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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.
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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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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Right hip OA <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: R THR <HISTORY OF PRESENT ILLNESS> ___ year old male with right hip osteoarthritis now s/p R THR via direct anterior approach. <PAST MEDICAL HISTORY> PMH: OA, Sinus surgery Meds: Tylenol All: NKDA Shx: ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm <PERTINENT RESULTS> ___ 07: 30AM BLOOD WBC-10.5* RBC-2.95* Hgb-9.3* Hct-28.1* MCV-95 MCH-31.5 MCHC-33.1 RDW-13.7 RDWSD-47.9* Plt ___ ___ 07: 55AM BLOOD WBC-8.8 RBC-2.94*# Hgb-9.3*# Hct-27.6*# MCV-94 MCH-31.6 MCHC-33.7 RDW-14.1 RDWSD-47.5* Plt ___ ___ 07: 55AM BLOOD Glucose-128* UreaN-6 Creat-0.8 Na-139 K-4.3 Cl-101 HCO3-28 AnGap-10 ___ 07: 30AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.1 ___ 07: 55AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.6 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H: PRN Pain - Mild <DISCHARGE MEDICATIONS> 1. Aspirin 325 mg PO BID 2. Docusate Sodium 100 mg PO BID stop taking if having loose stools 3. Gabapentin 300 mg PO TID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do NOT drink alcohol or drive while taking med 5. Pantoprazole 40 mg PO Q24H take daily while on aspirin 6. Senna 8.6 mg PO BID stop taking if having loose stools 7. Acetaminophen 1000 mg PO Q8H <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Right hip osteoarthritis <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> 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches. Wean assistive device as able. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. NO HIP BRIDGING, NO REPETITIVE RESISTANT HIP FLEXION Physical Therapy: Weight bearing as tolerated, no bridging or repetitive hip flexion Treatments Frequency: Remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed
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The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #1, patient had electrolytes repleted for Mg 1.6, Ca 7.9 and Phos 2.2. POD #2, Mg was 2.1, Ca 7.9 and Phos 2.5. Ca and phos were repleted with PO supplementation. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Walker or two crutches, wean as able. NO HIP BRIDGING, NO REPETITIVE RESISTANT HIP FLEXION. Mr. [REDACTED] is discharged to home with services in stable condition.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> UROLOGY <ALLERGIES> Coumadin / adhesive tape <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p Cystoprostatectomy with IC and right NU in ___ ___ pT2a UCC involving right ureter and ___ 4+3 Pt3b prostate cancer. Prior admission for SBO resolved with non-surgical therapy. Now presents with likely partial SBO. <PAST MEDICAL HISTORY> Benign lesion removed from his right breast ___ s/p 3 knee surgeries, LTR ___ Normal stress test in ___ Hyperlipidemia Pre-malignant skin lesions Tendonitis HTN <SOCIAL HISTORY> ___ <FAMILY HISTORY> He has a strong family history of coronary artery disease. Father died of MI at age ___. <PHYSICAL EXAM> Physical Exam General: Alert, oriented, no acute distress Card/pulm: no cardiopulmonary distress, no audible wheezing. Abdomen: Soft, NT, ND Extremities: WWP <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ketoconazole 2% 1 Appl TP QHS 2. Metoprolol Succinate XL 25 mg PO DAILY 3. amLODIPine 2.5 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Aspirin 325 mg PO DAILY 6. Ascorbic Acid Dose is Unknown PO Frequency is Unknown <DISCHARGE MEDICATIONS> 1. Ascorbic Acid ___ mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Ketoconazole 2% 1 Appl TP QHS 6. Metoprolol Succinate XL 25 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Partial small bowel obstruction (resolved) <DISCHARGE CONDITION> Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Patient may resume all prior activities to admission.
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Patient was admitted for concern for partial small bowel obstrcuction. He was kept NPO and an NGT was placed. The NGT became dislodged on his first night in the hospital but his symptoms of nausea and abdominal pain had already resolved and he was pasing flatus so it was left out. ON hospital day one he was pasing flatus and his diet was advanced to clear which he tolerated. Ct noted a slight tightness of the fascia at the level of stoma with fullness of the loop so a foley catheter was placed into the stoma for decompression. This subsequently fell out and was left out. on hospital day 2 the patient tolerated regular diet and had formed bowel movements. He was ambulating at baseline and making good urine. at that time it was felt safe for him to discharge home with instructions to follow up in Dr. [REDACTED] this week for a discussion regarding his tight stomal fascia with concern for loop dilation.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Iodine; Iodine Containing / Latex / Shellfish Derived <ATTENDING> ___. <CHIEF COMPLAINT> morbid obesity <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic gastric band <HISTORY OF PRESENT ILLNESS> ___ has class II severe obesity with weight of 254.1 lbs as of ___ (her initial screen weight on ___ was 250.8 lbs), height of 68 inches and BMI of 38.7. Her previous weight loss efforts have included low fat and low carb diet for one year in ___ losing 25 lbs and for ___ years in ___ losing 50 lbs, 6 months of acupuncture in ___ with minimal results, 6 months of hypnosis in ___ with no results. <PAST MEDICAL HISTORY> GERD, peptic ulcer disease with recurrent duodenal ulcer (___), asthma on inhalers with no recent exacerbations, intubation or use of steroid tapers, insulin resistance (polycystic ovary syndrome), thyroid disorder (___'s), urinary stress incontinence with urinary tract infections, weight related back and knee pain, pelvic inflammatory disease, allergic rhinitis and sinusitis <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother deceased age ___ of cancer with h/o asthma, arthritis and obesity; sister living age ___ with thyroid disease and obesity; grandmother deceased with diabetes and obesity; grandfather deceased with diabetes <PHYSICAL EXAM> blood pressure was 118/76, pulse 71, respirations 16 and O2 saturation 97% on room air. On physical examination ___ was casually dressed and in no distress. Her skin was warm, dry, no rashes or lesions. Anicteric sclerae, clear conjunctiva, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue pink and the oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple without adenopathy, thyromegaly or carotid bruits. Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen was obese but soft and non-tender, non-distended with normal bowel sounds, no masses or hernias there was well-healed lower incision scar. There was no spinal tenderness or flank pain. Lower extremities were without edema, venous stasis, clubbing and perfusion was good. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and her gait was normal. <MEDICATIONS ON ADMISSION> Metformin 850 mg twice daily for insulin resistance; Albuterol 2 puffs 4 times daily as needed, Atrovent 2 puffs 4 times daily as needed, Flovent 2 puffs twice daily and Singulair 10 mg daily for asthma; Protonix 20 mg daily for reflux; Loratadine 10 mg daily for allergic rhinitis; Sertraline 300 mg daily for depression; Naproxen 500 mg twice daily as needed and Tylenol as needed for back and knee pain; multivitamins with minerals daily, Vitamin D, calcium for nutritional supplementation. She has ALLERGIES TO IODINE <DISCHARGE MEDICATIONS> 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. 2. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation once a day. 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. Roxicet ___ mg/5 mL Solution Sig: ___ ml PO every four (4) hours as needed for pain. Disp: *500 ml* Refills: *0* 7. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp: *250 ml* Refills: *2* 8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO twice a week: empty capsule in water and mix. 9. Metformin 500 mg/5 mL Solution Sig: Eight (8) ml PO twice a day. Disp: *250 ml* Refills: *2* 10. Sertraline 20 mg/mL Concentrate Sig: Fifteen (15) ml PO once a day. Disp: *250 ml* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Morbid obesity History of: Gastroesophageal reflux, peptic ulcer in ___, asthma, polycystic ovary disease, Hashimoto's disease, urinary stress incontinence, back pain, knee pain, stress fractures in the feet secondary to weight <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> <DISCHARGE INSTRUCTIONS> Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 4. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites.
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Ms. [REDACTED] was admitted to the hospital and underwent a laparoscopic gastric band. She tolerated the procedure well without complication. After a brief stay in the PACU, she was transfered to the floor. She arrived to the floor on a stage 1 bariatric diet and roxicet for pain. Over the next [REDACTED] hours, she was advanced to a stage 3 diet which was tolerated well. She ambulated on the evening of POD 0. Good pulmonary toilet and incentive spirometry were encouraged throughout her stay. At the time of discharge on POD 1, she was afebrile with stable vital signs, tolerating a stage 3 diet, ambulating without assistance and with her pain well controled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PLASTIC <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right lower extremity wound defect <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Repair, right tibia nonunion with IM nailing and iliac crest bone grafting. 2. Free flap from left thigh to right pretibial wound. <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ gentleman who sustained an open distal tibia fracture that was initially treated with beading, antibiotic beads and a frame. Ortho removed his Ilizarov frame a month ago. The pin sites are now nice and clean and healed. He has a persistent nonunion that has been long-lasting for about over a year and now presents for bone grafting and conversion to intramedullary nailing and placement of a free flap to improve the soft tissue viability at the fracture site. <PAST MEDICAL HISTORY> right distal tibial fx, concussion as teenager . PAST SURGICAL HISTORY: right ankle, right tibia, right knee manipulation and removal of external frame <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Exam on Discharge: Vitals all wnl General: A&Ox3, NAD Cardiac: Extremities well perfused Pulm: Breathing comfortably on room air, no increased WOB . LLE: Donor site with staples in place, area of necrosis and bruising in the middle third of incision site, stable for last 5 days . RLE: Orthopedic incisions c/d/I s/p suture/staple removal R leg flap: warm, soft, well perfused with dopplerable pulse elevated at all times Area of epidermolysis at distal end of flap appears stable x 5 days <PERTINENT RESULTS> ADMISSION LABS: ___ 09: 03AM TYPE-ART PO2-187* PCO2-45 PH-7.34* TOTAL CO2-25 BASE XS--1 ___ 09: 03AM GLUCOSE-112* LACTATE-1.6 NA+-137 K+-4.1 CL--104 ___ 09: 03AM HGB-13.2* calcHCT-40 ___ 09: 03AM freeCa-1.17 ___ 08: 55AM WBC-8.1 RBC-4.26* HGB-12.7* HCT-37.7* MCV-89 MCH-29.8 MCHC-33.7 RDW-13.4 RDWSD-43.4 ___ 08: 55AM ___ PTT-32.3 ___ ___ 08: 55AM PLT COUNT-255 . MICROBIOLOGY: ___ 8: 30 am TISSUE # A NON ___ SITE. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. . Time Taken Not Noted Log-In Date/Time: ___ 2: 08 pm TISSUE #B NON ___ RIGHT CONTENTS. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. . RADIOLOGY: Radiology Report BILAT LOWER EXT VEINS Study Date of ___ 10: 40 AM IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited views of the right calf veins. . Radiology Report ANKLE (AP, MORTISE & LAT) RIGHT Study Date of ___ 10: 46 AM IMPRESSION: Compared with ___, bone and hardware alignment is unchanged. The degree of soft tissue swelling subcutaneous emphysema along the anterior calf has improved. <MEDICATIONS ON ADMISSION> PARoxetine 40 mg PO DAILY RisperiDONE 2 mg PO DAILY TraZODone 50 mg PO QHS oxycodone 15mg PO Q8H PRN <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN pain, HA, T>100 degrees 2. Aspirin 121.5 mg PO DAILY RX *aspirin 81 mg 1.5 tablet(s) by mouth once a day Disp #*45 Tablet Refills: *0 3. cefaDROXil 500 mg oral BID RX *cefadroxil 500 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*28 Capsule Refills: *0 4. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 6. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 injection SC once a day Disp #*14 Syringe Refills: *0 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills: *0 9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 14 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*28 Tablet Refills: *0 10. PARoxetine 40 mg PO DAILY 11. RisperiDONE 2 mg PO DAILY 12. TraZODone 50 mg PO QHS <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Right pre-tibial wound <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> -You should keep your right lower extremity elevated when you are not standing to urinate and/or not standing and pivoting to chair and not walking around with crutches, to help with swelling and drainage. The free flap that was placed over your right leg wound should not be down for more than 15 minutes at a time. -You may bear partial weight on your right lower extremity (50% wt bear) -Report any change in color of your flap area including increased redness and/or any dusky or darkened appearance to the office. -Your left thigh incision can be left open to air. -You may shower but no tub baths until directed by your doctor. . Diet/Activity: 1. You may resume your regular diet and continue your protein shakes 3x/day. 2. Avoid heavy lifting and do not engage in strenuous activity until instructed by your doctor. . Medications: 1. 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. 2. Take prescription pain medications for pain not relieved by tylenol. 3. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. . 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). 3. Fever greater than 101.5 oF 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.
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The patient was admitted to the plastic surgery service on [REDACTED] and underwent: 1. Repair, right tibia nonunion with IM nailing and iliac crest bone grafting (ORTHOPEDICS) 2. Free flap from left thigh to right pretibial wound (PLASTIC AND RECONSTRUCTIVE SURGERY. The patient tolerated the procedures well. . Neuro: Post-operatively, the patient received Morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#2. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO Bactrim and keflex for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, Plavix and ASA. . RLE Flap Progression: POD2: OOB to chair,dangles 5 minutes tid, donor dressing down POD3: Dangles 10 minutes tid POD4: Dangles 15 minutes tid Of note, throughout progression of dangles, vioptix dropped approximately 20 points and slowly increased to slightly below baseline over the course of 45 minutes. At this point dangles were held for the remainder of his inpatient stay. When flap site dressing was taken down on POD4, there was concern for color change and epidermolysis/poor vascular flow in the distal [REDACTED] of the graft. For this reason, patient remained in house with continued Vioptix, pulse checks, and strict elevation of RLE for prolonged stay. Over the course of the following week, flap changes stabilized revealing only partial thickness epidermolysis of flap. No need for return to OR. . After physical therapy evaluation it was agreed that he should be discharged to home. From the orthopedic standpoint, patient may be 50% partial weightbearing. From a PRS standpoint, patient allowed to have RLE dependent and partial weightbear for purposes of ADLs only and for no more than 15 minutes at a time then patient must re-elevate RLE. . At the time of discharge on POD#18, the patient was doing well, all drains had been removed, patient remained afebrile with stable vital signs, tolerating a regular diet, voiding without assistance, and pain was well controlled. He will follow-up with orthopaedics and Dr. [REDACTED] with plastic surgery as scheduled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> R ankle fracture <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. ORIF right trimalleolar ankle fracture without fixation of posterior malleolus. 2. Repair distal tib/fib joint disruption. <HISTORY OF PRESENT ILLNESS> ___ female who presents as transfer from ___ with a right ankle fracture dislocation s/p mechanical fall down one steps. She noted immediate pain and deformity. She denied open wounds. She was brought to ___ where reduction was attempted but failed. She was splinted and transferred here for definitive management. She currently endorses pain but denies any numbness/tingling/weakness. <PAST MEDICAL HISTORY> n/c unknown <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> Vitals: ___ ___ Temp: 98.3 PO BP: 121/63 L Lying HR: 89 RR: 18 O2 sat: 94% O2 delivery: Ra General: Well-appearing, breathing comfortably MSK: Right lower extremity: - Splint in place - Soft, non-tender thigh and leg - wiggles toes, sensation intact overlying toes - 2+ ___ pulses, WWP <PERTINENT RESULTS> Please see OMR for all lab and imaging results. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Divalproex (EXTended Release) 500 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. LamoTRIgine 100 mg PO BID 4. LORazepam 0.5 mg PO BID anxiety 5. Pravastatin 80 mg PO QPM 6. Propranolol LA 60 mg PO DAILY 7. Venlafaxine XR 150 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 5. Nicotine Patch 14 mg TD DAILY 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H: PRN Pain Please decrease in dosage and frequency as pain decreases. RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills: *0 7. Senna 8.6 mg PO BID 8. Divalproex (EXTended Release) 500 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. LamoTRIgine 100 mg PO BID 11. LORazepam 0.5 mg PO BID anxiety 12. Pravastatin 80 mg PO QPM 13. Propranolol LA 60 mg PO DAILY 14. Venlafaxine XR 150 mg PO DAILY <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Right trimalleolar ankle fracture. <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> 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: -NWB RLE MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox 40 mg 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. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: ___ LLE Treatment Plan: Progress functional mobility including bed mobility, transfers, gait and stairs as tolerated. Balance training Pt/caregiver education RE: fall risk Frequency/Duration: ___ for 2 week Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided.
