity, incontinence, or postictal confusion was present or described to suggest a seizure as the cause of his syncopal episode. He had no focal neurologic deficits to suggest stroke. Because there was arrhythmia on ECG, no known cardiac history or murmurs on exam, and no events noted on telemetry, it is unlikely that a rapidly recurrent arrhythmia was the cause. He was recently evaluated by a Holter monitor by Dr. [REDACTED] [REDACTED] with analysis still underway at the time of discharge. If the Holter monitor is unrevealing, an event monitor may be helpful to identify an arrhythmia, if arrhythmia continues to be considered a potential cause for his syncopal event. Additionally, structural and valvular abnormalities were evaluated by echocardiogram on [REDACTED] with no evidence of aortic stenosis, LVEF of 70% and dilated borderline hypocontractile right ventricle identified. It is most likely that his fall was secondary to orthostatic hypotension, especially since he met orthostatic heart rate criteria (HR 68->99 from sitting to standing) on arrival to the medicine floor. Prior to discharge Mr. [REDACTED] was advised to take time when changing from seated to standing position by allowing his feet to dangle first for about 30 seconds and to insure that he had nearby support structure while rising. . # Hyponatremia: He appeared euvolemic on exam. His urine osmolarity was > 100 suggesting SIADH secondary to SDH as the leading cause of his hyponatremia. His sodium was 121 on arrival to the ED. His TSH was normal at 1.6. His home dose HCTZ was held, and he was placed on a fluid restricted diet of < 1500ml daily and his sodium steadily improved. His sodium was 130 at the time of discharge and he was advised to continue his fluid restricted diet of < 1500ml daily. . # Hypokalemia: His potassium was 2.9 on admission. This hypokalemia was likely secondary to HCTZ in the setting of SIADH. His potassium was followed closely and supplemented at needed throughout admission. . # Anemia: His hematocrit was 33.7 on admission and remained stable. His hematocrit on discharge was 31.8. He receives regular phlebotomy for hemochromatosis. . # HTN: Elevated on admission. He was continued on his home metoprolol. HCTZ was held in the setting of hyponatremia. . # Significant alcohol intake: Negative CAGE questions. He consumed six beers daily. His alcohol intake did not appear to be affecting his daily activities. He will require follow up as an outpatient.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right abdominal and groin pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: EVAR of right CIA aneurysm, fem-fem bypass <HISTORY OF PRESENT ILLNESS> Mr. ___ is an ___ year old gentleman with a history of CAD s/p CABG, HTN, AAA s/p open repair ___ years ago and a known R CIA aneurysm, s/p attempted endovascular repair at ___ last ___. Per his daughter-in-law, the repair was unsuccessful due to difficulties with access and was deferred for a later date with planned brachial access. The patient was discharged home and was doing well until this morning, when he suddenly began complaining of severe abdominal and groin pain. He was apparently ashen, diaphoretic, and unable to get out of bed and was therefore taken emergently to ___ by ambulance. A CT abd/pelvis with IV contrast was done which showed a 6cm R CIA aneurysm with active extravasation of contrast into the retroperitoneum. He was therefore transferred emergently to ___ for further management. <PAST MEDICAL HISTORY> PMH: CAD s/p CABG (last stress test at OSH a few weeks ago as preop preparation for embolization procedure, reportedly passed per his daughter-in-law), AAA s/p open repair, HTN, HPL, AFib, COPD, DMII, BPH, mild dementia PSH: CABG, open AAA ___ years ago at ___), attempted coil embolization of R CIA, pacemaker placement, b/l inguinal hernia repairs <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Vitals: T 98.0, HR 83, BP 180/93, RR 20, 97% RA Gen: Alert, confused CV: RRR Pulm: CTAB Abd: S/NT/ND Ext: w/d Pulses: R dopplerable ___, L dopplerable ___ <PERTINENT RESULTS> ___ 07: 20AM BLOOD WBC-7.4 RBC-3.69* Hgb-10.9* Hct-33.1* MCV-90 MCH-29.6 MCHC-33.0 RDW-18.0* Plt ___ ___ 07: 20AM BLOOD Glucose-119* UreaN-27* Creat-1.0 Na-139 K-4.2 Cl-102 HCO3-29 AnGap-12 ___ 07: 20AM BLOOD Calcium-7.9* Phos-2.1* Mg-2.2 <MEDICATIONS ON ADMISSION> digoxin 0.125mg PO daily, omeprazole 40mg PO daily, lasix 40mg PO daily, glipizide 10mg QAM/5mg QPM, atenolol 200mg PO daily, potassium 20mg PO daily, lipitor 40mg PO daily, proscar 5mg PO daily, diovan 320mg PO daily, ASA 81mg PO daily, aricept 5mg PO daily, prednisone 5mg PO daily, flomax 0.5 <DISCHARGE MEDICATIONS> 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. glipizide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 1 weeks. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. donepezil 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day. 11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 15. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 1 weeks. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Common iliac artery aneurysm Peripheral vascular disease Hypertension Hyperlipidemia Type II diabetes Atrial fibrillation Dementia Wound infection <DISCHARGE CONDITION> Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Medications: · Take Aspirin (enteric coated) once daily · If instructed, take Plavix (Clopidogrel) 75mg once daily · Continue all other medications you were taking before surgery, unless otherwise directed · You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have swelling of the legs: · Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night · Avoid prolonged periods of standing or sitting without your legs elevated · It is normal to feel tired and have a decreased appetite, your appetite will return with time · Drink plenty of fluids and eat small frequent meals · It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing · To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: · When you go home, you may walk and go up and down stairs · You may shower (let the soapy water run over groin incision, rinse and pat dry) · Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed · No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) · After 1 week, gradually increase your activities and distance walked as you can tolerate · Call and schedule an appointment to be seen in ___ weeks for post procedure check and ultrasound What to report to office: · Numbness, coldness or pain in lower extremities · Temperature greater than 101.5F for 24 hours · New or increased drainage from incision or white, yellow or green drainage from incisions · Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) · Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room.
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The patient was admitted to the vascular surgery service after surgical repair of his aneurysm. Neuro: The patient was initially kept intubated and sedated. On POD0 his sedation was weaned and was awake and following commands. His pain was managed with IV medications with good effect and then transitioned to oral pain medications while tolerating a diet. He remained confused at baseline due to underlying dementia. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. He initially required a nitroglycerin drip for hypertension. This was weaned off and was placed on a labetolol/hydralazine regimen for adequate control. An ECHO was obtained in the ICU and it demonstrated mild LVH with EF 50-55%, moderate to severe TR, and pumonary artery hypertension. Serial cardiac enzymes were checked and demonstrated mild demand ischemia with peak troponin of 0.15. He was placed on his home lasix regimen. He was started on Metoprolol TID and this was titrated up to 75mg TID at the time of discharge. His diovan was increased to 240mg daily at the time of discharge. These will be titrated up to his home doses as tolerated. Pulmonary: The patient was extubated on POD 0 without difficulty. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: Post operatively, the patient was made NPO with IVF. The patient's diet was advanced to regular POD2, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. He remains edematous in the bilateral lower extremities and along the groin crease with extension to the back. He was diuresed as tolerated, with 1 episode of low blood pressure secondary to over-diuresis requing a small fluid bolus. He will continue diuresis as tolerated. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He spiked a temperature to 101.3 POD 0 and urine and blood cultures were obtained which were negative. On POD 5 he was noted to have increasing erythema over the groin incision and due to concern for wound infection was placed on Ancef. There was no change in the erythema overnight and the antibiotics were changed over to Vancomycin. Ultrasound of the groins revealed bilateral simple fluid collections approximately 3.2x2.3cm, likely seroma. Fluid of the drainage was cultured and was negative on gram stain, culture was pending. On [REDACTED] he spiked a temperature to 101.4. UA and chest xray was negative, and fever was due to wound infection. ID was consulted and Zosyn was added per recommendations. The erythema improved. He will be discharged with one week of IV antibiotics. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly and then was placed on his home glipizide regimen with adequate control. Hematology: The patient's complete blood count was examined routinely. He required a total of 6 units of blood between the intra-op and early post-operative periods in addition to 1 unit of platelets and 1 unit of FFP. His hematocrit remained stable thereafter and did not require further transfusions. Prophylaxis: The patient received subcutaneous heparin and aspirin during this stay in addition to pneumoboots. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, voiding, and pain was controlled. He was discharge to [REDACTED] where his PCP [REDACTED] be resuming his care and coordinating further management. The family was in agreement with this plan.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Cough, dyspnea <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ man with a history of opiate use disorder, previously on suboxone, who presents with cough, fever, congestion x 1 week. Patient notes increasing cough and shortness of breath over this time frame, with cough initially being nonproductive, now producing thick and green sputum. He denies chest pain but when he coughs he does have some mild chest discomfort. He reports fevers but denies chills. He denies abdominal pain, nausea, vomiting, diarrhea, dysuria or hematuria. He reportedly was hospitalized with pneumonia one time last year. He has not been hospitalized or taken any antibiotics in the last 3 months. In the ED: - Initial vital signs: T98.4 HR 90 RR16 O2sat98% RA - Exam: Comfortable, NAD. Lungs: diffuse rhonchi involving right middle and RLL. No increased respiratory effort. - Labs: WBC 11.6, H/H 11.8/36.5, normal electrolytes, normal lactate, flu negative - Studies: - Meds: Ceftriaxone 1 gram, Azithromycin 500 mg, Duonebs - Consults: - ED Course: Tmax 99.1 HR 75 BP 116/59 RR 18 O2sat100% RA Upon arrival to the floor, pt endorses the history above. When asked about living situation, he reports "bouncing around" and endorses IV heroin use a few days ago. He has been sober in the past when he was on suboxone. He currently feels diffuse abdominal and chest pain. <PAST MEDICAL HISTORY> None <SOCIAL HISTORY> ___ <FAMILY HISTORY> None provided <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: -======= VITALS: ___ ___ Temp: 98.9 PO BP: 113/66 R Lying HR: 64 RR: 20 O2 sat: 97% O2 delivery: RA GENERAL: Tired and not responding unless questioned repeatedly. Not interested in answering questions. HEENT: NCAT. Pupils dilated, equal, round and reactive to light, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Diffusely quiet breath sounds. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. Hypopigmented rash on back. NEUROLOGIC: AOx3. DISCHARGE PHYSICAL EXAM: -======== VS: 98.0 | 117/65 | 63 | 18 at 96% on RA GENERAL: Awake and laying down in bed. Answering questions appropriately. HEENT: Pupils dilated, equal, round and reactive to light, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of breathing. No cough. ABDOMEN: Normal bowels sounds, non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Hypopigmented rash on back and elbows on extensor surface. Erythematous rash diffuse across face NEUROLOGIC: A&Ox3. Moving all extremities spontaneously <PERTINENT RESULTS> ADMISSION LABS: -=== ___ 03: 25AM BLOOD WBC-11.6* RBC-4.48* Hgb-11.8* Hct-36.5* MCV-82 MCH-26.3 MCHC-32.3 RDW-13.0 RDWSD-38.2 Plt ___ ___ 05: 00AM BLOOD ___ PTT-29.3 ___ ___ 03: 25AM BLOOD Neuts-66.6 ___ Monos-7.0 Eos-1.8 Baso-0.5 Im ___ AbsNeut-7.72* AbsLymp-2.74 AbsMono-0.81* AbsEos-0.21 AbsBaso-0.06 ___ 03: 25AM BLOOD Ret Aut-1.0 Abs Ret-0.05 ___ 03: 25AM BLOOD Glucose-128* UreaN-14 Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-26 AnGap-14 ___ 03: 25AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6 Iron-21* ___ 03: 25AM BLOOD calTIBC-192* VitB12-740 Folate-12 Ferritn-321 TRF-148* ___ 03: 34AM BLOOD Lactate-1.6 NOTABLE INTERVAL LABS: -====== ___ 05: 05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* ___ 05: 05AM BLOOD HIV Ab-NEG ___ 05: 05AM BLOOD HCV Ab-POS* DISCHARGE LABS: -====== ___ 07: 03AM BLOOD WBC-5.9 RBC-4.85 Hgb-13.0* Hct-41.2 MCV-85 MCH-26.8 MCHC-31.6* RDW-13.1 RDWSD-40.0 Plt ___ ___ 07: 03AM BLOOD ___ PTT-30.1 ___ ___ 07: 03AM BLOOD Glucose-89 UreaN-17 Creat-0.7 Na-144 K-4.8 Cl-104 HCO3-28 AnGap-12 ___ 07: 03AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7 MICROBIOLOGY: -=== Blood Cultures X3 on ___: Negative to date Urine Culture on ___: Negative REPORTS: ========== CHEST (PA & LAT)Study Date of ___ 1: 50 AM Lungs are moderately well inflated. There is hazy opacification in the bilateral lower lobes, left greater than right, concerning for an infectious process. No large pleural effusion or pneumothorax is seen. The cardiomediastinal silhouette is within normal limits <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal as needed Disp #*1 Spray Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary Diagnosis: -== Community Acquired Pneumonia Opioid Use Disorder and Withdrawal <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for pneumonia and opioid withdrawal What was done for me while I was in the hospital? - You were treated with antibiotics for the pneumonia - You were started on methadone and received medications to help with withdrawal What should I do when I leave the hospital? - Please follow up with scheduled appointments - Please fill the prescription of Narcan in case it is every needed Sincerely, Your ___ Care Team