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The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a R trimalleolar fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [REDACTED] for 1. ORIF right trimalleolar ankle fracture without fixation of posterior malleolus. 2. Repair distal tib/fib joint disruption., 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 rehab 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 NWB in the RLE extremity, and will be discharged on lovenox 40 mg qd for DVT prophylaxis. The patient will follow up with Dr. [REDACTED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet <ATTENDING> ___ <CHIEF COMPLAINT> elevated BPs, photophobia, headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P1 with h/o Chiari malformation s/p SVD c/b gHTN (___), who developed severe preeclampsia by BPs and HA postpartum s/p 24hrs of mag (___), now with second readmission for severe BPs, HA, and photophobia. Patient reports since discharged on ___ she has taken her BP q8 at home. At 1800 last night had BPs 170s/70s and developed "blurry vision and seeing water droplets in left eye," as well as ___ posterior HA at this time. Presented to ___ and had severe BPs to 190s/95. CT head performed for HA was unremarkable per report. Pt was given IV hydral 10mg and BPs resolved to 120s/70s per patient. Photophobia resolved as BPs normalized. Pt was transferred to ___ ___ where she had normal-mild range BPs. On postpartum floor, patient reports posterior HA ___. Photophobia has not recurred. Denies SOB, chest pain, blurry vision or visual changes, dizziness/lightheadedness, palpitations. Last took labetolol 200mg at 1845. <PAST MEDICAL HISTORY> chiari I malformation (incidental finding on MRI for visual changes), h/o anxiety/depression <SOCIAL HISTORY> ___ ___ History: noncontributory <PHYSICAL EXAM> Vitals: ___ ___ Temp: 98.2 PO BP: 130/76 HR: 82 RR: 16 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ Gen: A&O, NAD CV: RRR, normal S1/S2 Resp: CTAB Abd: soft, NT/ND, no rebound or guarding Ext: calves nontender bilaterally, trace edema <PERTINENT RESULTS> ___ 07: 00AM CREAT-0.8 ___ 07: 00AM ALT(SGPT)-27 AST(SGOT)-30 ___ 07: 00AM URIC ACID-5.4 ___ 07: 00AM WBC-10.6* RBC-4.05 HGB-12.4 HCT-38.0 MCV-94 MCH-30.6 MCHC-32.6 RDW-13.2 RDWSD-45.2 ___ 07: 00AM PLT COUNT-432* <MEDICATIONS ON ADMISSION> 1. Amoxicillin 500 mg PO/NG Q12H Duration: 4 Days 2. NIFEdipine (Extended Release) 60 mg PO QPM RX *nifedipine 60 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills: *0 3. NIFEdipine (Extended Release) 30 mg PO QAM high blood pressure RX *nifedipine 30 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills: *0 <DISCHARGE MEDICATIONS> 1. Amoxicillin 500 mg PO/NG Q12H Duration: 4 Days 2. NIFEdipine (Extended Release) 60 mg PO QPM RX *nifedipine 60 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills: *0 3. NIFEdipine (Extended Release) 30 mg PO QAM high blood pressure RX *nifedipine 30 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> postpartum hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please call if BP >160/110 and < 90/60 headache, blurry vision, right upper quadrant pain or epigastric pain
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[REDACTED] BPs at home 180/70, headache/dizzy pt went to [REDACTED], photophobia, CT scan normal given IV 10 mg hydralazine [REDACTED] re-admission*** sent to [REDACTED] [REDACTED] to pp floor BPs 128/69, asympatomatic 130/76 postpartum floor 0600 Nifedipine 30 XL given 1800 Added Nifed 30 XL for 150/90s [REDACTED] increased to Nifed 30 XL AM and 60 XL [REDACTED] [REDACTED] Adequate control of BPs with Nifedipine regimen listed above
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> Penicillins / Sulfa (Sulfonamide Antibiotics) / Benadryl / Vistaril / Cephalosporins / lactose <ATTENDING> ___. <CHIEF COMPLAINT> "Feeling horribly physically and mentally." <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ trasgender man (female to male), with history of unspecified mood disorder, complex PTSD, cluster B traits, h/o polysubstance use, in remisssion and multiple psychiatric hospitalizations, who was admitted to ___ medicine on ___ for atypical pneumonia and has been endorsing suicidal ideation and worsening hallucinations. He was cleared medically after an ___ medical stay and transfered to ___ 4 for inpatient psychiatric care. . Upon presentation to the unit, patient reported that he felt "horribly physically and mentally." He stated that he had been feeling low recently and having worsening flashbacks as this time is around an anniversary of a sexual assault. He reported that he was still feeling suicidal and states "I would end my life, but I'm too scared to do it." He reported that he is not suicidal currently and has no plan. He confirms that he can be safe on the unit. . Mr. ___ stated that he was experiencing visual and auditory hallucinations of chipmumks. These chipmunks told him to kill himself. He reports that the hallucinations have become worse since admission to the hospital and he had seen them on Deac 4. He has been seeing the chipmunks for ___ years, prior to that it was mice around ___ years ago. . When asked about being admitted to an inpatient psychiatry unit, patient responds that he feels safe here. Patient felt they could be most helped by talking to people and rearraging medications. Likewise, he wanted to attain better coping skills and go to the ___ HRI Triangle program after discharge. <PAST MEDICAL HISTORY> PAST PSYCHIATRIC HISTORY - Diagnoses: Complex PTSD due to sexual assault, polysubstance use in remission, unspecified mood disorder, prior suicide attempts - Psychiatrist is Dr. ___ PAST MEDICAL HISTORY - HCV (2 weeks of treatment in ___ - Recurrent aspirations pneumonias (3 hospitalizations at ___ within past year) - Asthma - Hypothyroidism - Chronic low back pain - Sciatica <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___ health, anxiety, heart murmur, asthma MGF: Lung cancer PGM: Unknown cancer Parents with alcohol abuse/dependence <PHYSICAL EXAM> As per Dr. ___ on day of admission: * General: NAD. obese, coughing * HEENT: Normocephalic. PERRL, EOMI. right ear normal, left ear - non erythematous, minimal fluid behind tempanic membrane, +ear wax * Neck: Supple, trachea midline. * Back: No significant deformity. No focal tenderness. * Lungs: Clear to auscultation bilaterally. No crackles or wheezes. * CV: Regular rate and rhythm. No murmurs/rubs/gallops. * Abdomen: Obese, Soft, nontender * Extremities: No clubbing, cyanosis, or edema. * Skin: Warm and dry. No readily apparent rashes, scars, or lesions. Neurological: *Cranial Nerves: II-XII intact *Motor- Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength full power ___ UE, LLE ___ compared to right ___. No gross focal motor or sensory deficits, normal gait. *Coordination: Normal on finger-nose-finger. *Sensation: Intact to light touch, position sense intact. *Gait: Slow, steady. No truncal ataxia. walks w/ cane <PERTINENT RESULTS> ___ 06: 25AM ___ PTT-39.6* ___ ___ 03: 50PM ___ PTT-40.2* ___ ___ 06: 39AM GLUCOSE-122* UREA N-10 CREAT-1.2 SODIUM-140 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-30 ANION GAP-15 ___ 06: 39AM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.1 ___ 06: 39AM WBC-6.4 RBC-5.13 HGB-12.7* HCT-41.1 MCV-80* MCH-24.8* MCHC-30.9* RDW-16.9* RDWSD-49.1* ___ 06: 39AM PLT COUNT-297 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H: PRN wheezing, SOB 2. Benztropine Mesylate 0.5 mg PO QHS 3. Clozapine 150 mg PO QHS 4. Docusate Sodium 100 mg PO BID: PRN constipation 5. Ferrous Sulfate 325 mg PO BID 6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H: PRN SOb 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Prazosin 3 mg PO QHS 11. Sertraline 200 mg PO DAILY 12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 13. Testosterone Cypionate 25 mg IM WEEKLY 14. TraZODone 150 mg PO QHS 15. Warfarin 6 mg PO DAILY16 <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation 2. Ferrous Sulfate 325 mg PO BID 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H: PRN SOb 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Sertraline 150 mg PO DAILY RX *sertraline 100 mg 1.5 tablet(s) by mouth daily Disp #*15 Tablet Refills: *0 8. Testosterone Cypionate 25 mg IM WEEKLY 9. Warfarin 3.5 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 3.5 tablet(s) by mouth daily Disp #*35 Tablet Refills: *0 10. Clozapine 250 mg PO QHS RX *clozapine 100 mg 2.5 tablet(s) by mouth daily at bedtime Disp #*25 Tablet Refills: *0 11. Albuterol 0.083% Neb Soln 1 NEB IH Q2H: PRN wheezing, SOB 12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID <DISCHARGE DISPOSITION> Home with Service <DISCHARGE DIAGNOSIS> Major depressive disorder Complex PTSD Borderline personality disorder <DISCHARGE CONDITION> On day of discharge, Mr. ___ appeared to be at his baseline mental status. He continued to have suicidal ideation, but no plan or intent. His auditory hallucinations persisted, but they did not command him to harm himself or others and were slightly less intense. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -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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GLOBAL ASSESSMENT: Mr. [REDACTED] is a [REDACTED] transgender man (female to male) with a past psychiatric history of complex PTSD, unspecified mood disorder, and borderline personality disorder, who was transferred to DEAC4 from medicine (treated for atypical pneumonia) on [REDACTED] for suicidal ideation and command auditory hallucinations. His medical history is complex, including recurrent pneumonias, obesity, asthma, hypothyroid, low back pain, sleep apnea on CPAP, pericarditis, treated Hep B/C, and previous pulmonary embolism now on Coumadin. He was sent to the ED from his PCP's office for symptoms of atypical pneumonia and admitted to medicine where he was treated with Levofloxacin (total duration of treatment to total 14d). While admitted to medicine, he assessed by the consult psychiatry team for complaints of worsening suicidal ideation and command auditory hallucinations. . On presentation to the unit, Mr. [REDACTED] was severely depressed. He endorsed low mood, psychomotor retardation, anhedonia, and suicidal ideation that was more intense than baseline. He was experiencing command auditory hallucinations from chipmunk voices to harm himself. The team obtained collateral information from Mr. [REDACTED] outpatient psychiatrist, Dr. [REDACTED] stated that Mr. [REDACTED] seemed to be only slightly off his baseline. Given that Mr. [REDACTED] has been on clozapine 150 mg since [REDACTED], and he has accrued side effects (weight gain, drooling) without benefit, it was felt that it would be worthwhile to uptitrate the dose of clozapine during this admission. Our goal was to titrate up to a more therapeutic dose (300-350 mg). However, we only titrated the medication up to 250 mg due to concerns for orthostasis and oversedation in the morning. On one morning, he roused only to noxious stimuli. Thus, all his other sedating medications were stopped (prazosin, trazodone, cogentin) and after this, he roused in the mornings to verbal stimuli. It is our strong recommendation that clozapine be discontinued within 3 months if Mr. [REDACTED] does not experience a significant improvement in target symptoms (hallucinations and suicidality). . On day of discharge, Mr. [REDACTED] was in good spirits. He felt that the increased dose of clozapine had been beneficial for decreasing the intensity of hallucinations. However, they persisted, especially when he was alone. They appeared to go away when he engaged with peers or staff. He said his suicidality had remained constant - "thoughts, no plan." However, he was able to state that he would approach staff in the hospital or group home if the thoughts intensified. SAFETY: Maintained on q15 minute checks which is our lowest level of acuity. In good behavioural control and did not require any chemical or physical restraints. LEGAL: [REDACTED] PSYCHIATRIC: # For mood instability, continue home medications: - Benztropine Mesylate 0.5 mg PO QHS - Clozapine 150 mg PO QHS - Sertraline 200 mg PO DAILY - TraZODone 150 mg PO QHS increased to 200 mg QHS per patient request # For flashbacks, - Prazosin 3 mg PO QHS GENERAL MEDICAL CONDITIONS: # Asthma - controlled on home regimen. Pt continues to cough, no wheezing on physical exam. - Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, SOB - Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB - Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID # Atypical Pneumonia - resolved - Levofloxacin 750 mg PO DAILY Last dose on [REDACTED] to complete 14 days. # Pain - pleurtic pain from cough / pneumonia - Acetaminophen 1000 mg PO Q8H - OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain, weaned off once pneumonia resolved. # Cough - resolved - Guaifenesin-Dextromethorphan [REDACTED] mL PO Q6H:PRN cough, stopped once pneumonia resolved - Benzonatate 100 mg PO TID cough, stopped once pneumonia resolved. #Constipation - Docusate Sodium 100 mg PO BID PRN - Polyethylene Glycol 17 g PO DAILY PRN constipation - Senna 8.6 mg PO BID:PRN constipation #HTN - Controlled on home regimen. - Furosemide 20 mg PO BID - Metoprolol Succinate XL 50 mg PO DAILY #Hypothyroid - TSH 1.5 on [REDACTED] - Levothyroxine Sodium 75 mcg PO DAILY #GERD - Pantoprazole 40 mg PO Q24H #Rash - Miconazole Powder 2% 1 Appl TP BID:PRN rash #Iron deficiency - MCV 80 on [REDACTED] - Ferrous Sulfate 325 mg PO DAILY #Transgender F-->M - Testosterone Cypionate 25 mg IM WEEKLY, given on [REDACTED] and [REDACTED]. Next due [REDACTED]. #History of PE - in [REDACTED] - Warfarin to target INR of [REDACTED]. Plan is for 6 months of anticoagulation. - Daily INR while in hospital. Discharged on Warfarin 3.5 mg daily. PSYCHOSOCIAL: #) GROUPS/MILIEU: He participated in a number of groups and did well. He was frequently observed in the milieu and ate all meals in the day room. He interacted appropriately with other patients, enjoying talking and joking with them and playing card games. #) COLLATERAL CONTACTS: The team obtained collateral from Mr. [REDACTED] PCP and psychiatrist. #) FAMILY INVOLVEMENT: Mr. [REDACTED] declined our offer to contact his family. #) INTERVENTIONS: Medications Psychotherapeutic interventions: individual, group, and milieu therapy Coordination of aftercare Behavioral interventions INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of increasing CLOZAPINE, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT: #) Chronic/Static Risk Factors: multiple psychiatric hospitalizations, many medical problems, transgender status, previous suicide attempts, long history of suicidal idation, history of self-injurious behaviours such as cutting #) Modifiable Risk Factors: command auditory hallucinations, few social relationships outside of providers, stressor of moving into a group home #) Protective Factors: help seeking, motivated to engage in treatment, ongoing relationship with outpatient psychiatrist, robust outpatient team including crisis worker, stable housing, substance use disorder is in remission PROGNOSIS: Guarded - Mr. [REDACTED] has a number of risk factors that place him at chronically high risk of harm to himself. These include his somewhat refractory mental illness, trauma history, and complicated medical and psychiatric history that have resulted in many hospitalizations. Fortunately, he is supported by a supportive outpatient team and numerous providers who he has an ongoing relationship with. His overall prognosis will be most improved if he continues to receive this high quality outpatient care.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> CARDIOTHORACIC <ALLERGIES> Tetanus / albuterol <ATTENDING> ___ <CHIEF COMPLAINT> failure to thrive <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old woman s/p CABGx3 on ___ who had an uneventful post-operative course and was discharged to home on ___. Since then she has been nauseated and weak. She saw her PCP today and was found to have a systolic blood pressure of 90mmHg and was therefore referred to our emergency department. <PAST MEDICAL HISTORY> Coronary Artery Disease PMH: Iatrogenic adrenal insufficiency, Varicose veins, Osteopenia Pulmonary nodules, Colonic adenoma, DE QUERVAIN'S DISEASE - LEFT Rheumatoid arthritis, Essential hypertension, Mitral valve prolapse Obesity, Atrophic vaginitis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Brother with MI at ___ y/o age, another brother with CABG p/t ___ y/o age, and father died at ___ from CHD and had his first MI in his ___. <PHYSICAL EXAM> Pulse: 87 Resp: 16 O2 sat: 97%RA B/P Right: 103/47 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [x] <PERTINENT RESULTS> ___ 06: 45AM BLOOD WBC-8.3 RBC-3.55* Hgb-10.8* Hct-31.7* MCV-89 MCH-30.3 MCHC-34.0 RDW-14.7 Plt ___ ___ 04: 00PM BLOOD WBC-8.4# RBC-3.82*# Hgb-12.1# Hct-34.0* MCV-89 MCH-31.7 MCHC-35.6* RDW-14.6 Plt ___ ___ 06: 45AM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-130* K-3.4 Cl-93* HCO3-28 AnGap-12 ___ 04: 00PM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-127* K-3.4 Cl-88* HCO3-26 AnGap-16 ___ 06: 45AM BLOOD Mg-1.7 <MEDICATIONS ON ADMISSION> Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Atorvastatin 80 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Hydroxychloroquine Sulfate 200 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. PredniSONE 4 mg PO DAILY 7. Ranitidine 150 mg PO BID 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain 9. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,TH) 10. Hydrochlorothiazide 50 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Atorvastatin 80 mg PO DAILY 2. PredniSONE 4 mg PO DAILY 3. Ranitidine 150 mg PO BID 4. Carvedilol 6.25 mg PO BID hold and call ___ for SBP<100 HR<60 RX *carvedilol 6.25 mg 1 Tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 5. Naproxen 500 mg PO Q12H 6. Vitamin D 1000 UNIT PO DAILY 7. Acetaminophen 325-650 mg PO Q6H: PRN pain 8. Aspirin 81 mg PO DAILY 9. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,TH) 10. Hydroxychloroquine Sulfate 200 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Dehydration PMH: Coronary Artery Disease Iatrogenic adrenal insufficiency, Varicose veins, Osteopenia Pulmonary nodules, Colonic adenoma, DE QUERVAIN'S DISEASE - LEFT Rheumatoid arthritis, Essential hypertension, Mitral valve prolapse Obesity, Atrophic vaginitis <DISCHARGE CONDITION> Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: none <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge
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The patient received IV fluids and felt much better. Lopressor was discontinued and Coreg started in the setting of diminished EF (35%). She remained stable overnight and was discharged home in less than 24 hours.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Ampicillin / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> hematochezia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with hx of CKD stage III, DM2, htn, obesity, rectal prolapse (pending rectopexy with Dr. ___ presenting with abdominal pain, vomiting, and hematochezia. Pt reports developing abdominal pain and nonbloody emesis on ___ at 3 am, when she was awoken from sleep with nausea and abdominal discomfort. She went to the bathroom, and had nonbloody emesis, followed by essentially continuous loose stools x2-3 hours. At some point later on ___ she passed bright red blood per rectum, in ___ episodes, then took an over the counter antidiarrheal with improvement in diarrhea. She describes associated diffuse abdominal cramping that was worst at LLQ, sharp, constant, with associated chills, anorexia, and lightheadedness. She denies sick contacts, lives with a foster son who is ___ years old (___) who has not been sick. Denies recent travel or recent antibiotic use, believes last course of antibiotics was ___ year prior. She denies dysuria, hematuria, chest pain, headache, rhinorrhea, cough. In the ___ ED: VS 100.8->99.2, 95->83, 172/80, 98% RA Exam notable for LLQ tenderness to palpation, nondistended, no rebound or guarding Labs notable for WBC 13.9, Hb 11.6->9.9, Plt 275, BUN 21, Cr 2.0, TnT<0.01, INR 1.1, HbA1c 6.7%, lactate 1.7 Imaging: CT abd/pelvis without contrast: 1. Acute colitis in the region of the splenic flexure. Differential includes ischemic, infectious, or inflammatory. Please note that these findings are in a watershed vascular territory. 2. Multiple, incompletely characterized hypodensities in both kidneys, measuring up to 3.3 cm in the mid left kidney. Consults: Colorectal recommended admission to medicine after anoscopy, bleeding unlikely to be ___ rectal prolapse Received: Insulin IVF Metronidazole Ciprofloxacin On arrival to the floor, pt endorses ___ LLQ pain with mild nausea. She confirms above history in detail. <PAST MEDICAL HISTORY> Bleeding submucosal lipoma of stomach s/p Distal gastrectomy (Billroth I) Type II DM Hyperlipdemia HTN Urinary incontinence s/p hysterectomy for fibroids s/p C-section <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for DM, HTN, "bad knees". Patient denies cardiac history in the family. Denies CA hx in the family. Denies clotting disorders <PHYSICAL EXAM> ADMISSION EXAM: VS: 98.9 PO 158 / 75L Lying 78 18 94 Ra GEN: obese female lying in bed, alert and interactive, comfortable, no acute distress HEENT: disconjugate gaze, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, obese, diffusely TTP most pronounced at LLQ, without rebounding or guarding, nondistended with normal active bowel sounds, no hepatomegaly appreciated EXTREMITIES: no clubbing, cyanosis, or edema GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: Alert and interactive, cranial nerves II-XII grossly intact, strength and sensation grossly intact PSYCH: normal mood and affect Patient examined on day of discharge. AVSS, abdomen soft, non-tender, and non-distended. <PERTINENT RESULTS> LABORATORY VALUES: ___ 05: 04PM BLOOD WBC-13.9* RBC-4.21 Hgb-11.6 Hct-37.2 MCV-88 MCH-27.6 MCHC-31.2* RDW-12.9 RDWSD-41.5 Plt ___ ___ 07: 00AM BLOOD WBC-8.3 RBC-3.76* Hgb-10.5* Hct-33.4* MCV-89 MCH-27.9 MCHC-31.4* RDW-12.6 RDWSD-41.0 Plt ___ ___ 07: 30AM BLOOD ___ PTT-25.2 ___ ___ 05: 04PM BLOOD Glucose-113* UreaN-21* Creat-2.0* Na-139 K-5.4 Cl-99 HCO3-25 AnGap-15 ___ 07: 00AM BLOOD Glucose-88 UreaN-11 Creat-1.4* Na-144 K-3.7 Cl-101 HCO3-29 AnGap-14 ___ 07: 30AM BLOOD ALT-12 AST-16 AlkPhos-79 TotBili-0.7 ___ 07: 00AM BLOOD ALT-11 AST-17 LD(LDH)-205 AlkPhos-75 TotBili-0.4 ___ 05: 04PM BLOOD calTIBC-276 Ferritn-269* TRF-212 ___ 08: 33PM BLOOD %HbA1c-6.7* eAG-146* ___ 05: 06PM BLOOD Lactate-1.7 Creat-2.1* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK 2. levemir 30 Units Breakfast 3. Aspirin 81 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Allopurinol ___ mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY 8. Voltaren (diclofenac sodium) 1 % topical DAILY: PRN 9. Lisinopril 20 mg PO DAILY 10. amLODIPine 2.5 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Daily Disp #*2 Tablet Refills: *0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth Three times daily Disp #*6 Tablet Refills: *0 3. levemir 30 Units Breakfast 4. Allopurinol ___ mg PO DAILY 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Diclofenac Sodium ___ ___ sodium) 1 % topical DAILY: PRN pain 9. Diclofenac Sodium ___ ___ sodium) 1 % topical DAILY: PRN pain 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. Lisinopril 20 mg PO DAILY 13. HELD- Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK This medication was held. Do not restart Trulicity until you follow up with your PCP ___: Home <DISCHARGE DIAGNOSIS> Colitis <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 hospital with abdominal pain and rectal bleeding, and you were found to have colitis and an acute kidney injury. You were treated with IV antibiotics, fluids, and bowel rest, and your symptoms dramatically improved. As you were able to eat a regular diet, you are medically stable for discharge. You will need a repeat colonoscopy within six weeks. It has been a pleasure taking care of you!
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Ms. [REDACTED] was admitted and started empirically on ciprofloxacin and metronidazole, as well as given IV fluids. Dulaglutide was held as well, as GI side effects are common (usually diarrhea), though I could not find any reports of enteritis. She rapidly improved, and was able to tolerate a regular diet (with no more diarrhea, no stool studies were sent). Her renal function returned to normal after fluid resuscitation as well. Colorectal surgery did not feel that her symptoms were due to rectal prolapse. With her eating and kidney function back at her baseline, she will discharge home to finish two more days of antibiotics, and follow up with Dr. [REDACTED] planned rectopexy. HOSPITAL COURSE BY PROBLEM: 1. Colitis. - ciprofloxacin 500 mg daily x 2 days - metronidazole 500 mg TID x 2 days - holding dulaglutide until follow up with primary care 2. [REDACTED] on CKD. - resolved after 2 L LR; discharge creatinine 1.4 (baseline) 3. HTN. Home lisinopril, amlodipine, HCTZ. 4. Gout. Home allopurinol. 5. HLD. Home atorvastatin. 6. Rectal prolapse. Outpatient follow up with Dr. [REDACTED] [REDACTED] ISSUES - two more days of antibiotics - readdress dulaglutide -- low likelihood of it being the cause of enteritis, so likely safe to restart.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> ACE Inhibitors <ATTENDING> ___. <CHIEF COMPLAINT> cough/fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo F with CAD s/p PCI in ___, COPD on nocturnal O2, HTN, depression with recent diagnosis of gastric CA who had staging EUS today who returns with fever and cough with concern for pna. Pt felt well after procedure, had lunch with daughter and went home. Pt woke up from nap in later in the afternoon with shaking chills, fever ot 102 and persistent cough. Family called and were advised to bring her to the ED. In the ED, pt afebrile but with leukocytosis to 16 k. CXR showed infiltrate in lingula. Pt given metronidazole (??) and admitted for further care. Of note, pt on augmentin for past 8 days as she had infiltrate in RUL on staging PET/CT. Pt planned for EMR on ___. ROS: negative except as above Additional History: I spoke to her at length this morning and she recounted the following history: Given her history of gastric ca her outpatient provider ordered ___ to monitor spread. One month prior to admission a ___ revealed a focal area in her lingula, she was started on Levofloxacin which she completed a 7 day course. She then followed up with her Oncologist who indicated it was unknown whether the ___ revealed infection or a mass so decided to treat her for a 10 day course of Augmentin, today is day 8 of 10 and she continued the antibiotics on day of EUS following EUS. Following EUS yesterday she was feeling well, went to take a nap, woke up with chills and felt warm, she then developed a cough productive of "dark" sputum. She called with her symptoms and was sent to the ED. In the ED her vitals were normal but her CXR revealed a lingular infiltrate concerning for PNA so started on antibiotics. <PAST MEDICAL HISTORY> CAD s/p MI and stent ___ years ago COPD Depression HTN <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of GI malignancy. <PHYSICAL EXAM> Admission Exam: Vitals: 98.5 124/44 55 16 97%2L Gen: NAD HEENT: NCAT CV: rrr no r/m/g Pulm: clear bl Abd: soft, ntnd +bs Ext: no edema Neuro: alert and oriented x3, no focal deficits Discharge Exam: Vitals: 98.0 117/67 67 18 98%RA 98% RA Pain Scale: ___ General: Patient appears well, seated upright in bedside chair eating breakfast and doing well. She exhibits no dyspnea, SOB, labored breathing or cough HEENT: Sclera anicteric, MMM Neck: no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated <PERTINENT RESULTS> Admission Labs: ___ 08: 55PM GLUCOSE-138* UREA N-14 CREAT-0.6 SODIUM-133 POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-26 ANION GAP-14 ___ 08: 55PM WBC-16.6* RBC-4.31 HGB-12.7 HCT-36.2 MCV-84 MCH-29.3 MCHC-34.9 RDW-14.6 ___ 08: 55PM PLT COUNT-257 ___ 09: 08PM LACTATE-1.1 ___ 10: 16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Discharge Labs: ___ 06: 15AM BLOOD WBC-7.9 RBC-3.81* Hgb-10.9* Hct-32.1* MCV-84 MCH-28.7 MCHC-34.0 RDW-14.3 Plt ___ ___ 06: 15AM BLOOD Neuts-75.6* Lymphs-17.1* Monos-5.0 Eos-2.1 Baso-0.2 ___ 06: 15AM BLOOD UreaN-9 Creat-0.5 Na-141 K-3.6 Cl-102 HCO___ AnGap-14 ___ 06: 15AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2 CXR: Findings suggest pneumonia in the left lower lung, probably in the lingula. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 3. BuPROPion (Sustained Release) 150 mg PO BID 4. Clopidogrel 75 mg PO DAILY 5. Fluoxetine 10 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN: PRN chest pain 10. Pantoprazole 40 mg PO Q12H 11. Tiotropium Bromide 1 CAP IH DAILY 12. Aspirin 325 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. BuPROPion (Sustained Release) 150 mg PO BID 4. Fluoxetine 10 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. Tiotropium Bromide 1 CAP IH DAILY 8. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 9. Clopidogrel 75 mg PO DAILY 10. Hydrochlorothiazide 12.5 mg PO DAILY 11. Losartan Potassium 25 mg PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN: PRN chest pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Active: - Aspiration Pneumonitis Chronic: - Gastric Cancer - CAD s/p MI with PCI - COPD <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms ___, It was a pleasure treating you during this hospitalization. You were admitted with shortness of breath, cough and concern for pneumonia. After further evaluation it was thought that you do not have pneumonia but rather something called "aspiration pneumonitis". This is the result of stomach acid causing chemical irritation of your lungs. This is fully reversible and does not require antibiotics. You were observed overnight in the hospital off antibiotics and showed clinical improvement. Please discontinue the antibiotic you were taking prior to admission. While it is still possible the lung infiltrate seen on ___ could be old pneumonia it is also possible it represents early cancer. Given that, please be sure to follow up with your PCP, ___ and Pulmonary doctor to further evaluate such as with a bronchoscopy or biopsy.