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PATIENT SUMMARY: ==================== Mr. [REDACTED] is a [REDACTED] man with no known medical history, who presented with cough, fever, congestion x 1 week, who was initiated on antibiotic treatment for CAP. Also, he was seeking help in getting sober and receiving management of withdrawal symptoms. ==================== ACUTE ISSUES: ==================== #Community Acquired Pneumonia He was admitted with signs/symptoms concerning for CAP. Flu negative. Started on azithromycin and switched to doxy d/t interaction with methadone (QTc prolongation, ECG was stable). He completed 5-day course of antibiotics and showed improvement in his symptoms during the admission. Blood cultures were negative. #Opiate Use Disorder He endorsed last IV heroin use was a few days prior to admission on [REDACTED]. Patient did not endorse a stable living situation and appeared to be undomiciled. HIV negative. He received counseling from addiction specialist. Social work met with him to discuss social support resources for when he would leave the hospital. He was started on methadone 30mg for withdrawal. He also received medications for symptomatic relief of withdrawal. #Hepatitis C Thought to be newly diagnosed during the hospital admission, but per patient he has known about this for a few years. He has been unable to be treated due to inability to remain sober. Viral load was 6.6. He was set up with outpatient follow-up with Healthcare for the homeless, who can help with HCV treatment when he meets criteria. ==================== TRANSITIONAL ISSUES: ==================== #Hepatitis C [ ] need f/u re: management [REDACTED]: Please go to Habit OPCO located at [REDACTED] #Photo ID: Please speak to Habit OPCO to get ID but likely will be [REDACTED] located at [REDACTED] - New Meds: Methadone 30mg - Stopped/Held Meds: None - Changed Meds: None # CODE: Full # CONTACT: None provided This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Greater than 30 minutes were spent on discharge related activities.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> atorvastatin / influenza virus vacc,specific / ppd <ATTENDING> ___. <CHIEF COMPLAINT> nonhealing distal ___ toe distal gangrene and rest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: left groin cutdown and CIA/EIA stenting <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with history of cirrhosis secondary to autoimmune hepatitis presenting with left toe distal tip gangrene. She underwent a CTA on 323 showing right worse then left lower extremity artherosclerotic disease, however her left lower extremity is the side with toe gangrene. On CTA, her left lower extremity arterial system has evidence of femoral plaque iliac disease and then further disease in the distal vessels. She presents today for a left scheduled femoral endarterectomy and iliac stents to improve profusion to her left lower extremity. <PAST MEDICAL HISTORY> PMH: Cirrhosis seondary to autoimmune hepatitis HYPERTENSION - ESSENTIAL HYPERLIPOPROTEINEMIA RECENT RETINAL DETACHMENT - TOTAL / SUBTOTAL POSITIVE PPD TOBACCO DEPENDENCE IMPAIRED GLUCOSE TOLERANCE Uterovaginal prolapse, incomplete Uterovaginal prolapse, complete PSH: ___: Left inguinal hernia repair with mesh <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of heart disease or familial cancers. Hypertension runs in the family. <PHYSICAL EXAM> Discharge exam: Gen: NAD, sitting in chair CV: pink and perfused P: breathing comfortably, bilateral chest rise Abd: soft, NT, ND Ext: LLE palpable pulses, groin incision with staples, dressing c/d/i; foot warm, dry, with gauze packed between toes and over necrotic portion of ___ toe, no drainage or erythema; RLE: WWP <PERTINENT RESULTS> ___ 08: 46AM PO2-269* PCO2-36 PH-7.49* TOTAL CO2-28 BASE XS-5 ___ 08: 46AM GLUCOSE-130* LACTATE-1.0 NA+-137 K+-3.3 CL--102 ___ 08: 46AM HGB-10.1* calcHCT-30 ___ 08: 46AM freeCa-1.14 FEMORAL VASCULAR US LEFT ___ No evidence of pseudoaneurysm or hematoma in the left groin. <MEDICATIONS ON ADMISSION> AMLODIPINE - amlodipine 2.5 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) ATENOLOL - atenolol 50 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) FUROSEMIDE - furosemide 20 mg tablet. 0.5 (One half) tablet(s) by mouth daily SPIRONOLACTONE [ALDACTONE] - Aldactone 25 mg tablet. 1 tablet(s) by mouth daily ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth at night - (Prescribed by Other Provider) BISACODYL [DULCOLAX (BISACODYL)] - Dulcolax (bisacodyl) 5 mg tablet,delayed release. 1 tablet(s) by mouth nightly as needed Dr. ___ ___ reduced dose - (Prescribed by Other Provider) CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit tablet. 1 tablet(s) by mouth daily <DISCHARGE MEDICATIONS> 1. Amlodipine 2.5 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY Take for 1 month 5. Furosemide 20 mg PO DAILY 6. Spironolactone 25 mg PO DAILY 7. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain 8. Acetaminophen ___ mg PO Q6H: PRN pain/fever <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___: left ___ toe gangrene <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to ___ and underwent left groin cutdown and CIA/EIA stenting. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: WHAT TO EXPECT: 1. It is normal to feel tired, this will last for ___ weeks - You should get up out of bed every day and gradually increase your activity each day - Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: - Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night - Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time - You will probably lose your taste for food and lose some weight - Eat small frequent meals - It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing - To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: - Take aspirin as instructed - Follow your discharge medication instructions ACTIVITIES: - No driving until post-op visit and you are no longer taking pain medications - You should get up every day, get dressed and walk - You should gradually increase your activity - You may up and down stairs, go outside and/or ride in a car - Increase your activities as you can tolerate- do not do too much right away! - No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit - You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry - Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed CALL THE OFFICE FOR: ___ - Redness that extends away from your incision - A sudden increase in pain that is not controlled with pain medication - A sudden change in the ability to move or use your leg or the ability to feel your leg - Temperature greater than 100.5F for 24 hours - Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Sincerely, ___ Vascular Surgery
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Ms. [REDACTED] is a [REDACTED] with left nonhealing distal [REDACTED] toe distal gangrene and rest pain who was admitted to the [REDACTED] [REDACTED] on [REDACTED]. The patient was taken to the endovascular suite and underwent planned left femoral endarterectomy and iliac stents. However, after groin cutdown and common femoral artery exploration, it was deemed that repair of her common femoral artery atherosclerotic disease would require a interposition graft, which is a more high risk and extensive procedure. Therefore, femoral endarterectomy was aborted at this time and left common and external iliac stents were place. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where she remained through the rest of the hospitalization. Post-operatively, she did well without any groin swelling. On POD1, left groin ultrasound was obtained for concern of hematoma. Ultrasound revealed no evidence of pseudoaneurysm or hematoma in the left groin. She had a skin bleeder that required multiple pressure dressing before it fnally stopped later on POD1. She was cleared to go home with home [REDACTED] and a visiting nurse for her LLE wound care, and was ambulating with a walker, feelign well, not taking pain meds, etc.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Tetracycline / Iodine / Latex <ATTENDING> ___ <CHIEF COMPLAINT> Weakness, malaise, anorexia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a very pleasant ___ year-old man with metastatic kidney cancer. He has a long oncological history which is well described in the note by Dr. ___ in his ___ note dated ___. Briefly, he was diagnosed in ___. Since that time he has had right nephrectomy, ureteronephrectomy with resection of retro and paracaval lymph nodes; rx with sorafenib, sunitinib, CyberKnife to right nephrectomy bed and paraaortic mass, Phase II protocol ___ with c-Met inhibitor. He has either progressed and/or been intolerant of these therapies, and was recently started on palliative everolimus. He subsequently suffered an embolic MCA CVA of unclear etiology. He was coincidentally found to have extensive VTE, and is thought that the stroke may have been a paradoxical thromboembolism. Everolimus was held in the setting of the stroke, and then restarted on ___. . He is quite debilitated due to his illness, but over the past week has become more lethargic and anorectic. He spoke with Dr. ___ told him to hold the everolimus, and if he did not improve, to come in for evaluation. He presented to the ED this evening and was found to have acute renal failure, leukocytosis, and probable pneumonia. . He endorses fatigue and anorexia. He denies fever, chill, chest pain, shortness of breath, cough, abdominal pain, change in bowels. His wife - the primary caretaker indicates that his urine is much darker than normal. <PAST MEDICAL HISTORY> -Metastatic Renal cell ca - Presented initially in ___ underwent chemo and cyber knife, most recently moved to palliative chemo with everolimus -Hypertension -Hyperlipidemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> - The patient's mother died of ALS in her ___. - His father died in his ___ from possible lung cancer. - A sister has a history of breast cancer diagnosed in her ___. <PHYSICAL EXAM> GEN: Thin, ill appearing, comfortable VITALS: 98 ___ 24 97% RA. HEENT: Within normal limits, firm/fixed left suprclavicular LN COR: S1 and S2, no murmurs. CHEST: Poor effort, decreased breath sounds. No obvious signs of consolidation. ABD: Soft, non-tender, healed surgical scar. Large pitting edema of flanks into thighs, and down both legs. SKIN: Warm, dry. NEURO: Alert, interactive, appropriate. Moves all extermities, toes down going, face symmetrical .> <PERTINENT RESULTS> ___ 03: 40PM GLUCOSE-112* UREA N-36* CREAT-1.8* SODIUM-131* POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-23 ANION GAP-19 ___ 03: 40PM estGFR-Using this ___ 03: 40PM ALT(SGPT)-68* AST(SGOT)-106* ALK PHOS-370* TOT BILI-0.6 ___ 03: 40PM LIPASE-15 ___ 03: 40PM cTropnT-<0.01 ___ 03: 40PM WBC-12.5*# RBC-4.81 HGB-11.1* HCT-35.2* MCV-73* MCH-23.0* MCHC-31.5 RDW-16.7* ___ 03: 40PM NEUTS-81* BANDS-6* LYMPHS-4* MONOS-6 EOS-2 BASOS-0 ___ METAS-1* MYELOS-0 ___ 03: 40PM NEUTS-81* BANDS-6* LYMPHS-4* MONOS-6 EOS-2 BASOS-0 ___ METAS-1* MYELOS-0 ___ 03: 40PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 03: 40PM PLT SMR-NORMAL PLT COUNT-331 . ------------ CT HEAD Preliminary Report !! WET READ !! Chronic infarcts in R frontal and parietal regions. no acute process. Preliminary Report !! WET READ !! . CHEST PA/LATERAL IMPRESSION: Evaluation is limited by the profound low lung volumes. While there is an element of bronchovascular crowding, superimposed edema cannot be entirely excluded and is likely present to a mild degree. There is a focal area of opacity in the left lung base. Again confluent edema in concert with bronchovascular crowding and atelectasis is likely the culprit; however, an early developing pneumonia cannot be entirely excluded. <MEDICATIONS ON ADMISSION> Lovenox 95 mg SC BID Celexa 20 mg PO QD Lipitor 20 mg PO QD <DISCHARGE MEDICATIONS> 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Progressive metastatic renal cell cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You presented with severe fatigue and we found progression of your metastatic cancer. You had no pneumonia. You met with your Oncologist and palliative care and you and your family decided for hospice care at home with no more hospitalizations or treatments. Please keep hydrated with regular bowel movements using laxatives. We added Remeron to stimulate your appetite.