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[REDACTED] yo F with CAD with prior MI s/p PCI, COPD, HTN, recently diagnosed with gastric CA s/p EUS [REDACTED] showing 1.5 nodular mass at GE junction who presented to the ED with chills and cough initially concerning for pneumonia though more likely consistent with [REDACTED] aspiration pneumonitis # Aspiration Pneumonitis # Leukocytosis Patient was diagnosed with pneumonia on admission and started on Unasyn 3g q6h. While she did have a leukocytosis and infiltrate on imaging I do not believe her symptoms represented true acute bacterial pneumonia. She has had a lingular infiltrate dating back over a month prior to admission and received two rounds of antibiotics in the outpatient setting. Additionally, she was recently being treated as an outpatient with a course of Augmentin which she took on morning and afternoon of EUS procedure (Day 7 of 10 day course). Even if current "pneumonia" was GNR or anaerobic the Augmentin should cover adequately. Given the acuity of symptom presentation and rapidity with which her symptoms resolved after only one dose of IV antibiotics and lack of fever, I felt her signs and symptoms most likely represented acute aspiration pneumonitis rather than frank bacterial pneumonia. Aspiration pneumonitis could also result in leukocytosis detected on admisison labs. Aspiration event likely related to EUS several hours prior to presentation. Antibiotics were discontinued and she was observed for 4 hours without coverage. Clinically she improved off antibiotics without fevers and with improvement in pulmonary symptoms and normalization of WBCs consistent with pneumonitis rather than pneumonia. # CAD With prior MI s/p PCI, Plavix on hold for EUS per outpatient cardiologist approval. Continued aspirin, held Plavix. DCd on aspirin with plan to hold Plavix until appointment with Dr. [REDACTED] week. Continue Metoprolol and statin # COPD Chronic, stable, not O2 dependent, no wheezing on exam, no symptoms to suggest COPD exacerbation. Advair while inpatient, continued spiriva and nebs prn # HTN Continued losartan and hctz # Depression Continued welbutrin and fluoxetine Transitional Issues: # [REDACTED] need biopsy or BAL to assess if lingular infiltrate represents mass versus resolved PNA not yet cleared on imaging. This was discussed with patient and family at length, expressed their understanding and need for follow up. Outpatient pulm arranged prior to DC # Code - full # Plavix on hold, will need to be restarted if no plans for procedure this week
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo M no significant PMH presents with 4 days of progressive right sided HA. Pt was away in ___ when he developed HA. He felt that his eyelid was drooping. His HA progressively worsened over the next 4 days and so he presented to OSH when he returned to ___. He also developed nausea. Denies blurred or double vision. Denies numbness, weakness or tingling. <PAST MEDICAL HISTORY> right eye cataract surgery, cyst removed from anterior neck - benign <SOCIAL HISTORY> nonsmoker, married <PHYSICAL EXAM> Upon admission: Gen: WD/WN, comfortable, NAD. HEENT: right eyelid minimal erythema and minimal swelling of the lid Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils asymmetric, right 2.5, left 4.5 briskly reactive. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements Upon discharge: Mental status: A&Ox3, able to recount history accurately and swiftly, no speech changes CN: R sided ptosis (5-->3mm L pupil, 2-->1.5 R pupil), EOMI, tongue midline, VFF to finger wiggling Sensory exam: agraphesthesia on left upper extremity Coordination: no DDK Gait: narrow based, tandem, a bit lightheaded when he stands up initially but this is chronic and he knows he has to get up slowly <PERTINENT RESULTS> ___ MRI brain 1. Slow diffusion of the right temporal and frontal operculum as well as a right frontal lobe and right postcentral gyrus with associated FLAIR hyperintense signal compatible with late acute to subacute infarct. 2. There is lack of flow related signal visualized right extracranial internal carotid artery to the intracranial carotid terminus with distal reconstitution secondary to collaterals, compatible occlusion. Further evaluation with CTA or MRA of the head and neck is recommended. ___ CTA head and neck: 1. Segmental occlusion of the right internal carotid artery with reconstitution in the supraclinoid region. Patent major intracranial arteries. 2. Stable right operculum region infarction without hemorrhage. No new infarction. ___ 05: 05AM BLOOD WBC-5.6 RBC-4.53* Hgb-13.9 Hct-40.7 MCV-90 MCH-30.7 MCHC-34.2 RDW-12.6 RDWSD-41.0 Plt ___ ___ 06: 48PM BLOOD Neuts-67.0 ___ Monos-8.8 Eos-0.4* Baso-0.4 Im ___ AbsNeut-4.77 AbsLymp-1.64 AbsMono-0.63 AbsEos-0.03* AbsBaso-0.03 ___ 05: 05AM BLOOD Glucose-95 UreaN-19 Creat-1.1 Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 ___ 05: 05AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 Cholest-190 ___ 05: 05AM BLOOD %HbA1c-5.6 eAG-114 ___: 05AM BLOOD Triglyc-106 HDL-44 CHOL/HD-4.3 LDLcalc-125 ___ 05: 05AM BLOOD TSH-1.6 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN pain 2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H: PRN headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ capsule(s) by mouth three times a day Disp #*30 Capsule Refills: *0 3. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *3 4. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home with Service <DISCHARGE DIAGNOSIS> Headache Subacute infarct in R frontal and temporal lobe R ICA dissection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: agraphesthesia on LUE, R sided ptosis <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were hospitalized due to symptoms of nausea, vomiting, neckpain, and headache resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. We are changing your medications as follows: - aspirin 81mg daily - atorvastatin 40mg qhs We believe your stroke is caused by a carotid dissection leading to occlusion of your right internal carotid artery. Because of this, PLEASE DO NOT LIFT ANY HEAVY OBJECTS. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team
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Mr. [REDACTED] is a [REDACTED] yo M in a previous state of good health who presented with new onset right sided head and neck ache and R eye ptosis. He first presented to ED at [REDACTED] on [REDACTED], where they performed a CT scan which showed a right temporal hypodensity which they found concerning for underlying malignancy. He was transferred to [REDACTED] and admitted to the neurosurgical service where he was loaded with Keppra and started on a daily dose for seizure prophylaxis. On [REDACTED], a MRI with and without contrast was performed to evaluate for underlying mass. The MRI revealed subacute infarcts in the right frontal, right temporal and right parietal lobes with concern for R internal carotid artery occlusion. A stroke neurology consult was placed. CTA head and neck was ordered to further evaluate possible occlusion of R ICA, which revealed complete occusion of the R ICA with features strongly suggestive of dissection of the internal carotid artery. The patient's right sided head and neck pain, as well as his Horner's syndrome are all consistent with his right ICA dissection and occlusion. Though the patient has low risk factors for atheromatous disease, HbA1c, TSH and lipids were investigated as possible latent risk factors that could alternatively lead to his presentation. As his imaging and history are best explained by an ICA dissection, the patient was started on aspirin 81 mg for antiplatelet therapy that he will need to take for [REDACTED] months. He was also started on atorvastatin 40mg qhs for LDL 125. Prior to discharge, the patient was advised to not lift any heavy objects over the next few weeks and come back immediately for medical attention if he has any deficits in his vision or weakness or paralysis on the left side of his body.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Ativan / Morphine <ATTENDING> ___. <CHIEF COMPLAINT> Hypotension Bacteremia? <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ direct admit from ___ for sepsis. Initially p/w hypotension from Rehab. Blood and urine cultures taken from OSH on ___ positive for Staph epidermidis (sensitive to vanco and linezolid) and MDR Kleb pneum (sensitive to zosyn and amikacin). Pt is asymptomatic, afebrile, with no obvious signs of infection. There is no increased ostomy output. Patient does require extensive fluid repletion via intravenous access catheter for dehydration. He did report a similar incident in the past where his port-a-cath required surgical removal for bacteremia as well. . Of note, he was also recently admitted several weeks ago for abd pain after recent ileostomy (___) and UTI (___). <PAST MEDICAL HISTORY> PSH: 1. Colectomy, ileostomy for "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal ___ years ago 3. Lysis of adhesions on ___ 4. Appendectomy 5. Removal of cyst on his neck 6. Left hip replacement 7. Removal of 2 burs from his elbows 8. s/p talc pleurodesis (BWH) 9. s/p port removal for staph sepsis 10. Resection of ileocolic anastomosis and creation of end-ileostomy (___) 11. ___ tunnelled catheter ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Gen: NADS, AA0x3 HEENT: NCAT, EOMi, no icterus Neck: supple, no lymphadenopathy Lungs: CTA, coarse inferiorly Cardiac: RRR Abd: Soft, midline incsion, NT, ND, act BS, ostomy apliance to RLQ w/ stool and flatus. Ext: No, C/C/E <PERTINENT RESULTS> ___ 08: 13PM BLOOD WBC-11.6* RBC-2.57* Hgb-8.3* Hct-24.1* MCV-94 MCH-32.5* MCHC-34.6 RDW-14.8 Plt ___ ___ 06: 40AM BLOOD WBC-8.0 RBC-2.86* Hgb-9.2* Hct-26.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-14.8 Plt ___ ___ 08: 13PM BLOOD ___ PTT-42.1* ___ ___ 09: 55AM BLOOD ___ ___ 06: 40AM BLOOD Glucose-76 UreaN-9 Creat-1.0 Na-135 K-4.1 Cl-104 HCO3-24 AnGap-11 ___ 06: 40AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.5 . ___ 8: 15 pm URINE Source: ___. URINE CULTURE (Preliminary): THIS IS A CORRECTED REPORT ___ 11: 15AM. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. PREVIOUSLY REPORTED AS ENTEROCOCCUS SP. ON ___. REPORTED BY PHONE TO ___ ___ 11: 10AM. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 32 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R . ___ 8: 15 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . ___ and ___ BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): . <MEDICATIONS ON ADMISSION> protonix 20', amiodarone 200'', digoxin 0.125', lopressor 12.5'', Tylenol prn, Imodium 2mg tab''', coumadin (for afib, 3mg/d), levothyroxine 50mcg, mylicon, reglan 10''' PRN, <DISCHARGE MEDICATIONS> 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO TID (3 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___: Monitor INR. 12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 8 days. 13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 8 days. 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML Intravenous PRN (as needed) as needed for line flush. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Hypotension <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted with possible line infection, and hypotension. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within ___ hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all new meds as ordered. * 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. * Continue to increase activity daily * Continue with Ostomy care. Monitor fluid status closely.
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[REDACTED] w/ ?bacteremia and hypotension. He was admitted and had BC x 2, CBC, CHM 7, coags. He was started on Vanco. He was NPO with IVF. [REDACTED] regarding culture results - apparently, only one blood culture taken from a [REDACTED], peripheral site. No sensitivities or speciation from cultures. Report suggesting staph aureus. Physician notes indicate staph epidermidis. Repeat blod cultures were negative at time of discharge. UTI: ID curbsided and recommended Meropenem 500 IV q 8 h. for MDR Klebsiella in Urine renal dosing. D/C to Rehab with [REDACTED] 14 Days total. The [REDACTED] was not removed and antibiotics and fluids given through the line. Hypotension: Given his history of severe dehydration and fluid losses from the ostomy secondary to short gut, IVF were given to match ostomy output. Continue with IVF resuscitation 1cc:1cc of ostomy output. UE Edema: Due to swelling of the LUE, an US was ordered and The cephalic veins are not well visualized on either side. Bilateral subcutaneous edema more prominent on the right. No evidence of DVT within the imaged veins of bilateral upper extremities.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Iodine-Iodine Containing <ATTENDING> ___. <CHIEF COMPLAINT> duodenal adenoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: 1. Transduodenal resection, duodenal adenoma (T3). 2. Open cholecystectomy with common bile duct exploration. . ___: EGD <HISTORY OF PRESENT ILLNESS> ___ is a ___ year old man with history of a cecectomy for bleeding problems. It was a minimally invasive assisted resection that went well and he did fine. Over the last several years, he has had tumultuous medical history pivoting off of cardiopulmonary and cardiovascular disease processes including strokes, pulmonary hypertension, ischemic cardiomyopathy, peripheral vascular disease and coronary artery disease requiring numerous cardiac stents. He is seen by a cardiologist down in ___. In the past, in ___, ___ also had a fall and a brain bleed. He had heart stents placed throughout the ___ of ___, a balloon angioplasty to the right coronary artery at ___ ___ in ___, a transurethral resection of bladder polyps found to be cancerous in the ___ and again yet another cardiac stent placed at ___ on ___. He currently has no chest pain, although this has been often times a presenting symptom. He had fatigue and mild depression and was found to be in atrial fibrillation. This limited how much he was getting on his treadmill but he is becoming more and more deliberate with that. He has not had any episodes of chest pain or arm pain since this ___ intervention. He has gastroesophageal reflux and difficulty swallowing at times and some dysuria and trouble initiating his urinary stream. He has mild bloating with eating as well but does move his bowels on a regular basis and he denies any true melena. He has about two alcohol drinks a day and he quit smoking many years ago. He presents for resection of a duodenal adenoma with high grade dysplasia. <PAST MEDICAL HISTORY> PMH: CAD/MI, HTN, ?CHF, GERD, ^chol, BPH PSH: CABGx3 (___), stent x5, angioplasty x7, L4/5 discectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not pertinent. <PHYSICAL EXAM> GEN: Well appearing, no acute distress HEENT: NCAT, EOMI, sclera anicteric CV: HDS PULM: No signs of respiratory distress. ABD: soft, nontender, nondistended EXT: Warm, well-perfused NEURO: Conversing appropriately, but confused at times. <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Clopidogrel 75 mg PO DAILY 2. DULoxetine 60 mg PO DAILY 3. Ezetimibe 10 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Mirtazapine 15 mg PO QHS 8. mirabegron 25 mg oral DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN: PRN chest pain 10. Pantoprazole 40 mg PO Q24H 11. Ranitidine 150 mg PO DAILY 12. Ranolazine ER 500 mg PO BID 13. Rosuvastatin Calcium 20 mg PO QPM 14. Tamsulosin 0.4 mg PO QHS 15. Topiramate (Topamax) 100 mg PO BID 16. Aspirin 325 mg PO DAILY 17. DiphenhydrAMINE 25 mg PO DAILY 18. Docusate Sodium 100 mg PO BID <DISCHARGE MEDICATIONS> 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *0 2. Dabigatran Etexilate 150 mg PO BID RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth Twice a day Disp #*120 Capsule Refills: *0 3. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *0 4. Multivitamins W/minerals 15 mL PO DAILY 5. Ramelteon 8 mg PO QHS insomnia 6. TraZODone 25 mg PO QHS RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth QHS (before bedtime) Disp #*60 Tablet Refills: *0 7. Aspirin 81 mg PO DAILY 8. Metoprolol Succinate XL 150 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Ezetimibe 10 mg PO DAILY 11. Finasteride 5 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN: PRN chest pain 13. Pantoprazole 40 mg PO Q24H 14. Tamsulosin 0.4 mg PO QHS 15. Topiramate (Topamax) 100 mg PO BID 16. HELD- DULoxetine 60 mg PO DAILY This medication was held. Do not restart DULoxetine until you follow up with your PCP. 17. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you follow up with your PCP/Cardiologist. 18. HELD- mirabegron 25 mg oral DAILY This medication was held. Do not restart mirabegron until you follow up with your PCP/Cardiologist. 19. HELD- Mirtazapine 15 mg PO QHS This medication was held. Do not restart Mirtazapine until you follow up with your PCP. 20. HELD- Ranolazine ER 500 mg PO BID This medication was held. Do not restart Ranolazine ER until you follow up with your PCP/Cardiologist. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> 1. Duodenal adenoma 2. Post operative hemorrhage 3. Non-ST segment elevation myocardial infarction 4. Bacteremia 5. Hospital acquired pneumonia 6. Pulmonary edema <DISCHARGE CONDITION> Mental Status: Waxing and waning confusion Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted to the hospital for surgery which required a prolonged hospital course to address bleeding, cardiac dysfunction, and lung dysfunction. You have recovered well and you are ready to be discharged to a rehab center. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have pain that is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please take all your 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. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery.