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This is a [REDACTED] year old man who presented with fatigue and severe weakness. He was chronically ill and immunosuppressed from chemotherapy and wide spread malignancy. He was initially treated for "pneumonia" with vancomycin, levofloxacin, and cefepime but all of these medications were discontinued the following day as he had no respiratory symptoms and his CXR and CT torso did not show any consolidation. CT torso confirmed progressive metastatic disease despite treatment. His symptoms were related to his progressive metastatic cancer. He also had acute olguric renal failure complicating CKD. He was rehydrated but had severe anasarca and hypoalbuminemia. He and his wife met with me, his oncologist, and palliative care. He was discharged home with hospice and no further hospitalizations or treatments after several discussions. Total discharge time 46 minutes.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP (___) attach <PERTINENT RESULTS> ADMISSION LABS: ___ 06: 16PM BLOOD WBC-13.0* RBC-4.47* Hgb-13.1* Hct-38.6* MCV-86 MCH-29.3 MCHC-33.9 RDW-13.0 RDWSD-40.8 Plt ___ ___ 06: 16PM BLOOD ___ PTT-27.3 ___ ___ 06: 16PM BLOOD Glucose-124* UreaN-10 Creat-1.0 Na-144 K-3.1* Cl-104 HCO3-26 AnGap-14 ___ 06: 16PM BLOOD ALT-263* AST-204* AlkPhos-86 TotBili-5.6* ___ 06: 16PM BLOOD Lipase-25 ___ 06: 16PM BLOOD Albumin-3.9 DISCHARGE LABS: ___ 08: 00AM BLOOD WBC-7.9 RBC-4.02* Hgb-11.6* Hct-34.9* MCV-87 MCH-28.9 MCHC-33.2 RDW-12.8 RDWSD-41.0 Plt ___ ___ 08: 00AM BLOOD Glucose-82 UreaN-6 Creat-0.9 Na-140 K-3.9 Cl-101 HCO3-23 AnGap-16 ___ 08: 00AM BLOOD ALT-120* AST-42* AlkPhos-79 TotBili-1.5 ___ 08: 00AM BLOOD Calcium-8.8 Phos-1.8* Mg-1.6 IMAGING/PROCEDURES - CT A/P with contrast (___): IMPRESSION: 1. CT findings of acute cholecystitis. No radiopaque gallstones grossly seen. Associated intrahepatic and extrahepatic ductal dilation, although a radiopaque ductal stone is not grossly seen. Suggest correlation with MRCP. Also, possible cholangitis. 2. There is mild distension of the ascending and transverse colon with apparent focal transition at the proximal descending colon, where there is apparent mild wall thickening and mucosal hyperenhancement, suggesting possible partial colonic obstruction due to a colonic lesion versus colitis. Alternatively, this focal finding could reflect normal focal peristalsis with the mild proximal colonic distension reflecting ileus, reactive to the acute cholecystitis. Correlate with colonoscopy. 3. Borderline splenomegaly stable. 4. 3 mm hypodense focus pancreatic body/tail junction MRCP ___. Choledocholithiasis, with at least 3 millimetric stones within the CBD. 2. Cholelithiasis with sludge, within a dilated gallbladder demonstrating mild wall thickening, which could represent mild/early cholecystitis. 3. Partial views of the gastrointestinal tract do not demonstrate any bowel obstruction. ERCP ___: 2 stones found in CBD, sphincterotomy was performed with sludge and pus. Patient had some oozing of blood afterwards. A FCMS was placed. He will need ERCP in 4 weeks for removal of stent. No anticoagulation for 5 days. Continue IV abx <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain - Mild/Fever 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*6 Tablet Refills: *0 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*9 Tablet Refills: *0 4. Ondansetron 4 mg PO Q8H: PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 5 mg PO Q6H: PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills: *0 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until told by your doctor <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cholecystitis Cholangitis Obstructive jaundice <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, It was a pleasure taking care of you. You were admitted because you were having abdominal pain. You were found to have an infection of your gallbladder (cholecystitis) and bile duct (cholangitis) due to an obstructing stone. You had a procedure and they removed 2 stones. You were feeling better afterwards. You will need to continue antibiotics through ___. Please call Dr. ___ ___ to schedule surgery for removal of your gallbladder (cholecystectomy). We wish you the best, Your ___ team.
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[REDACTED] man with history of hypertension, [REDACTED] esophagus presenting with abdominal pain and found to have cholangitis and cholecystitis s/p ERCP with stone removal c/b oozing s/p placement of FCMS, with plans for outpatient cholecystectomy. ACUTE/ACTIVE PROBLEMS: # Cholecystitis/cholangitis: # Choledocholithiasis The patient presented with abdominal pain, found to have elevated transaminases and hyperbilirubinemia found to have cholecystitis and choledocholithiasis on MRCP. He started antibiotics with CTX/flagyl on [REDACTED]. He underwent ERCP on [REDACTED] with sphincterotomy with 2 stones removed, found to have some pus. Pt had some oozing at site of sphincterotomy and a FCMS was placed as well. Surgery was consulted and given stability recommended that he could receive cholecystectomy as outpatient. On day of discharge, LFTs were continuing to downtrend and he was able to tolerate a regular diet. He will finish a course of antibiotics to end on [REDACTED]. # Hypokalemia # Hypomagnesemia # Hypophosphatemia Likely in the setting of poor PO intake and previous diarrhea, required IV repletion. Hypokalemia also may have been influenced by use of hydrocholorothiazide. # Anemia: Mild, no evidence of active bleeding. CHRONIC/STABLE PROBLEMS: # Hypertension: Held hydrochlorothiazide on discharge given hypokalemia # [REDACTED] esophagus: Continue omeprazole TRANSITIONAL ISSUES [] Prescribed a course of ciprofloxacin/metronidazole to end on [REDACTED] (7 days total of abx, 5 days since removal of stones) [] Needs biliary stent removed in a month. ERCP already scheduled for [REDACTED]. [] Please repeat chemistry panel, in particular: Mg, phos, potassium were low while inpatient [] Hydrochlorothiazide held on discharge given hypokalemia. If still hypertensive, consider restarting agent vs alternative anti-hypertensive. [] CT Abdomen Pelvis done at [REDACTED] with: "There is mild distension of the ascending and transverse colon with apparent focal transition at the proximal descending colon, where there is apparent mild wall thickening and mucosal hyperenhancement, suggesting possible partial colonic obstruction due to a colonic lesion versus colitis. Alternatively, this focal finding could reflect normal focal peristalsis with the mild proximal colonic distension reflecting ileus, reactive to the acute cholecystitis. Correlate with colonoscopy;" therefore consider colonoscopy as outpatient for further evaluation >30 minutes spent on discharge planning and coordination of care
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> erythromycin base <ATTENDING> ___. <CHIEF COMPLAINT> Neck pain, chest pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> A ___ y/o F presents to the ED as a transfer with chest pain s/p a MVC. The patient was an unrestrained driver in a MCV earlier today. The patient had severe pain over her sternum and presented to OSH. At OSH, the patient had a CT which showed a C2 lateral mass fracture as well as an anterior mediastinal hematoma and sternal fracture. The patient was transferred here for further evaluation and management. Currently, the patient notes chest pain. She reports that she does not remember the entire accident and does not know if she lost consciousness or not. The patient denies a headache, neck pain, nausea, and vomiting. <PAST MEDICAL HISTORY> None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Temp: 98. HR: 74 BP: 108/70 Resp: 14 O(2)Sat: 100 Normal Constitutional: Awake and alert HEENT: Pupils equal, round and reactive to light, tender to palpation over R maxilla and R orbit, Extraocular muscles intact no laceration to the scalp blood in the lower dentition and dried blood on the lip, no battle sign, no blood in the nares Chest: tenderness to palpation of the sternum and chest wall bilaterally, no ecchymosis over the chest wall, Clear to auscultation, normal effort, airway intact, bilateral breath sounds Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds, DP pulses 2+ symmetric Abdominal: Soft, Nontender, Nondistended Rectal: rectal tone intact Extr/Back: Pelvis stable and nontender, no deformity or tenderness of the extremities, TTP mid thoracic spine with no other midline spine tenderness, no deformity or stepoff of spine Skin: mild ecchymosis to the R anterior knee Neuro: GCS 15, Speech fluent, moves all extremities Psych: Normal mood, Normal mentation <PERTINENT RESULTS> ___ 04: 50AM BLOOD WBC-6.8 RBC-3.66* Hgb-10.8* Hct-33.8* MCV-92 MCH-29.5 MCHC-32.0 RDW-11.4 RDWSD-38.8 Plt ___ ___ 03: 40AM BLOOD WBC-10.1* RBC-4.13 Hgb-12.4 Hct-37.1 MCV-90 MCH-30.0 MCHC-33.4 RDW-11.7 RDWSD-37.6 Plt ___ ___ 04: 50AM BLOOD ___ PTT-29.2 ___ ___ 03: 40AM BLOOD ___ PTT-29.3 ___ ___ 04: 50AM BLOOD Glucose-71 UreaN-10 Creat-0.6 Na-137 K-3.8 Cl-100 HCO3-27 AnGap-10 ___ 05: 30AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-25 AnGap-12 ___ 03: 40AM BLOOD Glucose-86 UreaN-10 Creat-0.8 Na-133* K-9.3* Cl-98 HCO3-27 AnGap-8* ___ 10: 50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG ___ 08: 51AM URINE bnzodzp-POS* barbitr-NEG opiates-POS* cocaine-NEG amphetm-NEG mthdone-NEG ___ CTA: IMPRESSION: 1. Fracture right lateral mass C 2, involves foramen transversarium, stable. 2. Normal CTA. No dissection. <MEDICATIONS ON ADMISSION> FLUoxetine 60 mg PO DAILY lisdexamfetamine 70 mg oral Q24H VYVANSE 70 MG CAPSULE <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H DO NOT exceed 4000 mg acetaminophen/24 hours. 2. Docusate Sodium 100 mg PO BID 3. Ibuprofen 600 mg PO Q8H: PRN Pain - Mild alternate with tylenol 4. Lidocaine 5% Patch 1 PTCH TD QAM 12 hours on; 12 hours off. RX *lidocaine 5 % apply 1 patch to affected area daily Disp #*30 Patch Refills: *0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate take lowest effective dose. RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills: *0 6. Polyethylene Glycol 17 g PO DAILY: PRN Constipation - First Line 7. FLUoxetine 60 mg PO DAILY 8. lisdexamfetamine 70 mg oral Q24H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fracture right lateral mass C 2 deep sternal hematoma with possible fracture <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the Acute Care Surgery Service on ___ after a motor vehicle crash sustaining a fracture in you neck and a deep bruise on your chest bone (sternum). You were evaluated by the neuro spine team and your spinal cord remains intact. You should continue to wear your hard cervical collar at all times and avoid all twisting, strenuous activity, and heavy lifting. You will follow up in the spine clinic to determine how long you need to wear this brace. Please continue to follow the diet prescribed by your outpatient dentist. You are now ready to be discharged home with the following instructions: * Your injury caused chest and rib pain which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus).
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Ms. [REDACTED] is a [REDACTED] yo F who presented to the Emergency department as a transfer from outside hospital after sustaining a motor vehicle crash. She underwent CT head, chest, and torso that showed a C2 transverse foramen fracture, sternal fracture, and mediastinal hematoma. Neurosurgery was consulted and recommended CTA to rule out vascular injury and there was none. The patient was maintained in a hard cervical collar and admitted to the floor on continuous telemetry monitoring for pain control and hemodynamic monitoring. The patient underwent tertiary survey that was negative for any further injuries. Pain was controlled on oral medications. She had no cardiac events on continuous telemetry monitoring. Diet was tolerated without difficulty. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching, including cervical collar care, and follow-up instructions with understanding verbalized and agreement with the discharge plan.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> invasive lobular carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> right simple mastectomy <HISTORY OF PRESENT ILLNESS> The patient is a ___ woman who recently underwent a right breast lumpectomy and axillary sentinel lymph node biopsy for invasive lobular carcinoma on ___. The tumor in the right breast was relatively large (5-6 cm) and the patient realized that lumpectomy would not be successful due to the size of the tumor. The margins were positive, and already at the time of the lumpectomy there was additional tissue in the lumpectomy cavity that was suspicious for malignancy. When that tissue was excised it also contained invasive lobular carcinoma. A sentinel lymph node biopsy yielded negative lymph nodes. After discussion of different management options, the patient was now scheduled for a right simple mastectomy. She was offered consultation and plastic surgery for breast reconstruction but declined that consultation. The patient now presents today for right simple mastectomy. <PAST MEDICAL HISTORY> PMHx right breast invasive lobular carcinoma depression asthma carpal tunnel syndrome PSurgHx: 1) R breast lumpectomy and sentinel node biopsy ___ 2) salpingo-oophorectomy several years ago while living in ___ ___ History: ___ <FAMILY HISTORY> The patient has a positive family history of breast cancer. The patient's maternal aunt and three maternal cousins have had breast cancer. She does not have any sisters with breast cancer and her mother has not had breast cancer. <PHYSICAL EXAM> post-op T 97.1 HR 63 BP 98/59 RR 18 SpO2 98% RA gen: NAD cardiac: RRR chest: no respiratory distress; incision covered by clean dressing, no seroma, 2 JPs with serosanguinous drainage abd: soft, nontender ext: wwp, no edema <MEDICATIONS ON ADMISSION> lorazepam 0.5 q8h prn anxiety fluticasone 50mcg 1puff both nostrils BID paroxetine 25mg ER daily zolpidem 10mg daily <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for anxiety. 3. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime). 4. paroxetine HCl 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal BID (2 times a day). 6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 7. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> invasive lobular carcinoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the ___ surgery service following your right mastectomy. Two bulb suction drains were placed during the surgery which will remain until your follow-up appointment. Please call your doctor or go to the emergency department if: *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General <DISCHARGE INSTRUCTIONS> Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. You should move your right arm frequently through a full range of motion to prevent a frozen shoulder. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *You may remove the dressing over your incision tomorrw (___). *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *Your steri-strips will fall off on their own or will be removed at your follow-up appointment. Please do not remove them. Bulb Suction Drain Care: *Please look at the drain site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warmth, and fever). *Maintain the bulb on suction. *Record the color, consistency, and amount of fluid in the drain. Call the surgeon, nurse practitioner, or ___ nurse if the amount increases significantly or changes in character. *Empty the drain frequently. *You may shower and wash the drain site gently with warm, soapy water. You may also wash with half strength hydrogen peroxide followed by saline rinse. *Keep the insertion site clean and dry otherwise. Place a drain sponge for cleanliness. *Avoid swimming, baths, and hot tubs. Do not submerge yourself in water. *Attach the drain securely to your body to prevent pulling or dislocation.
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Patient was admitted on [REDACTED] and underwent a right simple mastectomy. Please refer to Dr. [REDACTED] note of same date for further details. Surgery was without complication and patient was transferred to the PACU in stable condition. Patient was then transferred to the floor. Pain was controlled on a PCA, which was transitioned to oral medications. Patient was tolerating a regular diet and ambulating and voiding without difficutly. JP output was serosanguinous and moderate [REDACTED] cc). Patient was discharged home on postoperative day #2 with both JP drains in place with drain teaching. A visiting nurse appointment was set up to reinforce drain teaching and evaluate for any further need of home services.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Nausea, vomiting, diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo M with multiple myeloma s/p 10 cycles of Revlimid/Velcade/Decadron and high dose cytoxan therapy (admission on ___ for mobilization, s/p recent auto-SCT discharged on ___. During his admission for cytoxan, he tolerated tx without complication and was started on ciprofloxacin the day after discharge for prophylaxis and Neupogen. On follow-up, he reported having had some nausea. He also had some bony pain which was thought possibly ___ Neupogen use, so additional oxycodone/oxycontin was also prescribed to him. . During last admission, his auto-SCT course was complicated by N/V which was treated with zofran, zyprexa, and compazine. During that admission, he did not require any antiemetics for the last 3 days of hospitalization, so he was discharged without antiemetics. . Since that hospitalization, the pt states that the day PTA, he developed abdominal pain last evening after drinking OJ, and the pain was ___, and was described as an ache/cramp without radiation diffusely in abdomen. This am, the pt had continued abd pain (comes and goes), which was associated with N/V once he tried ensure. He took his AM oxycontin which didn't help the abd pain too much. He had normal BMs this am, and started developing loose stools after arriving at his ___ appt this am. He states that a 2nd stool became diarrhea. He vomited a ___ time here in clinic. He states the pain is now ___ (stopped with time without intervention), and tolerated a yogurt for lunch. He states that at home, no F, but some C/NS last night, denies any blood in stool urine, or in vomit. Denies recent EtOH, APAP, or NSAIDs. . ROS: (+) Per HPI (-) Denies fever, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied constipation. No dysuria. Denied arthralgias or myalgias. <PAST MEDICAL HISTORY> - Multiple Myeloma diagnosed in ___ with back pain for the last few months, weight loss, anemia, renal insufficiency, and lytic lesions of the spine. - s/p revlimid/velcade/decadron x 10 cycles - high dose cytoxan early ___ (day 1 ___ - auto-SCT ___, complicated by nausea/vomiting, no fevers . Other <PAST MEDICAL HISTORY> - psoriasis and psoriatic arthritis - hyperlipidemia - hypertension - h/o positive PPD as young adult for which he took anti-TB medicines. <SOCIAL HISTORY> ___ <FAMILY HISTORY> - negative for any hematologic malignancies - diabetes runs in the family <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM GEN: awake, alert, oriented HEENT: NCAT, MMM, OP clear Neck: supple, no LAD CV: distant, RRR, no m/r/g appreciated Resp: CTAB, no w/c/r Abd: soft, ND, hypoactive BS, no hepatosplenomegaly, mildly tender to palpation Extremities: warm, dry, 1+ pitting edema arouhnd ankles, 1+ distal pulses Skin: no rash Neuro: A+Ox3, grossly intact DISCHARGE PHYSICAL EXAM unchanged <PERTINENT RESULTS> ADMISSION LABS ___ 08: 48AM BLOOD WBC-6.2 RBC-4.46*# Hgb-12.7*# Hct-37.3*# MCV-84 MCH-28.5 MCHC-34.0 RDW-17.9* Plt ___ ___ 08: 48AM BLOOD Neuts-54 Bands-4 Lymphs-10* Monos-27* Eos-0 Baso-1 Atyps-1* Metas-2* Myelos-1* ___ 08: 48AM BLOOD UreaN-6 Creat-0.7 Na-137 K-4.3 Cl-100 HCO3-27 AnGap-14 ___ 08: 48AM BLOOD ALT-36 AST-39 LD(LDH)-387* AlkPhos-122 Amylase-PND TotBili-0.4 ___ 08: 48AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.0 ___ 08: 48AM BLOOD Lipase-PND DISCHARGE LABS ___ 07: 14AM BLOOD WBC-3.6* RBC-3.88* Hgb-10.8* Hct-32.0* MCV-82 MCH-27.9 MCHC-33.8 RDW-17.8* Plt ___ ___ 07: 14AM BLOOD Neuts-47* Bands-1 ___ Monos-25* Eos-0 Baso-0 Atyps-4* ___ Myelos-0 ___ 07: 14AM BLOOD Glucose-97 UreaN-2* Creat-0.6 Na-136 K-4.1 Cl-103 HCO3-26 AnGap-11 ___ 07: 14AM BLOOD ALT-31 AST-31 LD(LDH)-192 AlkPhos-88 TotBili-0.3 ___ 07: 14AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8 <MEDICATIONS ON ADMISSION> 1. acyclovir 400 mg Tablet PO Q8H 2. oxycodone 10 mg Tablet Extended Release 12 hr PO Q12H 3. oxycodone 10 mg Tablet PO every four (4) hours as needed for pain <DISCHARGE MEDICATIONS> 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 3. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 4. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp: *30 Tablet, Rapid Dissolve(s)* Refills: *2* 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every ___ hours. Disp: *30 Tablet, Delayed Release (E.C.)(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Abdominal Pain and diarrhea <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> It was a pleasure taking care of you during your hospitalization. You were admitted to ___ with nausea/vomiting/diarrhea after your recent autologous stem cell transplant. We observed you in the hospital and sent lab tests to make sure you weren't suffering from an infection in the colon. Some of these tests are still pending at the time of your discharge. Since you felt better, and were able to keep food down, we felt you could return home with close follow up as an outpatient. THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS: - START taking ZOFRAN 8 mg pills by mouth every 8 hours as needed for nausea - START taking PROTONIX (PANTOPRAZOLE) 40 mg pills by mouth daily Please follow up with your physicians as indicated below
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This is a [REDACTED] yo M with multiple myeloma s/p 10 cycles of REvlimid/Velcade/Decadron, s/p high dose Cytoxan and auto-stem cell transplant, recently discharged on [REDACTED], who p/w N/V/diarrhea. . # N/V/Diarrhea: Pt's CBC shows no longer neutropenic, and as such, less suspicion for infx process in setting of severe immunosuppression, however even so, am concerned given h/o MM and recent auto-SCT. As such, would treat symptomatically and check stool studies. Lack of blood in stool is also reassuring. GI infx would most likely be treated with cipro or flagyl, however given lack of fever and benign abdominal exam, would defer abx for now. Also, normal AST/ALT reassuring, and would like to check amylase/lipase to r/o pancreatitis. Most likely cause given hx would be a viral gastroenteritis. We conservatively managed his symptoms with ativan and zofran prn, and encouraged PO intake and slowly advanced his diet from clears to regulars. We also started PPI out of concern for PUD. An amylase/lipase were also checked which were engative. IVF were used supportively. Given immunosuppressed state, stool Cxs were sent and were pending at time of dishcarge and will need to be f/u (c-diff was negative). . # Multiple myeloma. s/p 10 cycles of chemo and recent auto-SCT. We trended his counts, and he started to have his WBC trend down. Further oncologic therapy was deferred to the primary oncologist, and as far as his cytopenia, this began trending back up at time of discharge. We continued his acyclovir for ppx. . # Hyperlipidemia - was on simvastatin, recently d/c'ed given chemo and auto-SCT - continued to hold simvastatin for now. . # Neuropathy, likely [REDACTED] velcade. We continued oxycontin and oxycodone. We did not use stool softeners given his diarrhea upon presentation
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Epistaxis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ with hx HTN, easy bleeding, on Coumadin for hx of DVT, non-compliant patient with severe epistaxis since 2AM on the morning prior to admission. He awoke from sleep with blood on his face and presented to ___ where the bleeding stopped spontaneously but then restarted at home. He presented to ___ ED for further care. He denies any anticedent trauma, cocaine use. . In ED, vitals were 97.8 85 161/116 16 96. Epistaxis was unresponsive to direct pressure, but responded to nasal balloon. He was swallowing significant blood and had some emesis. 2 balloons were placed into the left nostril and filled with 10cc NS. No further bleeding was apparent but he continued to cough up clots intermittently. Patient received zofran 2mg IV, morphine 4mg IV, cefazolin 1gm IV, lidocaine jelly for the balloon placement. SBPs of 170s persisted after bleeding resolved and he received metoprolol 5mg IV x1. ENT was made aware to see in am. . On arrival to FICU, patient was comfortable with trace bright red blood draining from right nostril. He denied further post-nasal drip, SOB, cough, hemoptysis, chest pain, nausea, or vomiting. . <PAST MEDICAL HISTORY> Epistaxis H/o DVT on coumadin Poorly Controlled HTN H/o alcohol abuse b/l dupuytrens contracture <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> GENERAL - obese male in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, Intranasal balloon in left nostril with large blood clot at nare, trace amount of bright red blood draining from right nostril NECK - supple, no thyromegaly, no JVD LUNGS - decreased BS bilat, no r/rh/wh, fair air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, + caput medusa EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), b/l hand dupuytren's contractures SKIN - ruddy skin coloring, few talengectasias, few scattered pustules LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, gait deferred, no asterixis <MEDICATIONS ON ADMISSION> coumadin 6mg every other day <DISCHARGE MEDICATIONS> 1. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal ONCE PRN () for 3 days: If you develop nosebleed, spray copious amount of this spray (Afrin) into each nasal side and seek medical attention. 2. Sodium Chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal QID (4 times a day) for 5 days: both nasal sides. 3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical BID (2 times a day) for 7 days: Apply to inner nasal nares for 7 days. Disp: *qs 1* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Epistaxis Hx DVT Hypertension, benign <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital with nose bleed. You were kept in ICU initially and then transferred to the floor. Your blood count dropped but not enough to require transfusion. ENT packed your nose and removed the packing after 5 days. You have history of blood clot in the leg for which you have been taking coumadin (warfarin). Due to your nosebleed, this medication has been held. Please do not take it when you go home; you should discuss with your PCP when it is safe to resume. The ENT physicians here recommended at least one week off the coumadin. Please seek medical attention for recurrent nose bleed, chest pain, shortness of breath, palpitations
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AP: [REDACTED] yo M with h/o DVT on warfarin(INR 1.5 ) poorly controlled HTN p/w epistaxis #. Epistaxis: Pt had 2 balloons placed in left nostril and packing placed in right nostril by ENT. Episodes of bleeding were treating with genorous doses of afrin to the right nostril. Vit K was given. The patient is on coumadin as an outpatient but INR was subtherapeutic on admission. His HCT slowly trended down from 40 to 35, but did not require transfusion. His nasal packing has been removed and he was observed x 24 hrs with no signs of rebleeding. ENT recommends holding on anticoagulation for at least [REDACTED] weeks. Pt is to see his PCP next week to discuss plan for long-term anticoagulation given hx of recurrent DVTs but ?possible hx of medication noncompliance. #. HTN. He was noted to be hypertensive in ICU and this was thought unlikely represent etoh withdrawl as it is longstanding. Had some drop in his bp on [REDACTED] AM after receiving 2 BP meds (labetalol & hydralazine). He was on hydralazine, lisinopeil, and labetolol in the unit. Hydralazine was discontinued on [REDACTED]. Lisnopril was discontinued on [REDACTED]. He was normotensive on the floor - recommend f/u with PCP to evaluate whether he needs antihypertensives long-gterm #. H/o DVT - Last documented in [REDACTED] with plan for warfarin therapy. Patient appears non-compliant with INR checks. INR was subtherapeutic on admission. - PCP also concerned about compliance. Pt supposedly was taking coumadin but had not had INR checked since [REDACTED]. For now, will keep him off coumadin and have him [REDACTED] w PCP [REDACTED] [REDACTED] to discuss longterm plans. Pt and wife/daughter informed of the plan to see pcp [REDACTED] [REDACTED] weeks # Ectopy - noted in ICU to have several very brief moments SVT, unable to capture. On the floor his 12 lead EKG showed several premature atrial beats, occasional PVC. He was asymptomatic from this. #. H/o EOTH Abuse Per ICU: The patient had tachycardia earlier in hospitalization that had not responded to valium. The patient is not agitated so there is decreased concern that this represents withdrawal. Has been 0 on CIWA scale for 4 days now, will dc CIWA FULL CODE
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ___, overall healthy with R radius fracture secondary to gun shot wound <MAJOR SURGICAL OR INVASIVE PROCEDURE> Irrigation and debridement and ORIF of R radius fracture <HISTORY OF PRESENT ILLNESS> Patient is an otherwise healthy RHD ___ with no sig PMH who presents s/p GSW to R forearm at approximately 1: 15AM on ___. He was outside a bar in ___ when he reports he was shot by an unknown person. He noted immediate pain and bleeding in his right upper extremity, no other sites of pain or injury.. He was brought to ___ and received 1g Ancef and TDAP. He was placed into a volar resting splint. X-rays demonstrated a comminuted midshaft radius fracture consistent with ballistic injury. He was subsequently transferred to ___ for definitive care. On evaluation in the emergency department the patient reports sensation to all of his fingers although notes difficulty moving. He has no other sites of pain. He noted immediate bleeding after the injury, but it has since stabilized since being placed into a splint at the outside hospital. He denies chest pain, shortness of breath, abdominal pain. Review of systems is otherwise <PAST MEDICAL HISTORY> Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Vitals: ___ Temp: 98.7 PO BP: 131/75 L Lying HR: 74 RR: 18 O2 sat: 98% O2 delivery: Ra General: Resting in bed with arm elevated MSK: RUE - forearm in a sugar tong splint, c/d/i - soft and compressible forearm compartments - appropriately tender, but no pain out of proportion and just appropriate surgical pain with passive movement of his fingers that actually improves with continued movement - SILT R/M/U distributions. -Able to adduct and abduct fingers, flexes at MCP, PIP and DIP on all digits, makes ok sign, thumbs up and crosses fingers. - Fires EPL, FHL, DIO fire <PERTINENT RESULTS> ___ 09: 52AM BLOOD WBC-12.9* RBC-4.67 Hgb-13.9 Hct-39.8* MCV-85 MCH-29.8 MCHC-34.9 RDW-13.1 RDWSD-40.3 Plt ___ <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO 5X/DAY RX *acetaminophen 325 mg 650 mg by mouth four times a day Disp #*100 Capsule Refills: *0 2. Aspirin 325 mg PO DAILY Duration: 28 Days RX *aspirin ___ Aspirin] 325 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours as needed Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Gunshot wound to right forearm with highly comminuted radial shaft fracture with radial artery laceration <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Non weight bearing right upper extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add *** as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take <<<<<>>>> daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet.