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Mr. [REDACTED] presented for planned open duodenectomy for mass excision and cholecystectomy on [REDACTED]. On post operative day 1, he had bright red blood per NGT. Aspirin, prophylactic heparin, and plavix were held, he was given a unit of pRBC and transferred to the ICU. He presented to ICU initially in hemorrhagic shock with ischemic gastropathy with clinical course complicated by H influenzae and Klebsiella pneumonia, enterococcal bacteremia (treated with Zosyn from [REDACTED] to [REDACTED], and two extubation failures due to failure to protect airway who tolerated extubation [REDACTED]. His post operative course was also complicated by a fib with RVR which was rate controlled with metoprolol, HFrEF with LVEF improving over the course of the admission, Type 2 NSTEMI in setting of hemorrhagic shock with underlying CAD and HTN, Possible Type 1 NSTEMI given new RWMA on echo. Following extubation, he was transferred to the floor where he was breathing well on room air, eventually tolerating an oral diet, foley was discontinued, and he was started on dabigatran for his a fib per cardiology recommendations. He did continue to have waxing and waning confusion / delirium, and geriatrics evaluated the patient recommending trazodone 25 mg PO HS up to 75mg PO HS for help with sleep, and regular re-orientation by nursing and family. After thorough discussion with the family between the surgical team, geriatrics team, and social work, the patient's code status was changed to DNAR/DNI in light of what the family iterated was the patient's prior expressed preferences. A MOLST form was documented and left in the patient chart. Physical therapy recommended discharge to rehab.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Amoxicillin / Levofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old female status post laparoscopic lysis of adhesions, cholecystectomy, enterotomy repair and ventral incisional hernia repair presents with nausea and emesis x 1. Emesis was bilious, and nonbloody. No fever, chills or night sweats. She still feels a little bit of nausea. Her last bowel movement was ___. She said that she had a moderate amount and that it was loose but no diarrhea. Still passing flatus. She is having she says gas crampy abdominal pain. <PAST MEDICAL HISTORY> PMHx: HTN . PSHx: Left breast lumpectomy ___, open appendectomy ___, SBR for ?lipoma ___ (per patient, no records available), right shoulder ORIF ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. <PHYSICAL EXAM> Vital Signs: T 97.8 HR 74 BP 110/48 RR 16 O2 Sat 97% RA General: No acute distress Lung: Clear to auscultation bilaterally, No rales or ronchi Cardiac: Regular rate and rhythm Abdomen: soft, non-distended nontender. Ext: WWP bilat <PERTINENT RESULTS> ___ 02: 55PM URINE HOURS-RANDOM ___ 02: 55PM URINE GR HOLD-HOLD ___ 02: 55PM URINE COLOR-Amber APPEAR-Clear SP ___ ___ 02: 55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-7.0 LEUK-SM ___ 02: 55PM URINE RBC-0 ___ BACTERIA-MANY YEAST-NONE ___ TRANS ___ 01: 00PM POTASSIUM-4.6 ___ 01: 00PM GLUCOSE-115* UREA N-12 CREAT-0.7 SODIUM-132* POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-25 ANION GAP-16 ___ 01: 00PM estGFR-Using this ___ 01: 00PM ALT(SGPT)-24 AST(SGOT)-48* LD(LDH)-459* ALK PHOS-66 TOT BILI-0.8 ___ 01: 00PM LIPASE-83* ___ 01: 00PM WBC-14.3*# RBC-4.22 HGB-12.0 HCT-36.4 MCV-86 MCH-28.5 MCHC-33.1 RDW-14.3 ___ 01: 00PM NEUTS-86.5* LYMPHS-10.3* MONOS-2.1 EOS-0.7 BASOS-0.4 ___ 01: 00PM PLT COUNT-467*# <MEDICATIONS ON ADMISSION> Atenolol 50 mg PO daily, Diovan 160 mg PO daily, Colace 100 mg PO BID, oxycodone 5 mg every 6 hours PO prn pain <DISCHARGE MEDICATIONS> 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO every ___ hours for 5 days. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Partial small bowel obstruction <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 a potential small bowel obstruction. While you were in the hospital you were managed conservatively with bowel rest and IVF fluids. When appropriate your diet was advance to a regular diet. Due to the fortunate resolution of your symptoms you are being discharged back to your extended care facility. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. 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. Avoid driving or operating heavy machinery while taking pain medications.
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This is a [REDACTED] year old female status post laparoscopic lysis of adhesions, cholecystectomy, enterotomy repair and ventral incisional hernia repair who presented with nausea and emesis x 1. At the time of presentation her abdominal exam was benign but given recent surgery there was concern for an ileus or partial small bowel obstruction. She admitted to the [REDACTED] surgery service and managed conservitely with bowel rest and IV hydration after a KUB demonstrated Multiple dilated loops of small bowel with air-fluid levels, concerning for early/partial small-bowel obstruction given air in distal bowel. Serial exams continued to improve and patient reported flatus at HD 3. Her diet was advanced slowly to a regular diet with out event. 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 was not experiencing any pain. She was discharged the her extended care facility She will follow-up with Dr. [REDACTED] follow-up regarding this hospital stay.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Right adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, peritoneal and omental biopsies, appendectomy, R ureterolysis, and cystoscopy <HISTORY OF PRESENT ILLNESS> This patient is a ___ gravida 0 woman who initially presented with increasing abdominal girth. Her primary care physician performed ___ pelvic ultrasound which revealed a 12 cm complex right adnexal cyst. She then developed severe pain and presented to the emergency room, where a repeat ultrasound revealed a 10 cm right adnexal complex cystic structure with less fluid component and new free pelvic fluid, consistent with rupture of the cystic components. Her left ovary appeared to be within normal limits. Her CA-125 was 31, which is normal. She was counseled on her options and agreed with the recommendation to proceed with surgical evaluation of her right adnexal mass. She was counseled that if the intraoperative pathology was suggestive of malignancy further staging procedure would be performed with the assistance of a Gynecologic Oncology surgeon. All questions were answered and all consents were signed prior to going to the operating room. <PAST MEDICAL HISTORY> OB Hx: G0; IVF x 2 unsuccessful, one adopted daughter is ___ yo GYN Hx: Menstrual Hx: Menarche age ___ LMP ___, reg pds q 28 days x 5days (mod flow), no significant dysmenorrhea PAP Hx: No h/o abnormal Pap smears; Last Pap ___ neg per pt STI Hx: none Sexually active: yes- ___: last ___ normal per pt PMH: 1. none PSH: 1. breast biopsy ___ - atypical ductal hyperplasia without recurrence <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: Living, age ___, DEEP VENOUS THROMBOPHLEBITIS HYPERLIPIDEMIA Father: Living, age ___, PROSTATE CANCER, BENIGN BRAIN TUMOR Maternal Aunt: Living, BREAST CANCER <PHYSICAL EXAM> Vitals: WNL, Stable Gen: Comfortable, NAD Heart: RRR, S1 S2 nl Lungs: CTA b/l Abd: Soft, non-distended, appropriately tender to palpation, +BS, four trocar insertion sites bandaged C/D/I Ext: No edema, Non-tender <PERTINENT RESULTS> ___ 08: 05AM BLOOD WBC-10.8 RBC-3.33* Hgb-11.1* Hct-32.3* MCV-97 MCH-33.2* MCHC-34.2 RDW-13.5 Plt ___ <MEDICATIONS ON ADMISSION> Citalopram 20 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Citalopram 20 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN Pain when tolerating PO. do not give with toradol RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours Disp #*50 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain start when tolerating sips RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth Every ___ hours Disp #*40 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Likely borderline mucinous ovarian tumor, final pathology pending <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 gynecology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions below: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 3 months * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication
Output:
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On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, omental and peritoneal biopsies, appendectomy, right ureterolysis, and cystoscopy for a complex right adnexal mass with intra-op pathology consistent with borderline mucinous cystadenocarcinoma. The GYN Oncology service performed an intra-op consult for this case. Please refer to the respective operative reports for full details of each portion of the case. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to percocet and motrin. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Fever, chills, abdominal pain, emesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Resection of duodenal mass with end-to-end duodenojejunostomy <HISTORY OF PRESENT ILLNESS> The patient is a ___ male who began having intermittant nausea and vomiting (clear non-bilious non-bloody) about 4 months ago. About three days ago, he began having fevers, chills, drenching sweats and severe sharp constant LUQ abdominal pain. He also complains of a severe global headache, and he has continued to have nausea and emesis. He says that he is hungry but hasn't eating anything in 2 days. His Tmax was ___. <PAST MEDICAL HISTORY> essentially healthy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother died with ___ disease and macular degeneration. Father is alive and well at age ___. Has one healthy sibling and no children. <PHYSICAL EXAM> PHYSICAL EXAM: 98.3 70 117/83 16 97 Gen: tired-appearing male, appears younger than stated age, NAD, no icterus, sensitive to light HEENT: NC/AT, EOMI, PERRLA bilat., MMM, without cervical LAD on my exam Cor: RRR without m/g/r, no JVD, no bruits Lungs: CTA bilat. ___: +BS, soft, + tender in LUQ without reboud/Rovsing/guarding/percussion tenderness. Palpable mass in LUQ. No hernias. Ext: warm feet, no edema <PERTINENT RESULTS> ___ 10: 20PM WBC-9.5 RBC-3.99* HGB-11.4* HCT-33.5* MCV-84 MCH-28.6 MCHC-34.1 RDW-13.1 ___ 10: 20PM ALT(SGPT)-141* AST(SGOT)-111* ALK PHOS-176* AMYLASE-32 TOT BILI-1.1 ___ 10: 20PM GLUCOSE-99 UREA N-18 CREAT-1.2 SODIUM-139 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Please do not take more than 4000mg of acetaminophen in 24 hrs. . Disp: *45 Tablet(s)* Refills: *0* 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp: *7 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary: duodenal mass Post-op ileus . Secondary: R inguinal herniorrhaphy remotely <DISCHARGE CONDITION> Stable. Tolerating regular diet. Pain well controlled with oral medications. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within ___ hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow up appointment. -Steri-strips will be applied and they will fall off on their own. Please remove any remaining strips ___ days after application. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. .
Output:
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The patient underwent a resection of duodenal mass on [REDACTED]. Afterwards he was provided with a PCA for pain control and was initially made NPO. An NGT was left in place for gastrointestinal decompression and IVF were provided for hydration. Return of bowel function was awaited. He developed a post-operative ileus which required him to be kept NPO for several days. On POD4, NGT clamp trials were performed with suitably low residual volumes and the NGT was discontinued. The foley catheter was also discontinued and the patient was able to void. Sips were started. The PCA was replaced first with intermittent IV narcotics and then oral narcotics on POD5 when the patient was able to tolerate clear liquids. On POD, his diet was advanced to regular. He was passing gas and stool and was ready for discharge to home.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 10: 24PM CREAT-0.8 ___ 10: 24PM estGFR-Using this ___ 10: 20AM WBC-6.7 RBC-4.04 HGB-10.8* HCT-34.4 MCV-85# MCH-26.7# MCHC-31.4*# RDW-17.2* RDWSD-53.3* ___ 10: 20AM PLT COUNT-362 <MEDICATIONS ON ADMISSION> iron, colace <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do not drive or take with sedatives/ alcohol RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hysterectomy, final pathology pending <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office at ___ with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * If TLH/TVH: Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On [REDACTED], Ms. [REDACTED] was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid, toradol. On post-operative day 1, her urine output was adequate so her foley was removed with a trial of void and she voided spontaneously (backfilled 300cc, voided 280c, PVR 1cc). Her diet was advanced without difficulty and she was transitioned to oxycodone, acetaminophen and ibuprofen (pain meds). By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Seziures <MAJOR SURGICAL OR INVASIVE PROCEDURE> Left temporal craniotomy for mass resection <HISTORY OF PRESENT ILLNESS> ___ male who initially presented s/p seizures with a recent finding of what seems to be a lesion on the left temporal lobe on MRI of his brain. Also recent finding of a chest lesion as well. Due to mass effect and edema and for diagnostic purposes, surgery was recommended and risks and benefits were discussed. <PAST MEDICAL HISTORY> Type 2 diabetes <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On admission: Nonfocal On discharge: strength full, sensation intact, ambulatory without assistance, incision c/d/i with staples. periorbital ecchymosis secondary to surgery <PERTINENT RESULTS> CT HEAD ___. Subtle foci of high attenuation layering along the sulci of the frontal lobes, bilaterally; a small amount of post-operative subarachnoid hemorrhage is not excluded. There is no large extra-axial hemorrhage. 2. Expected post-operative changes with resection cavity within the left temporal region and pneumocephalus. MRI BRAIN ___ The patient is status post left frontotemporal craniotomy and resection of a previously known rim-enhancing mass lesion in the left temporal lobe. The expected post-surgical changes are identified consistent with pneumocephalus, residual blood products in the surgical bed, unchanged minimal midline shifting towards the right with approximately 2 mm of deviation. No new lesions are identified. Patchy bilateral mucosal thickening is noted in the mastoid air cells bilaterally. <MEDICATIONS ON ADMISSION> Dilantin, Tylenol, Percocet, Ranitidine, Nicotine, Dexamthasone <DISCHARGE MEDICATIONS> 1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 5. Dexamethasone 2 mg Tablet Sig: See Taper Order below Tablet PO four times a day: Please take 4mg(2 tablets) 4 times a day on ___ and ___, then take 2mg(1 tablet) 4 times a day on ___, then take 2mg(1 tablet) 2 times a day until your appointment on ___. Disp: *45 Tablet(s)* Refills: *0* 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp: *120 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left Temporal Brain Mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -Have a friend/family member check your incision daily for signs of infection. -Take your pain medicine as prescribed. -Exercise should be limited to walking; no lifting, straining, or excessive bending. -You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. -You may shower before this time using a shower cap to cover your head. -Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. -You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. -You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. -Clearance to drive and return to work will be addressed at your post-operative office visit. -Make sure to continue to use your incentive spirometer while at home. - You had a seizure and cannot drive for 6 months CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING -New onset of tremors or seizures. -Any confusion or change in mental status. -Any numbness, tingling, weakness in your extremities. -Pain or headache that is continually increasing, or not relieved by pain medication. -Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. -Fever greater than or equal to 101° F.