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Patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a fracture in his right radius secondary to gunshot wound and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [REDACTED] for irrigation and debridement and open reduction internal fixation of right radius fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [REDACTED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [REDACTED] who determined that discharge to home was appropriate. The [REDACTED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weightbearing in the right upper extremity, and will be discharged on aspirin 325 mg for DVT prophylaxis. The patient will follow up with Dr. [REDACTED] in 2 weeks at the orthopedic trauma clinic. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Fosamax / Amoxicillin / Crestor <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal pain, bloating, constipation <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic and therapeutic paracentesis, CT-guided biopsy of pelvic mass <HISTORY OF PRESENT ILLNESS> This is a ___ year G0 female who presented to the ED on ___ with several months of worsening abdominal pain, constipation, and bloating. She complained of decreased appetite, denied nausea or vomiting. She reported recent weight loss. Denied fevers. Has constipation. Noted occasional difficulty with voiding. On review of OMR notes, she had multiple visit related to similar complaints which had been attributed to constipation and IBS. <PAST MEDICAL HISTORY> -Mitral valve regurgitation s/p valvuloplasty and annuloplasty in ___ ___. Had post-operative atrial fibrillation which converted spontaneously. -Paroxysmal atrial fibrillation in ___ prior to MV surgery. -Osteoporosis -Borderline hyperlipidemia -Osteoarthritis -History of squamous cell carcinoma in situ resected from chin ___ -Presumed IBS (normal colonoscopy ___ Past Surgical History: -Squamous cell carcinoma in situ resected from chin Past Gynecologic History: -Menopause age ___. No post-menopausal bleeding. -___ Pap normal -Mammogram ___ BIRADS-2 Past Obstetric History: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and cousin deceased from ovarian CA. No history of breast CA or other Gyn malignancies. <PHYSICAL EXAM> On arrival to the ED: 97.9, HR 110, BP 140/86, RR 16, 98% RA NAD, cachetic RRR CTA bilaterally Abdomen: Distended, tympanitic to percussion in areas and dull to percussion in other areas, palpable mass up to umbilicus, no rebound or guarding. No ___ edema, calf tenderness . . ___ CT abd/pelvis: CT ABDOMEN WITH IV CONTRAST: The lung bases demonstrate several sub-4-mm pulmonary nodules, in the right middle lobe (2: 1), in the right lower lobe (2: 5), and in the left lower lobe (2: 6). There are trace bilateral pleural effusions with minimal subsegmental atelectasis. The abdomen demonstrates severe diffuse ascites, with multiple abnormal soft tissue omental/peritoneal implants, as well as multiple large pelvic heterogeneously enhancing masses, the largest of which is in the left pelvis and measures 8.5 x 7.5 cm (2: 72). These findings are highly suspicious for ovarian carcinomatosis, although it is not possible to identify the primary site given the presence of widespread soft tissue abnormalities. Additional soft tissue implants are identified along the diaphragm (2: 7), in the right lower quadrant (2: 60), as well as the anterior abdominal wall (2: 65). . The liver, spleen, pancreas, adrenal glands, kidneys, ureters, and large bowel are unremarkable. The small bowel demonstrates multiple loops of dilated ileum, up to 3.4 cm (2: 53), where it enters the region of the large pelvic masses. However, presence of relatively collapsed distal bowel indicates a partial or early small-bowel obstruction, likely secondary to mass effect from the pelvic masses. . CT PELVIS WITH IV CONTRAST: The rectum demonstrates a small amount of stool. The sigmoid colon is collapsed, and lack of oral contrast makes it difficult to trace its course. The uterus demonstrates multiple popcorn calcifications indicative of uterine fibroids. Neither right or left ovary is identified separate from the large pelvic masses. Vascular calcifications of the infrarenal aorta and origins of the renal arteries are noted. Osseous structures demonstrate degenerative change of the lumbosacral spine, without suspicious lytic or blastic lesions. . IMPRESSION: 1. Multiple large pelvic masses with large amount of ascites and diffuse peritoneal implants and omental caking are most suggestive of ovarian cancer. 2. Small-bowel obstruction, partial or early, likely from mass effect from the pelvic lesions. . Pelvic Ultrasound ___: PELVIC ULTRASOUND: Transabdominal ultrasound was performed. The patient refused transvaginal ultrasound. The pelvis demonstrates a large amount of free fluid, with multiple large soft tissue masses demonstrating vascularity. Given the presence of multiple vascular soft tissue masses, the ovaries are not clearly delineated. The largest soft tissue mass measures 9.7 x 8.8 x 9.0 cm. The findings are suggestive of peritoneal carcinomatosis, most likely from an ovarian neoplasm. . IMPRESSION: Multiple vascular soft tissue masses suggestive of an ovarian or other neoplasm. However, the ovaries are not well delineated, given the presence of multiple soft tissue masses. Please refer to the earlier CT report for a more detailed evaluation of the lesions. . ___ CXR FINDINGS: The lungs appear clear bilaterally. The cardiomediastinal silhouette is within normal limits given low lung volumes. The aorta is slightly tortuous and calcified. There is a significant amount of air within the stomach. . IMPRESSION: No acute intrathoracic process. Significant amount of air within the stomach. . ___ EKG Sinus tachycardia with ventricular premature depolarizations. Non-diagnostic inferolateral T wave flattening. Compared to the previous tracing of ___ no diagnostic change. . <PERTINENT RESULTS> ___ 11: 55AM WBC-9.4 RBC-4.60 HGB-12.6 HCT-38.0 MCV-83 MCH-27.3 MCHC-33.1 RDW-12.8 ___ 11: 55AM NEUTS-81.5* LYMPHS-9.8* MONOS-8.3 EOS-0.1 BASOS-0.3 ___ 11: 55AM PLT COUNT-606* ___ 11: 55AM GLUCOSE-120* UREA N-20 CREAT-0.7 SODIUM-136 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18 ___ 11: 55AM ALT(SGPT)-8 AST(SGOT)-18 ALK PHOS-73 TOT BILI-0.5 ___ 11: 55AM LIPASE-16 ___ 11: 55AM CEA-<1.0 CA125-201* ___ 12: 11PM LACTATE-2.5* ___ 02: 20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 02: 20PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02: 47PM ___ PTT-25.3 ___ <MEDICATIONS ON ADMISSION> Aspirin 81 mg QOD <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable ___. 2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: ___ MLs ___ QID (4 times a day) as needed. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1) Tablet,Rapid Dissolve, ___ ___. 4. Morphine 10 mg/5 mL Solution Sig: 2.5-5 mg mg ___ Q4H (every 4 hours) as needed for pain. 5. Morphine 10 mg/5 mL Solution Sig: 2.5-10 mg sublingual mg ___ Q2H (every 2 hours) as needed for Acute pain: Sublingual dose if needed. 6. Dexamethasone 4 mg IV Q8H Duration: 5 Days <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Abdominal pain Partial small bowel obstruction Abdominal ascites Presumed ovarian adenocarcinoma Gastroesophageal reflux Chest pain <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ notify MD if develop fevers, inability to tolerate oral intake, increased abdominal pain, pain with urination, or severe constipation. You have pending pathology results at ___ from the biopsy performed on ___ and these can be followed by calling the Gyn Oncology office at ___.
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The patient was admitted to Gyn Oncology from the ED for further evaluation. She had been evaluated in the ED by General Surgery and was found to have no clinical evidence of small bowel obstruction. Please see the following below for hospital course by system: . Heme/Onc: Please see attached CT and U/S reports regarding the mass. The CA-125 was 201 and the CEA < 1. She was counseled that based on the CT findings and the elevated CA-125 that this was likely ovarian cancer. She was also counseled that it was important to rule out other malignancies that can present in a similar manner but that would be treated differently such as a lymphoma or a GI tract cancer. . On [REDACTED], the patient underwent a CT-guided biopsy of the pelvis mass and a paracentesis of 1.7 L of fluid. She fluid cytology was significant for malignant cells consistent with adenocarcinoma (stromal or sarcomatous component may be present). The final pathology results are pending at the time of this dictation but preliminary evaluation is most consistent with ovarian adenocarcinoma as the primary and not GI. Medical oncology was consulted. Chemotherapy was discussed with the patient, but she was counseled that given her frail status that this might not be the best option. She was also counseled that surgical management would not be advised given the risks in her current frail state. Throughout the hospitalization, the patient expressed a desire to pursue palliative care and hospice. She received Dilaudid 0.125 mg IV as needed for pain. . Palliative care was consulted on [REDACTED] and recommended the following: Decadron 4 mg IV TID, if no response in 5 days this can be stopped. Roxanol 2.5-5 mg q 4 hours round the clock (pt may refuse), Roxanol 2.5-10 mg SL q 2 hrs prn pain. Social work met with the patient to assist with funeral planning. . GI/FEN: The patient did not develop any clinical evidence of a small bowel obstruction and did not require nasogastric tube placement or anti-emetics. She complained of decreased appetite and early satiety with any [REDACTED] intake. Her [REDACTED] intake was mainly for comfort measures--ice, juice, sherbet--and was approximately 200-300 cc/day. She was seen by nutrition who recommended monitoring [REDACTED] intake, supplementation as tolerated, and considering TPN as clinically indicated. The patient declined supplementation because of difficulty swallowing the liquid. She declined having a swallow study to further evaluate her swallowing function. . CARDIAC: The pt complained of chest pain vs. epigastric discomfort from reflux on [REDACTED]. She received aspirin and pepcid. Cardiac enzyme x 1 was negative. The EKG showed sinus tachycardia without ischemic changes. A CXR showed no acute process and air within the stomach c/w with the partial SBO seen on CT scan. Medicine was consulted and it was thought that this event was likely GERD and no cardiac in origin. She was written for Protonix and Maalox. . GU: The patient complained of difficulty urinating on [REDACTED]. A urine culture was negative. A Foley catheter was placed. Throughout her hospitalization, she had oliguria likely due to hypovolemia from fluid shifts related to the ascites. Her Cr was normal at 0.4 to 0.7 throughout her hospitalization. FeNA was < 1% consistent with a prerenal etiology. She was seen by Medicine and was started on NS for IVF and received multiple 250-500 cc boluses to keep her urine output greater than 10 cc/hour. On [REDACTED], the Foley was not draining well despite flushes and it was removed and the patient declined having it replaced. She was voiding spontaneously at time of discharge. . Prophylaxis: She received SC Heparin for DVT prophylaxis . Code status: She was DNR/DNI after discussion with attending. Paperwork signed [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> General ache <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with MS, wheelchair bound, with neurogenic bladder s/p supra pubic tube, p/w generalized body aches. The patient is living at home and has a hospital bed there that the mechanical component of it is no longer working. Her daughter and her aids attempted to fix the bed, but were unable. She slept on the mechanical bed all night in an upright position that was very uncomfortable for her. All night slept crooked on the bed and now having some mild discomfort in low back and neck. No falls, trauma, fevers, chills, LOC, CP/SOB. In the ED, initial vs were: T 98.8 80 145/88 18 100% RA. Labs were were not obtained in the ED, most recent labs were from ___ that showed an unremarkable CBC, Cehm 7 was remarkable for Na 130 stable from earlier in ___, and BUN/Cr ___. Patient was given acetaminophen and tums. Vitals on Transfer: 97.6 71 140/78 16 97% RA <PAST MEDICAL HISTORY> -multiple sclerosis, diagnosed ___, wheelchair bound -optic neuritis ___ MS -neurogenic bladder ___ MS, suprapubic tube since ___ -cognitive impairment ___ MS -___ ulcers -h/o recurrent "UTIs" -E. coli bacteremia -sphincter dyssynergia -R hip fracture, s/p closed reduction and open internal fixation, ___ -osteoporosis -depression -hypercholesterolemia -eczema -HTN <SOCIAL HISTORY> ___ <FAMILY HISTORY> father, ___, MI mother, MI genetic twin, HTN <PHYSICAL EXAM> Vitals-T97.8 P75 BP138/82 R18 O2 sat100%RA General- Alert, oriented, NAD HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes/crackles/rhonchi CV- RRR, Nl S1,S2 No MRG Abdomen- soft, NT/ND, NABS suprapubic catheter in place without surrounding erythema Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, patient unable to ambulate, difficulty with fine motor skills. ___ strenght on ___ ___ EXAM ON DISCHARGE: T98 BP 123/61 HR 71 RR18 100%RA General- Alert, oriented, NAD HEENT- Sclera anicteric, MMM, oropharynx clear - Left Ptosis but chronic Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes/crackles/rhonchi CV- RRR, Nl S1,S2 No MRG Abdomen- soft, NT/ND, NABS suprapubic catheter in place without surrounding erythema Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, patient unable to ambulate, difficulty with fine motor skills. ___ strenght on ___ ___ <PERTINENT RESULTS> no labs done <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY hold for SBP<100 2. Calcium Carbonate 500 mg PO QID: PRN indigestion 3. Glycerin Supps ___VERY OTHER DAY 4. Senna 2 TAB PO HS 5. solifenacin *NF* 5 mg Oral every other day 6. Multivitamins 1 TAB PO DAILY 7. Citalopram 10 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY hold for SBP<100 <DISCHARGE MEDICATIONS> 1. Senna 2 TAB PO HS 2. Multivitamins 1 TAB PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Glycerin Supps ___VERY OTHER DAY 6. Citalopram 10 mg PO DAILY 7. Calcium Carbonate 500 mg PO QID: PRN indigestion 8. solifenacin *NF* 5 mg Oral every other day <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Broken bed at home <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure having you here at the ___ ___. You were admitted here after your hospital bed broke at home. You will be discharged to ___ for the time it takes to get a hospital bed in your house. Please keep your follow up appointments below
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[REDACTED] with MS, wheelchair bound, with neurogenic bladder s/p supra pubic tube, p/w generalized body aches after sleeping on a [REDACTED] hospital bed at home. # Generalized body aches: most likely secondary to poor position while on a [REDACTED] hospital bed at home. Patient was unable to be placed in ED OBS given that she is non-ambulatory. Patient required one dose of acetaminophen for pain control. She will be discharged to [REDACTED] for a bed until she gets one in her house. CHRONIC ISSUES: # Neurogenic Bladder with suprapubic catheter - c/w suprapubic catheter # HTN - continued HCTZ, lisinopril # MS: Patient reports she is at her baseline functional status TRANSITIONAL ISSUES: -left eye ptosis, which was an isolated neurologic finding that is likely chronic per the patient. Her neurologist was contacted about this who will follow this finding.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Ibuprofen / lisinopril / Percocet <ATTENDING> ___. <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP EUS <HISTORY OF PRESENT ILLNESS> ___ yo M with Hep C/EtOH cirrhosis, with stage II fibrosis, pancreatitis, HTN, RLL squamous cell carcinoma s/p XRT, now with five day h/o fever. Per patient, fever to 103 at home. + chills, night sweats, fatigue. + n/v x1 last week. + anorexia x several days. + 10 lb weight loss over 3 months. + SOB on the day PTA. In the ED, received cipro/metronidazole and albumin. Liver team recommended MRCP. Pt admitted for further care. On admission, pt feels well, without complaints - no f/c, n/v, CP, abd pain, diarrhea. REVIEW OF SYSTEMS: CONSTITUTIONAL: As per HPI HEENT: [X] All normal RESPIRATORY: [X] All normal CARDIAC: [X] All normal GI: As per HPI GU: [X] All normal SKIN: [X] All normal MUSCULOSKELETAL: [X] All normal NEURO: [X] All normal ENDOCRINE: [X] All normal HEME/LYMPH: [X] All normal PSYCH: [X] All normal 10 point review of systems negative except as noted above <PAST MEDICAL HISTORY> Hep C/EtOH cirrhosis Pancreatitis HTN RLL squamous cell CA s/p XRT Tongue lesions <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Alcoholism - DM - CAD - Denies family history of GI cancer or pancreatitis <PHYSICAL EXAM> <PHYSICAL EXAM> afeb 142/76 94 94% (RA) GENERAL: NAD Mentation: Alert Eyes: NC/AT Ears/Nose/Mouth/Throat: MMM; + tongue lesions Neck: Supple Resp: CTA bilat CV: RRR, normal S1S2 GI: Soft, NT/ND, normoactive bowel sounds Skin: No rash Extremities: No edema Lymph/Heme/Immun: No cervical ___ noted Neuro: Alert & oriented x3 <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-10.8* RBC-4.97 Hgb-13.5* Hct-38.9* MCV-78* MCH-27.2 MCHC-34.7 RDW-14.7 RDWSD-42.2 Plt ___ ___ 02: 55PM BLOOD Neuts-66.0 ___ Monos-13.5* Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.78 AbsLymp-1.41 AbsMono-0.98* AbsEos-0.00* AbsBaso-0.02 ___ 07: 15AM BLOOD ___ PTT-28.7 ___ ___ 07: 15AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-136 K-3.6 Cl-93* HCO3-22 AnGap-21* ___ 07: 15AM BLOOD ALT-64* AST-38 AlkPhos-120 TotBili-1.4 ___ 02: 55PM BLOOD proBNP-1044* ___ 02: 55PM BLOOD Lipase-11 MRCP: IMPRESSION: 1. New dilatation of the common bile duct and the intrahepatic bile ducts with abrupt termination within the pancreatic head with slight increase in chronic pancreatic ductal dilatation. No choledocholithiasis or discrete mass identified on MRI, however the configuration of ductal dilatation remains suspicious for an occult ampullary or periampullary lesion, and further evaluation with EUS/ERCP is recommended. 2. Active cholangitis without definite abscess. Hyperenhancement surrounding a previously-seen hepatic cyst is nonspecific and does not necessarily represent superinfection. 3. 2 cm hypoenhancing right renal mass is suspicious for papillary-subtype renal cell carcinoma. An oncocytic neoplasm is also on the differential. 4. Right lower lobe nodularity consistent with known malignancy with surrounding atelectasis or consolidation. CT ABD: IMPRESSION: 1. No evidence of pneumoperitoneum. 2. The main pancreatic duct remains dilated and tapers abruptly in the pancreatic head, where there is a 6 mm calcification in the pancreatic duct. Additionally, the presence of mild peripancreatic stranding suggest a component of acute on chronic pancreatitis. 3. The ill-defined, hypodense 2.0 cm lesion in the right upper pole kidney is better assessed on the same day MRCP, and is again concerning for malignancy. 4. Again partially imaged is the known right lower lobe pulmonary malignancy with surrounding atelectasis and/or consolidation. 5. Postsurgical changes related to recent ERCP and stent placement. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Calcium Carbonate 500 mg PO DAILY 5. Vitamin D 400 UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*3 Tablet Refills: *0 2. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*4 Tablet Refills: *0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 5. Amlodipine 5 mg PO DAILY 6. Calcium Carbonate 500 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Vitamin D 400 UNIT PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Acute cholangitis Bile obstruction/CBD stricture cirrhosis Lung cancer Kidney nodule, possible cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted with fever and abdominal pain caused by infection and obstruction in your bile system. You required an ERCP procedure and as stent was placed in your bile duct. You will need to complete your course of antibiotics. You will need to return in 6 weeks to have your stent removed. Biopsies were taken as well and the GI team will call you with the results As we discussed, we also saw a nodule on you right kidney. It is possible that this could be cancer. We strongly recommend follow up with a urologist after discharge.
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[REDACTED] yo man with Hep C/EtOH cirrhosis s/p Harvoni treatment with SVR, with stage II fibrosis, chronic pancreatitis, HTN, RLL squamous cell carcinoma s/p XRT, who presented with fever, abd pain, and acute cholangitis with bile obstruction, s/p ERCP with stenting, and ongoing abdominal pain. Acute cholangitis: Bile obstruction/CBD stricture: Acute on chronic Pancreatitis: Diagnosis based on fever and abd pain with evidence of cholestasis. No clear alternative infection found. MRCP demonstrated CBD stricture possibly related to either chronic pancreatitis, or possibly malignancy. He underwent ERCP/EUS with stent placement and brushings sent for cytology. His LFTs improved and his fever resolved. Post procedure he had increased pain and follow up CT neg for perforation. We favored mild acute on chronic pancreatitis. He was treated supportively and his diet was advanced. He was ordered to complete 5 day course of Cipro/Flagyl - will need stent pull in 6 weeks - CBD brushings pending EtOH/HCV cirrhosis: Appreciate hepatology input. He was compensated. He had no ascites on RUQ US. He has SVR from his Harvoni treatment Squamous Lung Cancer: History reviewed. Recommend ongoing follow up with oncologist R Renal Mass concerning for RCC: This was reviewed with patient. He will need to follow up with urology on discharge. HTN: Stable on amlodipine Moderate malnutrition: Now tolerating diet well The patient was seen and examined on the day of discharge and is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> penicillin <ATTENDING> ___. <CHIEF COMPLAINT> "I have a device in my head" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ y.o. ___ male with a self reported history of schizophrenia and depression who was admitted to the ED on a ___ from ___ after stating that ___ has a device in his head that ___ would like removed. Psychiatry is consulted for evaluation and assistance with management and disposition. Mr. ___ is a poor historian in terms of chronological history often contradicting his own time frames. ___ reports that the device has been in his head for the past month. ___ states that the device was implanted through the air. ___ hears voices coming through the device that are very bothersome. ___ says the voices are commentary about his day, telling him to do certain daily tasks or they will talk about him and his future. ___ states there are 5 voices and they are typically fighting with each other which is especially bothersome. Mr. ___ reports that ___ was started on risperidone ___ years ago for voices and a different device in his head. ___ states that the medication had helped with the voices and ___ does not know where that device went. The voices came back 6 months ago, although at another time ___ said they came back 2 months ago. ___ reports that 3 mo ago ___ stopped his medication and then within 1 mo the voices returned, then the device was implanted. ___ has not had relief from the voices. ___ states that ___ was diagnosed with schizophrenia 7 months ago. ___ also states that ___ was diagnosed with depression in ___ which ___ cured with taking daily Vitamin D. Pt denies SI/HI/VH. <PAST MEDICAL HISTORY> PAST PSYCHIATRIC HISTORY: - Diagnoses: Schizophrenia 7 months ago, Depression from ___ - Hospitalizations: - ___ in ___ for 2 weeks - Current treaters and treatment: - Saw a psychiatrist once at ___, stated his name was ___ - Medication and ECT trials: - Risperidone 3mg qhs for ___ years - Self-injury: denies - Harm to others: denies - Access to weapons: not assessed PAST MEDICAL HISTORY: PCP: ___ care from ___ No acute medical problems <SOCIAL HISTORY> SUBSTANCE ABUSE HISTORY: - EtOH: denies - Tobacco: denies - Marijuana: denies - Opiates, including heroin: denies, denies IVDU - Benzodiazepines: denies - Cocaine/Crack: denies - Amphetamines: denies - LSD/PCP/Ecstasy/Mushrooms: denies FORENSIC HISTORY: - Arrests: denies - Convictions and jail terms: denies - Current status (pending charges, probation, parole): NA SOCIAL HISTORY: ___ <FAMILY HISTORY> FAMILY PSYCHIATRIC HISTORY: - Completed or attempted suicide: denies - Substance use or dependence: denies - Mental Illness: MOther has depression <PHYSICAL EXAM> EXAM: *VS: T: 98.7 HR: 91 BP: 150.86 RR: 16 SaO2: 100% RAM Neurological: *station and gait: normal stance, steady gait *tone and strength: normal tone, ___ strength in upper and lower extremities / moves all 4 extremities spontaneously and against gravity cranial nerves: II-XII intact abnormal movements: no tremor or abnormal posturing, tremulousness: Left hand has a resting tremor, fingers move repeatitively through extension and flexion, tremor gone with movement frontal release: not observed Cognition: Wakefulness/alertness: awake and alert *Attention (digit span, MOYB): correctly lists MOYB *Orientation: oriented to person, time, place, situation Executive function (go-no go, Luria, trails, FAS): not assessed *Memory: ___ registry, ___ recall after 5 minutes *Fund of knowledge: able to name 4 most recent US Presidents in descending order / knew capital of US and ___ Calculations: $2.25 = "9 quarters" / $1.00 = "4" Abstraction: apple/orange = "round, apples"; marker/pen= "both write"; did not understand ___ proverb Visuospatial: not assessed *Speech: accent in ___, normal rate, tone, volume, and prosody *Language: no paraphasic errors, appropriate to conversation Mental Status: *Appearance: well nourished Hispanic male, appears stated age, good hygiene, appropriately dressed in hospital gown Behavior: calm, cooperative, engaged, appropriate eye contact, orients to interviewer, no abnormal posturing, no psychomotor agitation or retardation *Mood / Affect: "The device is bothering me" / euthymic, normal intensity, appropriate to situation, congruent with mood *Thought process / *associations: linear, coherent, goal-oriented, associations intact *Thought Content: denies SI/HI/AH; no evidence of delusions or paranoia, does not appear to be responding to internal stimuli *Judgment: poor *Insight: impaired <PERTINENT RESULTS> ___ 06: 10PM URINE HOURS-RANDOM ___ 06: 10PM URINE HOURS-RANDOM ___ 06: 10PM URINE GR HOLD-HOLD ___ 06: 10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 06: 10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06: 10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 03: 00PM URINE HOURS-RANDOM ___ 03: 00PM URINE HOURS-RANDOM ___ 02: 25PM GLUCOSE-86 UREA N-12 CREAT-0.7 SODIUM-140 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 ___ 02: 25PM estGFR-Using this ___ 02: 25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02: 25PM WBC-6.7 RBC-4.91 HGB-14.7 HCT-43.7 MCV-89 MCH-29.9 MCHC-33.6 RDW-11.8 RDWSD-37.8 ___ 02: 25PM NEUTS-70.1 ___ MONOS-8.2 EOS-0.7* BASOS-0.4 IM ___ AbsNeut-4.70 AbsLymp-1.38 AbsMono-0.55 AbsEos-0.05 AbsBaso-0.03 ___ 02: 25PM PLT COUNT-232 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. RISperidone 1 mg PO BID 2. Vitamin D 50,000 UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. RISperidone 3 mg PO BID RX *risperidone 3 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 2. Vitamin D 50,000 UNIT PO DAILY 3. Benztropine Mesylate 1 mg PO BID RX *benztropine 1 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Schizophrenia <DISCHARGE CONDITION> *Appearance: Age appearing Hispanic man, wearing expensive looking trendy clothes, very good hygiene and grooming, no acute distress *Behavior: Guarded, evasive, engaged better today with treatment team than prior, limited eye contact, some psychomotor slowing *Mood: 'Good' *Affect: Flat *Thought process: Linear, very concrete *Thought Content: Delusional thought of device being implanted behind his ear, +AH of multiple voices telling him negative things about himself, denies AH commanding him to hurt himself or others. Denies suicidal ideation, intent, or plan. Likely thought blocking, possibly responding to internal stimuli during exam. *Judgment: Improving *Insight: Improving <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were hospitalized at ___ for depression with suicidal thoughts and problems with alcohol use. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. *It was a pleasure to have worked with you, and we wish you the best of health.*