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Patient presented electively on [REDACTED] for resection of left temporal mass via left temporal craniotomy. He tolerated the procedure well and was extubated int he operating room. He was transported to the ICU post-operatively for observation and his post-op head CT showed minimal blood in the resection cavity. Post-op MRI showed gross total resection of the mass and his exam was nonfocal with the exception of mild affect change. He was transferred to the floor on [REDACTED] in the evening where he remained stable voernight. On the morning of [REDACTED] his exam was nonfocal and his affect improved. he ambulated in the hallways without difficulty, was tolerating a diet and was deemed fit for discharge to homewithout services. He was given instructions for follow-up in the brain tumor clinic.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elective admission for C5-7 ACDF <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ ACDF C5-7 <HISTORY OF PRESENT ILLNESS> ___ with cervical stenosis who presented with bilateral digits ___ numbness. <PAST MEDICAL HISTORY> Varicose veins <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Pre-op Exam: Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, proprioception but paresthesias B UE D3-D5 Reflexes: B T Br Pa Ac Right 1+ 1+ 1+ 1+ 1+ Left 1+ 1+ 1+ 1+ 1+ Propioception intact Toes downgoing bilaterally Negative ___ bilaterally slight bilateral fine flapping remors On Discharge: a&ox3 PERRL Motor: D B T WE WF FI R ___ L ___ Sensation: decreased sensation over digits ___ bilaterally Incision: c/d/i in hard cervical collar <PERTINENT RESULTS> C-SPINE NON-TRAUMA ___: final read pending at time of discharge: Hardware with good placement, no malalignment <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q6H: PRN pain 3. Multivitamins 1 TAB PO DAILY 4. Ibuprofen 200 mg PO Q8H: PRN pain 5. Omeprazole 20 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Multivitamins 1 TAB PO DAILY 2. Cyclobenzaprine 10 mg PO TID: PRN spasm RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*50 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 4. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 1 patch once a day Disp #*1 Box Refills: *0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cervical stenosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Spine Surgery Dr. ___ -Do not smoke. -Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. -Dressing may be removed on Day 2 after surgery. -If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. -No pulling up, lifting more than 10 lbs., or excessive bending or twisting. -Limit your use of stairs to ___ times per day. -Have a friend or family member check your incision daily for signs of infection. -If you are required to wear one, wear your cervical collar or back brace as instructed. -You may shower briefly without the collar or back brace; unless you have been instructed otherwise. -Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. -Do not take any medications such as Aspirin/ibuprofen unless directed by your doctor. -Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: -Pain that is continually increasing or not relieved by pain medicine. -Any weakness, numbness, tingling in your extremities. -Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. -Fever greater than or equal to 101° F. -Any change in your bowel or bladder habits (such as loss of bowl or urine control).
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Mr [REDACTED] under went a C5-7 ACDF, post-operatively he was placed in a hard cervical collar, extubated and taken to the PACU for monitoring. Post operatively, patient reported stable numbness and tingling in bilateral digits [REDACTED]. He was transferred to the floor in stable condition. On [REDACTED], patient was seen to have L tricep weakness 4+/5 on the left and [REDACTED] on the R, otherwise full. C-spine AP/LAT films were done which showed good placement of hardware. He was ambulating independently and voiding appropriately. He was discharged in stable condition.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Ovarian cyst and menorrhagia <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> ___ y.o. female with a history of heavy, painful menses. She had a CT scan for hematuria in ___ which showed had a pelvic ultrasound on ___ which showed a large left an 8cm cystic left ovarian mass. She had a complex cyst, 8.8 x 8.7 x 7cm, resembling either a chocolate cyst of endometriosis or possible a large hemorrhagic functional or follicular cyst. It also showed a partially submucosal posterior funday wall fibroid 2.5 x 2.2cm. No other significant pelvic abnormality. She says that she has always had heavy painful menses and pain with intercourse. She also has perimenopausal symptoms, including hot flashes. Her menstrual cycles are beginning to become irregular. It skips some months, then has long periods of bleeding. An EMBx was attempted in the office, but had to be discontinued due to cervical stenosis and patient discomfort. Since these findings, she has been taking norethindrone. Over this past week, she was visiting family in ___ when she had very heavy bleeding. The bleeding was accompanied by large tennis ball size clots, and severe cramping. She felt fatigue and some dizziness, and was found to be anemic, with a fingerstick Hgb = 8.5 in the office. She was seen in GYN triage 2 days ago and found to be hemodynamically stable. Venipuncture Hgb = 8.9. Ultrasound findings were stable with no evidence of ovarian torsion. After passing some large blood clots, she felt much better and went home. She deferred the blood transfusion to today because she had to attend a funeral. She presents to day with abdominal cramps again. She is taking norethindrone 15mg daily, but the bleeding has not slowed. She took cytotec to prepare the cervix for a repeat EMBx today. She is planning OpHsc/D&C/LSO, possible hysterectomy, on ___. She felt very crampy and nauseated until she passed a blood clot vaginally in the GYN triage bathroom. Then she had no pain at all. <PAST MEDICAL HISTORY> OB Hx: G0 GYN Hx: 8cm complex L ovarian cyst, multiple submucosal fibroids; dysmenorrhea, perimenopause PMH: h/o skull fracture s/p ___ PSH: wisdom teeth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> Unknown (adopted) <PHYSICAL EXAM> On admission Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm, No edema or varicosities. Lungs: Clear, Normal respiratory effort. Breasts: Symm, NT, No dominant masses, D/C, nodes retraction, inversion. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skein & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, well supported, Cystocel absent, Rectocele absent, Bladder non-tender, no masses appreciated. Cervix: No CMT, no lesions, no discharge. Uterus: Enlarged uterus, mobile, NT, Prolapse absent. Adnexa: Small, non-tender, no masses or nodules. Rectal: Nl anus & perineum, No hemorrhoids, Nl NT, no masses. <PERTINENT RESULTS> ___ 09: 26AM BLOOD WBC-6.3 RBC-3.04* Hgb-9.1* Hct-28.2* MCV-93 MCH-30.0 MCHC-32.3 RDW-16.7* Plt ___ ___ 09: 26AM BLOOD Plt ___ ___ 09: 26AM BLOOD ___ PTT-26.3 ___ ___ 09: 26AM BLOOD ___ <MEDICATIONS ON ADMISSION> ibuprofen, norethindrone ___ daily, venlafaxine <DISCHARGE MEDICATIONS> ibuprofen, venlafaxine <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal uterine bleeding <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 gynecology for observation and for a blood transfusion due to heavy bleeding. The team believes you are now stable for discharge home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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[REDACTED] yo perimenopausal G0 woman with a history of heavy, painful menses and pelvic ultrasound on [REDACTED] which showed a large left an 8cm cystic left ovarian mass resembling either a chocolate cyst of endometriosis or possible a large hemorrhagic functional or follicular cyst. She was admitted to labor and delivery for a blood transfusion of 2 units packed RBC for blood loss anemia. Her coags were within normal limits and she was hemodynamically stable. An endometrial biopsy was attempted but unsuccessful. Her vaginal bleeding improved after passing a clot. Northindrone was discontinued. She was discharged home in stable condition with outpatient follow-up. She is currently planned for operative hysteroscopy with D&C with frozen section of endometrial sample and likely LSC LSO (as long as frozen section is benign) later this month ([REDACTED]), is also awaiting MIGS referral for second opinion.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Morphine / Gentamicin / Bactrim / Gyne-Lotrimin 3 / chlorhexidine <ATTENDING> ___. <CHIEF COMPLAINT> Melena <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with history of duodenal ulcer (___) in the setting of NSAID use presents with two episodes of melena. Patient reports that she began feeling weak and presyncopal while at work yesterday. She also reports mild epigastric discomfort. She had one episode of melena yesterday and had one more episode of melena today. She initially present to ___ Urgent Care where she was found to have melenic stool that was guaiac positive. The patient denies any chest pain, shortness of breath, fever, chills, back pain, or bright red blood per rectum. She reports use of NSAIDs, most recently Excedrin Migraine and ibuprofen. She denies significant etOH use. In the ED intial vital signs were 97.8 83 145/66 16 100%. Initial labs demonstrated WBC 6.7k, HCT 32.9% (last 35% in ___, normal coags and unremarkable chem-7. A UA was negative. The patient was given pantoprazole and admitted for further management. On the floor, initial vital signs are 97.7 137/68 75 20 99%RA. <PAST MEDICAL HISTORY> Duodenal ulcers Osteoarthritis s/pbBilateral knee replacements (___) PVCs UTI Migraines Diverticulosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Multiple family members with diverticulitis. No colon cancer. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: -====== Vitals: 97.7 137/68 75 20 99%RA GENERAL: well-appearing female, NAD HEENT: NCAT, MMM, OP clear, conjunctive pink CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild tenderness in epigastrium EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: -= unchanged <PERTINENT RESULTS> ADMISSION LABS: -=== ___ 09: 50PM BLOOD WBC-6.7 RBC-3.63*# Hgb-10.5* Hct-32.9*# MCV-91 MCH-28.8 MCHC-31.8 RDW-13.9 Plt ___ ___ 09: 50PM BLOOD Glucose-90 UreaN-22* Creat-0.6 Na-142 K-3.9 Cl-107 HCO3-26 AnGap-13 DISCHARGE LABS: -= ___ 04: 25PM BLOOD WBC-5.2 RBC-3.10* Hgb-9.3* Hct-27.8* MCV-90 MCH-29.9 MCHC-33.4 RDW-14.1 Plt ___ ___ 10: 55AM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-144 K-3.9 Cl-113* HCO3-24 AnGap-11 ___ 10: 55AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 IMAGING: ======== Findings: Esophagus: OtherIrregular Z-line with a single tongue of salmon-colored mucosal suggestive of short-segment ___. Cold forceps biopsies were performed for histology at the gastro-esophageal junction. Stomach: OtherMild antral erythema. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: Excavated LesionsA 1cm clean-based ulcer was noted in the duodenal bulb. A second, smaller ucler was noted adjacent to this. There were no high-risk stigmata. There was evidence of surrounding duodenitis. Impression: Irregular Z-line with a single tongue of salmon-colored mucosal suggestive of short-segment ___. (biopsy) Duodenal ulcer Mild antral erythema. (biopsy) Recommendations: Omeprazole 20mg bid x 2 weeks. Will follow up biopsy report and inform patient Limit NSAID intake. If you need to take NSAIDS in the future, I would recommend ongoing use of omeprazole for GI protection, which should reduce, but not eliminate, risk of ulcer formation. Ok to advance diet. Discharge today can be considered given that clean-based ulcer is at low risk for rebleeding. PATHOLOGY: ========== Gastric biopsies pending at time of discharge. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Zonisamide 200 mg PO QHS 2. Atenolol 25 mg PO BID 3. Nortriptyline 20 mg PO HS 4. Omeprazole 40 mg PO BID: PRN GI upset 5. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65 mg oral Daily: PRN headache 6. flaxseed oil 1,000 mg oral daily 7. Multivitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Nortriptyline 20 mg PO HS 2. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Zonisamide 200 mg PO QHS 4. Acetaminophen 1000 mg PO Q6H: PRN pain 5. Atenolol 25 mg PO BID 6. flaxseed oil 1,000 mg oral daily 7. Multivitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PRIMARY: duodenal ulcers Barretts headaches <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted with melena and mild abdominal pain. You were found to have 2 duodenal ulcers and evidence of Barretts esophagitis. Because of this, you were started on omeprazole twice a day. It is important that you limit your NSAID use, as this may be contributing to your ulcers. Please talk with your PCP about referral to a GI physician, if you do not have one already. We also recommend that you talk with your neurologist regarding other options for controling your headaches,
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Ms. [REDACTED] is a [REDACTED] with history of duodenal ulcers presenting with two days of melena and lightheadedness, found to have recurrent duodenal ulcers and barretts esophagitis. ACTIVE ISSUES: #Upper GI bleed/barretts esophagus: Pt has distant history of duodenal ulcers with EGD this admission confirming recurrent ulcers, which is likely the source of her melena. This is probably due in part to her daily NSAID use. Per GI recommendations, she was started on omeprazole 20 mg BID. Her baseline hct appears to be 36-38%, down to 28% after admission in the setting of IVF resuscitation, and remained stable throughout the day. Given the clean based nature of the ulcer, and low risk of rebleeding, pt was discharged the same day. She was advised to minimize her NSAID usage. CHRONIC ISSUES: #Headaches: Patient reports long history of headaches and is followed by neurology at [REDACTED]. She is currently on zonisamide, nortriptyline, and atenolol along with various NSAID preparations which she uses on a nearly daily basis. Given history of duodenal ulcers in setting of NSAID use and current presentation, patient would likely benefit from additional attempts at headache prophylaxis to decrease or obviate NSAID requirement. #Orthopedic pain: Patient has history of osteoarthritis, now s/p bilateral knee replacement in [REDACTED] for which she also takes NSAIDS. Her NSAIDs were replaced with acetaminophen as needed for pain. TRANSITIONAL ISSUES: - Biopsy results from EGD are pending at time of discharge and should be followed by pt's PCP. - Consider referral to migraine specialist to aid in optimizing migraine management.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> Central cord syndrome, cervical stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: C3-C6 lami and fusion <HISTORY OF PRESENT ILLNESS> ___ with history of central cord syndrome after a fall in ___ who was planned for cervical laminectomy & fusion but lost to follow-up. He presents today for C3-C6 laminectomy & fusion. <PAST MEDICAL HISTORY> seizure disorder HTN DM2 CAD s/p angioplasty ___ Frequent UTIs COPD Obesity Glaucoma Callus Myopia of both eyes with astigmatism and presbyopia Optic nerve cupping s/p ACDF ___ s/p Lumbar spine surgery (pt does not recall levels) ___ both at ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> No HTN, cancer, seizure disorders, + DM and glaucoma. <PHYSICAL EXAM> ON DISCHARGE ============ General: ___ ___ Temp: 99.0 PO BP: 138/79 L Lying HR: 98 RR: 19 O2 sat: 97% O2 delivery: Ra Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: Trap Delt Bi Tri Grip WF/WE IP Q Ham AT ___ G Right 5 5 4+ 4+ 5 4+ ___ 5 4+ 5 Left5 4+ ___ 4+ ___ 5 4+ 5 Hx of rotator cuff injury - c/o LUE pain Wound: Surgical incision dsg c/d/I with staples, no drainage, well approximated <PERTINENT RESULTS> See OMR <MEDICATIONS ON ADMISSION> Aspirin 325mg daily (81mg x 1 week prior to surgery) Albuterol AAP Atorvascatin Bisacodyl Carbamazepine Colace Finasteride Flonase keppra Nystatin Zonisamide Ranitidine Tamsulosin <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q4H: PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Nystatin Cream 1 Appl TP BID groin infection 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: at the floor RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*30 Tablet Refills: *0 7. Senna 8.6 mg PO BID 8. Thiamine 100 mg PO DAILY Duration: 5 Days 9. Albuterol Inhaler 2 PUFF IH Q6H: PRN Wheezing 10. Atorvastatin 40 mg PO QPM 11. Carbamazepine (Extended-Release) 200 mg PO BID 12. Finasteride 5 mg PO DAILY 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. LevETIRAcetam 1500 mg PO BID 15. Ranitidine 150 mg PO BID 16. Tamsulosin 0.8 mg PO DAILY 17. Zonisamide 500 mg PO DAILY <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Central cord syndrome, adjacent level disease <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> Surgery - Your incision is closed with staples. You will need staple removal. - Do not apply any lotions or creams to the site. - Please keep your incision dry until removal of your staples. - Please avoid swimming for two weeks after staple removal. - Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity - You must wear your brace at all times. - You must wear your brace while showering. - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - No contact sports until cleared by your neurosurgeon. - Do NOT smoke. Smoking can affect your healing and fusion. Medications - Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. - Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: - Severe pain, swelling, redness or drainage from the incision site. - Fever greater than 101.5 degrees Fahrenheit - New weakness or changes in sensation in your arms or legs.
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#Central Cord Syndrome On [REDACTED], Mr. [REDACTED] presented for elective C3-C6 laminectomy and fusion. His operative course was uncomplicated, please see OMR for pertinent imaging & labs as well OR details. Postoperatively, he was monitored on the floor where he remained neurologically stable. Pain was well controlled with Tylenol, oxycodone as needed, and IV morphine for breakthrough pain. Patient's posteroperative films were obtained and did not demonstrate hardware migration or other complications. Patient was evaluated by physical therapy who recommended discharge to rehab. #Urinary retention The patient had a difficult Foley coude placement likely due to prostate hypertrophy. Flomax was started. The patient was discharged to rehab with the Foley with plan to follow with Urology as outpatient At the time of discharge, patient was tolerating a regular diet, voiding with Foley, doing activity as appropriate. He was given appropriate prescriptions and instructions to followup in clinic.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Ace Inhibitors <ATTENDING> ___ <CHIEF COMPLAINT> Angioedema <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old male with history of gout and recently diagnosed hypertension presents with throat swelling 3 days after starting lisinopril. The patient reports that on the day of admission he noted swelling in the anterior of his mouth that progressed over the course of the day until he noted, difficulty breathing through his mouth, odynophagia with his soup dinner, voice change and increased throat swelling. Patient also endorsed a sore throat and denies shortness of breath, fevers, chills, rash or similar prior episodes. In the ED, initial vitals temp 98.1 HR 100, BP 200/129, RR 20, O2sat 100% RA. He received solumedrol, famotidine, and benadryl. ENT scope revealed angioedema after starting ACEI, with mild right AE fold edema. Patient BP improved 170/95 and all other vitals remained stable at time of transfer. Patient's airway remains patent. On review of systems: no headache, blurry vision, chest pain, palpitations, shortness of breath, weight change, dysuria <PAST MEDICAL HISTORY> Celiac - on gluten free diet HTN Gout - last episode ___ yr ago Peripheral polyneuropathy ___ celiac disease Osteopenia Sjogren's- dry mouth and dry eyes, SSA ANTIBODY 7.34, positive <SOCIAL HISTORY> ___ <FAMILY HISTORY> Brother DM1, HTN, renal failure, deceased 2 sisters healthy mother breast ca age ___ father died in car accident uncle HTN Physical ___: ON ADMISSION Temp: 37 °C HR: 75 BP: 175/111 RR: 18 SpO2: 95% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL, malonpotty ___ with throat/facial swelling Head, Ears, Nose, Throat: Normocephalic, CN II - XII intact Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand Skin: Warm, Rash: non-blanching right and left shins, chronic intermittent, No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person/place/date/reason for admission, Movement: Purposeful, Tone: Normal <PERTINENT RESULTS> ON ADMISSION ___ 09: 30PM WBC-7.2 RBC-4.53* Hgb-14.1 Hct-40.9 MCV-90 MCH-31.1 MCHC-34.5 RDW-13.5 Plt ___ Neuts-72.0* Lymphs-17.4* Monos-4.0 Eos-5.1* Baso-1.5 ___ 09: 30PM Glucose-104 UreaN-25* Creat-1.1 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-13 RENAL ULTRASOUND <MEDICATIONS ON ADMISSION> Lisinopril 10 mg PO DAILY Multivitamin one tablet PO DAILY Caltrate 600+D two tablets PO DAILY Benzoyl peroxide 4.5 %-10 % to affect areas daily <DISCHARGE MEDICATIONS> 1. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp: *30 Capsule, Sust. Release 24 hr(s)* Refills: *1* 2. Prednisone 20 mg Tablet Sig: as directed Tablet PO once a day for 5 days: please take 2 (two)tablets, ___ and ___ please take 1 (one) tablet ___ please take one- half tablet ___ and then stop. Disp: *7 Tablet(s)* Refills: *0* 3. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 4. Caltrate 600+D Plus Minerals 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Angiotensin converting enzyme inhibitor angioedema Hypertension <DISCHARGE CONDITION> Stable, no respiratory distress <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted with angioedema (swelling of your airway) most likely due to your LISINOPRIL. Your lisinopril was discontinued and you were given steroids, benadryl and famotidine to help with the swelling. You have recovered and are ready to go home. . You should not take any medications in the class of angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (___). . If you develop fevers, chills, nausea, vomiting, shortness of breath, increased facial swelling or trouble swallowing, chest pain or any other concerning symptoms please return to the Emergency Department. . Please take your medications as prescribed. - Your lisinopril was discontinued. - You should continue a prednisone taper for treatment of swelling. - You were started on diltiazem for blood pressure.
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[REDACTED] year-old male with recently diagnosed hypertension presenting with angioedema due to ACE-inhibitor. . ANGIOEDEMA: The patient was recently started on lisinopril. He was seen by ENT on admission with mild right AE fold edema. Lisinopril was discontinued and this was documented as a medication allergy. The patient was initially treated with famotidine 20 mg IV, benadryl 25 mg IV and solumdrol 60 mg IV. He was monitored overnight in the intensive care unit without any compromise in respiratory status. He was transitioned to prednisone 60 mg daily and discharged on a rapid prednisone taper. . HYPERTENSION: Recent diagnosis. The patient underwent renal artery ultrasound during admission that could not exclude renal artery stenosis. The patient's lisinopril was discontinued as above and diltiazem ER 120 mg daily was started with good control. He will follow-up with his primary care physician. . CELIAC SPRUE: He was continued on a gluten-free diet. . NEUROPATHY: No acute issues. . GOUT: No acute issues.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> morbid obesity <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic gastric band placement <HISTORY OF PRESENT ILLNESS> ___ has class III morbid obesity with a weight of 307.7 pounds as of ___ (her initial screen weight on ___ was 308.8 pounds), height of 64 inches and BMI of 52.8. Her previous weight loss efforts include Weight Watchers, ___ and prescription weight loss medication for which she lost 8 pounds but denied that it was Fen/Phen. <PAST MEDICAL HISTORY> ___ borderline hypertension on no medications hyperthyroidism ___ (was on medication for ___ years but has been off since her levels have normalized) h/o urinary tract infections during her teenage years fibroids exposure to parvovirus. PSH Csect x3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother deceased age ___ with lung CA; sister deceased age ___ with history of diabetes. There is a history of hypertension in her grandparents and uterine CA in maternal grandmother. <PHYSICAL EXAM> Blood pressure was high at 147/97, pulse 75, respirations 14 and O2 saturation 100% on room air. On physical examination ___ was casually dressed, pleasant and in no distress. Her skin was warm, dry with no rashes or lesions. Sclerae were anicteric, conjunctiva are clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was pink and the oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple with no adenopathy, thyromegaly or carotid bruits. Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops. The abdomen was obese but soft and non-tender, non-distended with positive bowel sounds and no appreciable masses or hernias, lower transverse incision scars were well healed. Curvature of the back was normal and there was no spinal tenderness or flank pain. Lower extremities were without edema, venous stasis or clubbing with good perfusion and capillary refill. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and her gait was normal. <PERTINENT RESULTS> ___ Liver US : 1. There are no gallstones. 2. Unchanged simple cyst in the liver dome <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Roxicet ___ mg/5 mL Solution Sig: ___ ml PO every ___ hours as needed for pain. Disp: *500 ml* Refills: *0* 2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp: *250 ml* Refills: *2* 3. Multivitamins Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. 4. Cholecalciferol (Vitamin D3) 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> morbid obesity <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> <DISCHARGE INSTRUCTIONS> Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 4. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 5. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites.
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Mrs. [REDACTED] was admitted to the hospital and taken to the Operating Room where she underwent a laparoscopic gastric band. She tolerated the procedure well and returned to the PACU in stable condition. Her hemodynamics were stable and her pain was well controlled with Roxicet. Following transfer to the surgical floor she continued to make good progress. She started a stage 1 diet on the evening of surgery and this was gradually advance on post op day 1 to a stage 3 diet which was well tolerated. Her pain as well controlled with Roxicet and she was up and walking without difficulty. Her port sites were dry except for the upper left which had serous drainage. She was instructed to keep a dry gauze over it until it dried up. She will check her incisions daily for any increased drainage or redness and will call Dr. [REDACTED] she has any concerns. She was discharged to home on [REDACTED] and will follow up with Dr. [REDACTED] in 2 weeks.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Ampicillin / Epogen / Efavirenz <ATTENDING> ___. <CHIEF COMPLAINT> Hiatal hernia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Herniorrhaphy w/ ___ fundoplication <HISTORY OF PRESENT ILLNESS> This patient is a ___ year old female with a medical history significant for known hiatal hernia who presents to ___ on ___ with sudden onset left chest, flank and radiating arm pain. The patient states that this pain was sharp, constant, and similar in quality to other episodes of chest pain that she has experienced in the past though this episode of pain is the most intense. An extensive cardiac work-up including EKG and stress tests all without focal pathology. One set of cardiac enzymes sent last night are negative. The patient states that she experienced severe nausea last night and had several episodes of non-bilious emesis. This nausea abated somewhat over the course of the night but is still present. The patient states that she had an episode of flatus last night, but has not had flatus today. Last bowel movement was yesterday. The surgical service is now consulted for further management of this patient's hiatal hernia. <PAST MEDICAL HISTORY> Hiatal Hernia 1. HIV. 2. HCV 3. Anemia 4. Hypertension 5. Hypercholesterolemia 6. GERD 7. Depression 8. Obesity 9. Glaucoma 10. Spinal arthritis, chronic neck and shoulder pain <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of lung disease in the family. Brother had MI last year (early ___. Dad w/ fatal MI at ___ <PHYSICAL EXAM> VS: T 97.6 HR 63 BP 94/62 RR 16 SpO2 98%RA PE: General: Awake/alert, pleasantly conversant CV: RRR Lungs: CTA bilaterally Abdomen: soft, tender LUQ to deep palpation, no rebound/guarding, +BS Ext: Warm, no edema <PERTINENT RESULTS> ___ 07: 58PM POTASSIUM-3.7 ___ 07: 58PM CK(CPK)-120 ___ 07: 58PM CK-MB-4 cTropnT-<0.01 ___ 07: 58PM MAGNESIUM-1.4* ___ 07: 58PM HCT-32.1* Upper GI Study with Small Bowel Follow Through: ___ IMPRESSION: No extravasation of contrast at surgical site. Marked tapering of distal esophagus with delayed passage of contrast into the stomach is likely due to post-operative edema. Incidentally noted is dense opacification of the left lower lobe of the lung, raising concern for pneumonia. Bilateral pleural effusions left greater than right. <MEDICATIONS ON ADMISSION> ___ Atazanavir ___ Famotidine ___ Sucralfate ___ Camphor-Menthol [Sarna Anti-Itch] ___ Cyclobenzaprine [Flexeril] ___ Emtricitabine-Tenofovir [Truvada] ___ Lidocaine [Lidoderm] ___ Oxycodone ___ Ritonavir <DISCHARGE MEDICATIONS> 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp: *60 Tablet(s)* Refills: *2* 2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain/muscle spasms. Disp: *30 Tablet(s)* Refills: *0* 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical BID (2 times a day) as needed. Disp: *1 tube* Refills: *0* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp: *120 Tablet(s)* Refills: *2* 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Paraesophageal hernia Positive blood culture <DISCHARGE CONDITION> Good, ambulating and voiding without difficulty, taking po without problems, VSS <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please take your medications as prescribed. Please try to stay active throughout the day, as this will further speed up your recovery. The steri-strips on your belly will fall off on their own. Do not take a bath or swim until your follow up appointment, but you may shower. Do not scrub the surgery sites. Call your doctor or return to the Emergency Department right away if any of the following problems develop: * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 100.4 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you.