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PSYCHIATRIC Mr. [REDACTED] was admitted to [REDACTED] due to an acute decompensation of his underlying schizophrenia in the context of medication alterations just prior to hospitalization. [REDACTED] was admitted with complaints of experiencing auditory hallucinations of multiple unknown voices of both genders commenting on him and saying negative things about himself. [REDACTED] did not experience command auditory hallucinations to harm himself or others. Additionally, [REDACTED] noted that there was a device implanted behind his ear and [REDACTED] wanted it to be removed. [REDACTED] was disorganized and responding to internal stimuli but there were no behavioral or safety concerns on admission. Prior to hospitalization his outpatient psychiatric NP had re-started his risperidone earlier this month after tapering him off in [REDACTED]. Prior to hospitalization [REDACTED] was prescribed risperidone 1mg qAM and 3mg qhs. We increased his risperidone to 3mg bid and provided him with benztropine 1mg bid to counteract any potential side effects including stiffness. [REDACTED] tolerated this medication change well and responded appropriately to the escalated dose of risperidone. Throughout this hospitalization [REDACTED] was guarded with the team when discussing his symptoms always minimizing his experience and saying [REDACTED] was "fine" and ready for discharge. [REDACTED] did note that [REDACTED] did not hear the voices with the increased dose of risperidone. [REDACTED] was very reluctant to share with the team about the device [REDACTED] believed was implanted behind his ear but by discharge was saying it had disappeared and the medication made it go away. Despite his report of decreasing psychotic symptoms [REDACTED] appeared flat, somewhat internally preoccupied, and showed evidence of thought blocking even at admission. However, [REDACTED] adamantly denied any current or prior suicidal ideation, intent, or plan and continued to deny experiencing command auditory hallucinations to harm himself or others. On the day of discharge [REDACTED] was future oriented with plans to return home to spend time with his family, continue his risperidone, and further engage in outpatient treatment with his psychiatric NP. On discharge, mood was "good", MSE was pertinent for a young Hispanic man who appeared his stated age. [REDACTED] is well groomed and wearing expensive looking casual clothes. [REDACTED] is at times guarded and evasive and at other times cooperative, and maintains intense intermittent eye contact. His thought process is linear and very concrete. His thought content is significant for recent auditory hallucinations of multiple voices commenting on his behavior and actions and delusional thoughts of a device being implanted behind his ear. Additionally there is evidence of thought blocking and some paucity of thoughts. His speech is slowed with some speech latency and limited prosody. His [REDACTED] is nearly fluent though [REDACTED] speaks with an accent. His judgment has improved since admission though his insight is likely chronically impaired. Safety: The patient remained in good behavioral control throughout this hospitalization and did not require physical or chemical restraint. The patient remained on 15 minute checks, which is our lowest acuity level of checks. GENERAL MEDICAL CONDITIONS No acute issues during this hospitalization. We recommend that the patient continues his routine primary care at [REDACTED] [REDACTED]. PSYCHOSOCIAL #) MILIEU/GROUPS The patient mostly demonstrated a flattened affect while on the unit. Although [REDACTED] was visible in the milieu, [REDACTED] was seen mostly pacing around the unit. [REDACTED] was pleasant on approach though showed little spontaneous engagement with staff or other patients. [REDACTED] was not interested in attending any groups while on the unit. [REDACTED] never engaged in any unsafe behaviors. [REDACTED] all meals in the milieu, slept well, and cooperated with unit rules. #) FAMILY CONTACTS [REDACTED] family visited daily and [REDACTED] spent a considerable amount of time with his [REDACTED] year old sister. [REDACTED] family were his main social contact and support while on the unit. The treatment team spoke with the [REDACTED] mother on the phone soon after admission. She stated that while [REDACTED] was not at baseline she felt comfortable with him discharging due to lack of safety concerns and plans to continue medications and follow up on discharge. On the day of discharge, the treatment team met with the patient and his mother to discuss progress, medication changes, and aftercare planning. #) COLLATERAL We spoke with the [REDACTED] psychiatric NP, [REDACTED], at [REDACTED]. [REDACTED] had started caring for [REDACTED] at the beginning [REDACTED] when the patient was asymptomatic and wanted to be tapered off his medications. [REDACTED] tapered him off of his risperidone and in [REDACTED] the patient returned with emergence of his psychotic symptoms. [REDACTED] restarted him on risperidone 1mg qAM and 3mg phs. The treatment team spoke with [REDACTED] about [REDACTED] hospitalization, symptoms, and medication changes. [REDACTED] notes that there have never been any safety concerns with [REDACTED] will follow up with him in outpatient clinic on [REDACTED]. LEGAL STATUS The patient remained on a CV throughout the duration of this admission. [REDACTED] signed a 3-Day notice which expired on the day of discharge. RISK ASSESSMENT: This patient does not abuse substances, is not suicidal or homicidal, is feeling well all of which indicate a low immediate risk of harm. Static risk factors include: -Chronic and severe mental illness -Male sex Modifiable risk factors include: -Acute psychosis -Disorganization -Recent Medication Changes We modified this risk by uptitrating the [REDACTED] risperidone to 3mg bid, with good effect. Protective factors include: -Current outpatient providers/treatment -Strong connections to family -No substance abuse -No history of suicide attempts or suicidal ideation -High pre-morbid functioning Current risk is low for intentional self-harm given that the patient denies suicidal ideation, intent and plan, is accepting of treatment, is currently sober and is future oriented with plans to return home with his mother and sister and continue treatment as an outpatient. INFORMED CONSENT I discussed the indications for, intended benefits of, and possible side effects and risks of this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the [REDACTED] right to decide whether to take this medication as well as the importance of the [REDACTED] actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the [REDACTED] questions. The patient appeared able to understand and consented to begin the medication. PROGNOSIS: Fair: [REDACTED] has been diagnosed with a chronic psychotic illness which will likely have an impact on his future relationships, functioning, and employment. However, given his high pre-morbid function and his adherence to medications in the past [REDACTED] has been able to do fairly well and function as a [REDACTED] in some capacity during this time. [REDACTED] has an outpatient treater who [REDACTED] trusts and presents to him when [REDACTED] is experiencing psychotic symptom that require treatment. [REDACTED] does not want to experience his psychotic symptoms and is interested in continuing medication. Overall, [REDACTED] can potentially do quite well given the support [REDACTED] has from his family, excellent pre-morbid function, and interest in continuing care if [REDACTED] is able to stabilize on his risperidone.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> rituximab <ATTENDING> ___. <CHIEF COMPLAINT> rituxan desensitization <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old woman with marginal zone lymphoma and Waldenstrom's Macroglobulinemia who presents for Rituxan desensitization. During her first infusion, she developed erythema and hives on her back and around her ears, conjunctival injection, nasal congestion, throat swelling (subjective). She had a rise in her systolic blood pressure and her lungs remained clear without changes in her voice. She received steroids (Hydrocortisone 100mg, dexamethasone 20mg) , benadryl 50mg IV, and pepcid 20mg IV. She felt better approximately 60 minutes later. Her second infusion on ___ which was done according to desensitization protocol was fine without complications. She is feeling well without any concerning symptoms today. She has had no fevers, chills, night sweats, abdominal pain, nausea, vomiting, paresthesias or headache. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. <PAST MEDICAL HISTORY> PAST ONCOLOGIC HISTORY (per OMR): -- With a history of breast cancer, she was found to have on routine mammogram in ___ multiple abnormal-appearing lymph nodes in the left inframammary and bilateral axillary chains. -- On ___, a fine needle aspirations of nodes in both the R and L axilla were performed. Immunophenotypic findings were consistent with a kappa-restricted B-cell lymphoproliferative disorder that was negative for CD5 and CD10, suggesting a possible marginal zone or lymphoplasmacytic lymphoma. -- On ___, CT of the torso and neck were performed. Neck CT reported numerous bilateral cervical lymph nodes with abnormal morphology at all levels measuring up to 8 mm in short axis. Torso CT found lymphadenopathy involving L axillary, mediastinal, L hilar, retrocrural, retroperitoneal, pelvic and inguinal chains. In the chest, the largest focus was an infracarinal lymph node measuring 3.2 x 1.3 cm. In the abdomen, the largest focus was a conglomerate of lymph nodes at the level of the left renal hilum measuring 2.5 x 2.9 cm. In the pelvis, the largest foci were a lymph node on the right measuring 1.8 x 1.6 cm and a lymph node on the left measuring 2.0 x 1.7 cm. -- On ___, excisional lymph node biopsy procedure in the left axilla yielded 2 firm and large rubbery LNs ~1.2 cm in size. Histologic sections revealed an enlarged lymph node that was entirely effaced by an atypical nodular lymphoid population. Cellularity was composed of small mature appearing lymphocytes, lymphoplasmacytoid cells, and many conspicuous plasma cells. ___ bodies were seen. By immunohistochemistry, B cells were highlighted by CD20 and BCL2 and were the predominant component of lymphoid population. They were negative for CD5 and CD10. PAX5 was positive in a large subset of B cells, and appeared to be lost in plasma cells, while MUM1 had a reciprocal staining pattern. CD3 and CD45 were immunoreactive in a small subset of T cells. CD23 highlighted several residual follicular dendritic cell meshworks, and BCL6 and CD10 highlighted occasional germinal centers, which appeared reactive and were appropriately negative for BCL2. The MIB1 defined proliferation index was low overall, ___. -- On ___, SPEP documented a monoclonal IgM-kappa representing 19% (1630 mg/dL) of total protein. Serum viscosity was 2.3. UPEP was negative for protein including BJP. Serum FLC assay showed normal free kappa and free lambda levels, with a slightly increased ratio of 1.78. -- On ___, diagnostic lymph node biopsy in the left axilla confirmed the diagnosis of a low-grade, indolent lymphoma, characterized by our pathologists as nodal marginal zone lymphoma, not lymphoplasmacytic lymphoma as might be seen with IgM-kappa in the range associated with smoldering ___. -- ___, bone marrow biopsy and blood tests revealed worsening IgM levels and increasing serum viscosity. She started plasmapharesis on ___ and then started rituximab on ___ but she developed an allergic reaction and thus was seen by allergy to undergo recommended desensitization protocol. -- ___: Rituxan infused per desensitization protocol without incident PAST MEDICAL HISTORY: -- s/p R poorly differentiated, ER-negative, 0.3 X 0.5 cm infiltrating ductal carcinoma in ___, treated with R lumpectomy, R axillary node dissection followed by XRT. -- HTN. -- Macular scarring. -- Psoriasis. -- Hx of Lyme disease ___ years ago, tx with 1 month course of doxycycline. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Both parents had rheumatoid arthritis. Father died of metastatic melanoma at age ___ yrs, hx of lymphoma; mother with hx of retroperitoneal fibrosis, lymphoma s/p chemotherapy, which included rituximab. 4 sisters/1 brother alive & well. <PHYSICAL EXAM> VS: T98 BP 133/66 HR 76 RR 18 98% RA GENERAL: alert and oriented, NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B, good air movement bilaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved sensation throughout. ___ strength throughout. ___ reflexes, equal ___. Gait assessment deferred <PERTINENT RESULTS> LABS: ___ IgM 3963 ___ serum viscosity 3.6 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. ClonazePAM 0.5 mg PO BID: PRN anxiety 3. Gabapentin 600 mg PO TID <DISCHARGE MEDICATIONS> 1. Allopurinol ___ mg PO DAILY 2. ClonazePAM 0.5 mg PO BID: PRN anxiety 3. Gabapentin 600 mg PO TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 1. Rituxan allergy 2. ___'s Macroglobulinemia 3. Hyperviscosity 4. Marginal Zone Lymphoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital to receive Rituxan with careful monitoring under a desensitization protocol. You tolerated this well without side effects or reactions.
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Ms. [REDACTED] is a [REDACTED] year old woman with marginal zone lymphoma and Waldenstrom's Macroglobulinemia who was admitted for Rituxan desensensitization. Her serum viscosity yesterday was 3.6 with an IgM of 3963. She did not need pheresis this morning. She received Zyrtec the morning of admission as well as benadryl 50 mg IV x 1, acetaminophen 650 mg x 1, famotidine 20 mg IV x 1 and dexamethasone 10 mg IV x 1. Following this received Rituximab 6 mg, 60 mg, 600 mg as per the desensitization protocol. She was monitored closely and did not experience any reactions. She was discharged following the transfusion with plans to return in 1 week for repeat rituxan administration. She will have viscosity labs checked again prior to admission.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> open reduction internal fixation left hip fracture <HISTORY OF PRESENT ILLNESS> Ms. ___ is a very pleasant ___ yr old female who most recently underwent a successful kyphoplasty here at ___ with a post-op course complicated by asymptomatic a-fib, converting with amiodarone, who was at her assisted living facility mobilizing with her walker when she tripped an fell, landing on her left side. She immediately had significant left hip and arm pain. She was then brought to ___ ED where she was evaluated and found to have a 7th rib fracture and left intertrochanteric hip fracture. The pt denies any antecedent dizziness, palpitations, chest pain, sob or any other concerning symptoms. She states that she has been doing very well since being discharged on ___ until today. Currently she complains of left hip and upper arm pain. No numbness or tingling. <PAST MEDICAL HISTORY> Breast cancer status post incisional biopsy, XRT & chemo (___) Osteoporosis treated for ___ years on Fosamax Spastic colon Gastroesophageal reflux Thyroidectomy for cancer (___) Cholecystectomy (___) Appendectomy (___) Cataract surgery (___) Anemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. <PHYSICAL EXAM> Physical Exam on Admission: AFVSS 100% RA A&O x 3 , NAD Cor: RRR Pulm: CTAB CN II-XII grossly intact PERRL Head is AT/NC MSK: Cervical Spine: non-tender, no stepoff Thoracic and Lumbar Spine: non-tender, no stepoff <PERTINENT RESULTS> CT Chest/Abd: 1. Multiple fractures including left posterior rib cage (___), left inferior scapular fracture, left femoral neck fracture. 2. L5 bilateral pars defect with grade I anterolisthesis, old fractures in T-spine and right scapula. 3. Small left pleural effusion with mild left base atelectasis. 4. Incidental findings in the chest, abdomen, pelvis as detailed above. 5. No pneumothorax BILAT HIPS (AP,LAT & AP PELVIS IMPRESSION: Left intertrochanteric femoral neck fracture. ___ 05: 55AM BLOOD WBC-12.4* RBC-3.69* Hgb-10.7*# Hct-31.1* MCV-84 MCH-29.1 MCHC-34.5 RDW-15.5 Plt ___ ___ 09: 11AM BLOOD Hct-26.6* <MEDICATIONS ON ADMISSION> 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. letrozole 2.5 mg Tablet Sig: One (1) Tablet PO once daiily () as needed for cancer therapy. 3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg Subcutaneous once a day. 4. sulfacetamide sodium 10 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. sulfacetamide-prednisolone ___ % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Amiodarone 400 Daily <DISCHARGE MEDICATIONS> 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. letrozole 2.5 mg Tablet Sig: One (1) Tablet PO once daiily () as needed for cancer therapy. 3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg Subcutaneous once a day. 4. sulfacetamide sodium 10 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. sulfacetamide-prednisolone ___ % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): 12.5 mg BID. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> left hip fracture, rib frxs (___), and left scapula fracture <DISCHARGE CONDITION> Stable and Oriented. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Wound Care: - Keep Incision clean and dry. - Do not soak the incision in a bath or pool. Activity: - Continue to be weight bearing as tolerated on your left arm and left leg. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - You have also been given Additional Medications to control your pain. Please allow 72 hours ___ through ___, 9am to 4pm) for refill of narcotic prescriptions, so plan ahead. There will be no prescription refils on ___, or holidays. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. Physical Therapy: Patient is WBAT on left leg and WBAT on left arm. Sling to left arm for comfort. Treatments Frequency: Staples to be removed Post-operative day #14. Date of operation is ___.
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Ms [REDACTED] was evaluated in the emergency room by the orthopaedic trauma service and found to have a left hip fracture, rib fractures, and a left scapula fracture. He was admitted to Ortho and prepped for surgery on her left hip. On HD 2, she was taken to the OR. See operative report for full details. She tolerated the procedure well without complication. After a brief stay in PACU, she was transferred to the floor. She was transfused one unit of blood post-operatively. She arrived to the floor on a regular diet and with PO meds for pain. He was started on lovenox 40 mg daily for DVT prophylaxis. She was seen by cardiology who recommended discontinuing her amiodarone and continuing her on aspirin 81 mg. At the time of discharge, she was afebrile with stable vital signs, tolerating a regular diet, voiding spontaneously, and with herpain well controled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right breast DCIS <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right total mastectomy and sentinel lymph node biopsy: ___ <HISTORY OF PRESENT ILLNESS> ___ is a ___ woman with a history of right breast DCIS (reported grade II with necrosis, ER negative) treated with a lumpectomy, SLNB, and radiation in ___. Required re-excision of margins. Her care was at an outside institution. She had recent imaging revealing suspicious calcifications with 2 cm of the lumpectomy site. Biopsy confirmed DCIS. <PAST MEDICAL HISTORY> PMH: HYPERCHOLESTEROLEMIA DCIS HYPERPARATHYROIDISM POST-MENOPAUSAL BLEEDING PSH: BREAST BIOPSY PARATHYROIDECTOMY OVARIAN CYSTECTOMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother-OSTEOARTHRITIS ___, DIABETES MELLITUS, ALZHEIMER'S DISEASE Son-HYPERTENSION No family history of cancer. <PHYSICAL EXAM> PHYSICAL EXAM GENERAL: comfortable, NAD HEENT: no icterus, no neck mass, no bruit HEART: RRR LUNGS: CTA ABDOMEN: soft, ND, MT MSK: no spine tenderness SKIN: no jaundice EXTREMITIES: no upper ext swelling. normal ROM LYMPHATICS: no adenopathy BREAST: incision c/d/I, R JP with serosanguinous drainage <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Tamoxifen Citrate 20 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Multivitamins 1 TAB PO DAILY 6. Calcium Carbonate 1500 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H Do not exceed 4000 mg daily. 2. amLODIPine 5 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcium Carbonate 1500 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 1000 UNIT PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Ductal carcinoma in situ <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the ___ for breast surgery. You have recovered well and are now ready for discharge. Personal Care: 1. You may remove your surgical dressing after 48 hours and leave your incision open to air. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) ___ times per day. 4. A written record of the daily output from your drain should be brought to every follow-up appointment. Your drain will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may shower daily. No baths until instructed to do so by Dr. ___. 6. You may wear a soft, non-restrictive camisole but no tight or underwire bras. Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. ___. Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by tylenol. 4.Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 F 4. Severe pain NOT relieved by your medication. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Thank you for allowing us to participate in your care. Sincerely, Your ___ Surgery team
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Ms. [REDACTED] presented as a same day admission for surgery on [REDACTED]. She was taken to the operating room where she underwent right total mastectomy and sentinel lymph node biopsy. For full details of the procedure, please see the separately dictated operative report. She tolerated the procedure well, and was returned to the PACU in stable condition. After satisfactory recovery from anesthesia, she was transferred to the surgical floor for further monitoring. Her diet was advanced immediately post-operatively which she tolerated well and IV fluids were stopped with adequate oral intake. Pain was well-controlled with oral pain medication She had no difficulty voiding post-operatively and was able to ambulate independently. She received drain education on POD1 and was discharged home thereafter. She declined a narcotic prescription at the time of discharge. She was discharged with instructions to follow-up with Dr. [REDACTED] in clinic on [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> jaw pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ORIF and CRMMF of mandibular symphisis and right subcondylar fractures <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ male prisoner who presents as a transfer from ___ for an open mandibular fracture after sustaining an assault this morning by another prisoner. Per the patient he was waiting in line for breakfast when another prisoner came up and "sucker punched" him in the right jaw, causing him to fall and hit his head. He reports being punched three times to the jaw. He was brought to ___, where a CT mandible demonstrated a right subcondylar and mandibular symphysis fracture. He was transferred to ___ for ___ evaluation. His only complaint is of right jaw pain and malocclusion, but denies any headache, paresthesias, visual disturbances, motor or sensory deficits. <PAST MEDICAL HISTORY> Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies <PHYSICAL EXAM> Vitals: 24 HR Data (last updated ___ @ 2342) Temp: 97.2 (Tm 97.9), BP: 133/65 (133-134/65-86), HR: 105 (97-105), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra Fluid Balance (last updated ___ @ 2218) General: NAD, A&Ox3, well developed & nourished patient Respiratory Effort: unlabored without accessory muscle use Eyes: Extraocular movements intact, pupils equally round and reactive to light CN: V1-V3 intact except for V3 paresthesia consistent with procedure EOE: No gross lesions. Sinuses not tender to palpation. No asymmetry Nose: Straight nasal septum, no nasal discharge, tender to palpation Oral Cavity: Maxillary IMF screws x3, mandibular arch bar. Wire loops x2 (one right side, one left side) maintaining MMF. Md arch bar separating slightly on posterior aspect and may require shortening. Anterior vestibular incision approximated with Vicryl sutures, which are c/d/i. TMJ: MMF with maxillary IMF screws and mandibular arch bar Neck: No masses, adenopathy or tenderness. Trachea midline, neck supple with normal ROM. <PERTINENT RESULTS> CT C-Spine ___ FINDINGS: No evidence of traumatic malalignment or acute fracture of the cervical spine. No prevertebral edema. No neural foraminal or spinal canal stenosis. There is a minimally displaced fracture through the ramus of the right mandible. Partially imaged lung apices are clear. Streak artifact courses through the thyroid gland and assessment is suboptimal. Mild opacification of the right sphenoid sinus, possibly mucosal thickening. Panorex ___ FINDINGS: There is a nondisplaced fracture of the mandibular body in the midline, which crosses the cortex to the left of midline, but crosses to the right of midline to extent to the base of the right central incisor. Nondisplaced fracture of the ramus of the right mandible better seen on CT. Left third mandibular molar may be partially impacted. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen (Liquid) 650 mg PO Q6H: PRN Pain - Mild/Fever RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every 6 hours as needed Disp #*1 Bottle Refills: *0 2. cephALEXin 500 mg oral TID Duration: 7 Days RX *cephalexin 250 mg/5 mL 500 mg by mouth three times daily Refills: *0 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID Duration: 2 Weeks RX *chlorhexidine gluconate [Peridex] 0.12 % 15 ml mouth rinse twice daily Refills: *0 4. OxycoDONE Liquid ___ mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg/5 mL 5 mg by mouth every ___ hours Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> mandibular symphisis and right subcondylar fractures now s/p ORIF and CRMMF <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Mr. ___, You were admitted to the hospital after an injury to your jaw. The Oral and Maxillofacial Surgery (___) team performed fixation of your jaw fractures. You are now ready to be discharged. Please note you will need to eat a full liquid diet until instructed otherwise by the ___ surgeons. You will also need to take antibiotics (Keflex) three times a day for 7 days and use Peridex mouth rinse twice a day for 2 weeks.
Output:
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Mr. [REDACTED] was found to have mandibular symphysis and right subcondylar fractures, open to the mouth. He was evaluated by [REDACTED], who recommended Ancef Q8H and peridex mouth rinse BID. He was admitted to the Acute Care Surgery service. [REDACTED] then took him to the operating room on [REDACTED] for ORIF and CRMMF of the mandibular symphisis and right subcondylar fractures. Postoperatively he was continued on ancef and peridex mouth wash and started on a full liquid diet. He will be discharged on 7 days of Keflex oral solution 500mg TID and 24 days of Peridex mouth rinse 15mL BID and has scheduled follow up with the [REDACTED] team. After discharge he will need to continue a full liquid diet until instructed otherwise by the [REDACTED] team.
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