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Pt was evaluated in the Emergency Room for symptoms as described in HPI on [REDACTED] and CT scan showed persistent, unchanged hiatal hernia. She was already scheduled for a [REDACTED] fundoplication with Dr. [REDACTED] on [REDACTED], so she was discharged to home with a plan to follow up as scheduled on the [REDACTED]. On [REDACTED], she underwent her Laparoscopic repair of paraesophageal hernia with fundoplication, Colles gastroplasty, and placement of prosthetic graft. The surgery was without complications or unexpected findings. She was transferred to the floor and was initially made NPO and had an NG tube in place. She complained of chest pain and "heaviness" so cardiac enzymes were drawn to rule out MI. Enzymes were negative and her chest pain was likely post-operative. Her pain was intially controlled with a PCA. On POD1, she was given clear liquids and her Foley was discontinued. There was initally some concern for low urine output, so she received a fluid bolus for resuscitation and her urine output improved. Her Foley was reinserted so that urine output could be closely followed. On POD4, she spiked a fever. Blood cultures were sent x1. Enterococcus faecalis was grown. She also complained of abdominal pain. An upper GI study with small bowel follow through was obtained which showed anastomotic edema but no extravasation of contrast (no leak). She was started on Ciprofloxacin, but this was discontinued after 24 hours after consultation with infectious disease. ID was consulted for the fever and recommended drawing another set of blood cultures the next day and closely following her temperature. They also recommended removal of her port. Port was not removed during hospital stay as venous access was very difficult in this patient and she remained afebrile with negative cultures after the initial incident. She remained afebrile throughout the rest of her hospital course; further blood cultures were negative as was a urine culture. She was given miconzole powder for her candidasis in her skin folds. ID recommended outpatient follow up with them for resumption of HAART therapy; pt has been on HAART several times and had failed to follow up at several appointment over the past month which had been scheduled for her to restart HAART. On POD8, she had been afebrile for 4 days, her cultures were negative, she was tolerating regular diet, urine output was good, and pain control had been transitioned off PCA and was well controlled on oral medication. [REDACTED] had evaluated her and determined that she was stable to go home. She met discharge criteria and was discharged to home with plans for follow up with ID for HAART therapy and a follow up appointment with Dr. [REDACTED] in 2 weeks. She was also instructed to follow up with her infectious disease doctor to discuss removal of the port.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> aphalesein / tramadol / codeine / Cephalexin / amlodipine <ATTENDING> ___. <CHIEF COMPLAINT> Right great toe infection. <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year old sp recent admission for right superficial femoral artery and anterior tibial angioplasty to promote wound healing of right great toe, presents with increased pain and redness in the toe since discharge. <PAST MEDICAL HISTORY> - ESRD - CVA c/b hemiparesis - CAD s/p CABG - HTN / HL - PVD - Sick sinus syndrome s/p PPM - Non-Hodgkin's lymphoma - Atrial fibrillation on anticoagulation - Hyperparathyroidism (ESRD) - Subdural hematoma - DM (diabetes mellitus), type 2 with complications - Seizure disorder, complex partial - Anemia in chronic kidney disease <PHYSICAL EXAM> <PHYSICAL EXAM> Alert and oriented x 3 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left Femoral palp, DP dop ,___ dop Right Femoral palp, DP dop ,___ dop Right great toe with dry eschar. No reddness or warmth. <PERTINENT RESULTS> ___ 08: 00AM BLOOD WBC-10.3 RBC-3.15* Hgb-9.5* Hct-30.9* MCV-98 MCH-30.2 MCHC-30.8* RDW-14.6 Plt ___ ___ 08: 50AM BLOOD ___ PTT-34.3 ___ ___ 08: 00AM BLOOD Glucose-141* UreaN-39* Creat-5.9* Na-141 K-3.4 Cl-102 HCO3-28 AnGap-14 ___ 08: 00AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.0 ___ 08: 00AM BLOOD Vanco-13.4 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. LeVETiracetam 500 mg PO ___ 2. LeVETiracetam 250 mg PO AM 3. Digoxin 0.0625 mg PO DAILY ___ MD to order daily dose PO DAILY16 5. Atorvastatin 10 mg PO DAILY 6. NPH 30 Units Breakfast Regular 6 Units Breakfast Insulin SC Sliding Scale using REG Insulin 7. Ferrous Sulfate 325 mg PO DAILY 8. Ferrous Sulfate 650 mg PO HS 9. Metoclopramide 10 mg PO TID: PRN nausea 10. Pantoprazole 40 mg PO Q24H 11. Aspirin 81 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Pyridoxine 100 mg PO DAILY 14. Vitamin D ___ UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Ferrous Sulfate 325 mg PO DAILY 5. Ferrous Sulfate 650 mg PO HS 6. NPH 30 Units Breakfast Regular 6 Units Breakfast Insulin SC Sliding Scale using REG Insulin 7. FoLIC Acid 1 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY Duration: 28 Days 9. Ciprofloxacin HCl 500 mg PO Q24H 10. Nephrocaps 1 CAP PO DAILY 11. Vancomycin 1000 mg IV HD PROTOCOL 12. TraMADOL (Ultram) 25 mg PO Q6H: PRN pain 13. Senna 8.6 mg PO BID: PRN constipation 14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 15. LeVETiracetam 250 mg PO DAILY 16. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral daily 17. Acetaminophen 1000 mg PO TID 18. Docusate Sodium 100 mg PO BID 19. Metoclopramide 10 mg PO TID: PRN nausea 20. ___ MD to order daily dose PO DAILY16 please hold this medication until surgery ___. Pantoprazole 40 mg PO Q24H 22. Pyridoxine 100 mg PO DAILY 23. Vitamin D ___ UNIT PO DAILY 24. LeVETiracetam 500 mg PO ___ <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Right great toe infection Peripheral Arterial Disease <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> You were admitted to the hospital with worsening pain and discoloration in your right great toe. We started you on IV antibiotics and the pain and color improved. We will continue antibiotics until you return for surgery on your toe. Please keep the area dry and protected until that time. We will restart your home coumadin dose tonight, ___. The last dose of coumadin prior to your surgery will be ___.
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The patient was admitted to the hospital from the clinic secondary to an infected right great toe on [REDACTED]. He was started on vanco, cipro and flagyl. The warmth, redness and tenderness of the toe improved over time. He never experienced any systemic signs of infection sure as elevated wbc, temp or rigor. We performed forefoot PVRs that showed adequate circulation, after the recent angioplasty, to heal a surgical debridement of the clearly devitalize tissue on the toe. We will discharge him to home with [REDACTED] services, continue the IV vanco with HD as well as oral cipro and flagyl. He will return for surgery on [REDACTED]. We will restart his coumadin and have instructed him and his family to hold the coumadin after the [REDACTED] dose.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> levofloxacin <ATTENDING> ___. <CHIEF COMPLAINT> leg swelling, anemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> echo <HISTORY OF PRESENT ILLNESS> ___ with NIDDM, HTN, CKD 3, chronic low back pain, recent diagnosis of ___ fistula(? due to constipation, planned for CRS as outpatient). She is here with 10 days of worsening bilateral lower extremity swelling. Earlier it was also a/w redness, currently not. No h/o leg swelling in the past. No h/o heart disease. No recent illness. no dyspnea. ROS positive for increased urinary frequency, high chronic sodium intake. no fever, chills, AMS. has chronic constipation, no recent change, o abdominal pain/nausea/vomiting. appetite poor, no weight loss. Of note, her gabapentin was recently increased from 1200mg/day to 1600mg/day for low back pain. Review of outpatient records show that amlodipine was increased from 5mg to 10mg daily in ___. Otherwise negative across 10 systems <PAST MEDICAL HISTORY> "back surgeries", "some screws in there", most recently ___ years prior to this admission pancreatitis, on Creon GERD constipation TAH <SOCIAL HISTORY> ___ <FAMILY HISTORY> no significant family history contributing to this admission <PHYSICAL EXAM> Gen: obese female in no acute distress HEENT: . no icterus. MMM< neck supple Neck: supple. no JVD Chest: CTAB, no wheezes or crackles ___: s1s2, RRR ___: soft, nt, nd, bs present Ext: b/l 1+ ___ edema Neuro: normal speech, non focal Psych: mood appropriate, pleasant <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Gabapentin 400 mg PO Q6H 3. amLODIPine 10 mg PO DAILY 4. Ranitidine 300 mg PO DAILY 5. Rosuvastatin Calcium 10 mg PO 3X/WEEK (___) 6. Aspirin 81 mg PO 3X/WEEK (___) <DISCHARGE MEDICATIONS> 1. Carvedilol 6.25 mg PO BID RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 2. Aspirin 81 mg PO 3X/WEEK (___) 3. Gabapentin 400 mg PO Q6H 4. Losartan Potassium 100 mg PO DAILY 5. Ranitidine 300 mg PO DAILY 6. Rosuvastatin Calcium 10 mg PO 3X/WEEK (___) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> bilateral leg edema, non cardiac <DISCHARGE CONDITION> ambulating, alert and oriented x3, tolerating diet. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital with leg swelling. After switching your blood pressure medication from amlodipine to carvedilol. Amlodipine has been known to cause leg swelling. You had an ultrasound of your heart which was unremarkable. Of note, on your blood work, it showed anemia, likely iron deficiency. Since you are not symptomatic from this, and had no blood in your stool or urine, you can safely follow this up with your primary care doctor as an outpatient.
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[REDACTED] with NIDDM, HTN, CKD 3, chronic low back pain, recent diagnosis of [REDACTED] fistula(? due to constipation, planning for colorectal surgery). She is here with 10 days of worsening bilateral lower extremity swelling. also noted to have anemia, pyuria [REDACTED] edema: -medication induced, from recently increased amlodipine [REDACTED]. -echo checked, without evidence of heart failure. Lower extremity edema lessened overnight. BNP checked and was normal, and no volume overload on imaging or physical exam. -check TSH - mildly elevated, follow up as outpt #Anemia: acute on chronic: ferritin is on low end of normal (13). no hemolysis per labs. Counts have increased overnight. Discussed sources of [REDACTED] diet, apparently she does not eat red meat. Hesitant about starting oral iron supplements because of chronic constipation. She can review starting a supplementation with her primary care physician. #Pyuria: in absence of symptoms, will not treat. #DM: NIDDM. on linagliptin at home. will do ISS here, and discharge on home medications. #HTN: uncontrolled. d/c amlodipine due to leg swelling(can reduce it too but then she will need 3 meds). started on Coreg 12.5mg po bid. Tolerated this well. Can [REDACTED] fistula, Chronic constipation: continued on home regimen. #CKD 3: Cr at baseline. from prior [REDACTED] episodes, on home losartan dose #Sleep apnea: CPAP at night #DVT px: hep subq 5000u bid #Nutrition: low salt diet
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain and weakness <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ with history of HCV, ___ s/p left lateral segmentectomy in ___ who presents now with ___ weeks of abdominal pain and overall weakness. He reports that ~10 days ago he had a few days of nausea and emesis; after this passed he began to feel very weak with decreased energy and dyspnea on exertion. Over the same time period he has begun to have sharp right upper quadrant pain, described as under his ribs, worsening with deep breaths in. He has been treating this with advil, he states that he takes three pills (unk strength) once a day. He also endorses involuntary 20lb weight loss over the past month. He denies hematemesis, denies blood in his stool or dark stools, denies changes in urinary frequency/urgency or color. He denies fevers or chills at home. 13 point review of systems is otherwise negative. <PAST MEDICAL HISTORY> PMHx: perforated diverticulitis Hepatitis C, diagnosed in ___ w/o antiviral therapy h/o alcohol abuse h/o tobacco abuse glaucoma cataracts PSurgHx: sigmoidectomy & diverting loop ileostomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PHYSICAL EXAM: 98.7 95 100/61 16 100% Gen: AAOx3, comfortable, NAD, cooperative and pleasant HEENT: PERRL, sclera anicteric, oropharynx clear CV: RRR, no m/r/g Pulm: CTAB Abd: BS(+), soft, ND, mild TTP at RUQ. Prior surgical incisions consistent with previous segmentectomy well-healed, non-indurated, non-erythematous, non-tender. G/U: Deferred MSK: No c/c/e <PERTINENT RESULTS> ___ 04: 00PM GLUCOSE-122* UREA N-19 CREAT-1.3* SODIUM-132* POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15 ___ 04: 00PM ALT(SGPT)-34 AST(SGOT)-120* LD(LDH)-537* ALK PHOS-472* TOT BILI-0.9 ___ 04: 00PM LIPASE-160* ___ 04: 00PM proBNP-251* ___ 04: 00PM ALBUMIN-3.5 IRON-19* <MEDICATIONS ON ADMISSION> Occasional NSAID use. <DISCHARGE MEDICATIONS> 1. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth q12 hours Disp #*60 Tablet Refills: *2 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q ___ hours PRN Disp #*40 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth BID PRN Disp #*60 Capsule Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Extensive liver lesions (presumably recurrent hepatocellular carcinoma) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call Dr. ___ office at ___ for fever, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications. You will be following up with the oncologist Dr ___ for possible liver biopsy and treatment discussions. Please continue omeprazole 2 of the 20 mg tablets twice a day due to the stomach and small intestine ulcers that developed most likely due to the amount of advil (ibuprofen) you were taking. This prescription has been called into the ___ at ___ (___) in ___. It should be covered by your insurance. Please take 2 of the 20 mg tablets twice a day and avoid the use of ibuprofen (advil), aspirin or any aspirin containing products. Please see Dr ___ (___) as soon as possible for further evaluation and treatment options. No driving if taking narcotic pain medication.
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Mr. [REDACTED] was admitted to the Hepatobiliary Surgical Service on [REDACTED] with abdominal pain and weakness as described above. His initial labs demonstrated a significant anemia, with a hematocrit of 19.7. Further review of his history raised the possibility of an upper GI bleed, as it was determined he had been taking high doses of NSAIDs for his abdominal pain, and had unclear history of melanotic stools and/or blood-tinged emesis. He was initially admitted to the Surgical ICU, where he was stabilized with 2 units of packed red blood cells. His hematocrit then rose to 23.4, at which time he was transfused an additional 2 units. His hematocrit then stabilized at 28.2. A CT of his abdomen performed shortly after admission on [REDACTED] revealed the following: 1. Extensive hepatic lesions (presumably HCC) with extensive mesenteric root, porta hepatis lymphadenopathy, and mediastinal lymphadenopathy as well as mesenteric/omental implants and possible pancreatic and mesenteric vein invasion as described above. Nonhemorrhagic ascites. No areas of active hemorrhage within the mass lesions or along the course of the bowel are present. 2. Gastroesophageal varices. 3. Nonhemorrhagic right pleural effusion with associated atelectasis. New bilateral pulmonary nodules concerning for metastases. Given the size and distribution of his hepatic lesions, Mr. [REDACTED] was determined to be not eligible for surgical resection. Mr. [REDACTED] also received an esophago-gastric endoscopy to evaluate his suspected upper GI bleed, anemia, and abdominal pain. This study revealed the following: - [REDACTED] B distal esophagitis, 2 cords of small esophageal varices without red whale signs left undisturbed, irregular GEJ with 2 tongues of salmon like mucosa left undisturbed. - Diffuse mild to modorate erythema with deformed antrum and pyloric area. One small 1cm clean based ulcer with surrounding edema and erythema left undisturbed. Retroflex view revealed a moderate hiatal hernia, hiatus ~3cm. - Duodenitis and one small <1cm superficial clean based ulcer in the duodenal bulb left undisturbed, normal second portion. - Otherwise normal EGD to second part of the duodenum. The etiology of his anemia was determined to be a combination of hepatic lesions/HCC as well as upper GI bleed, possibly secondary to NSAID use. After hemodynamic and cardiovascular stabilization with transfusions as above, Mr. [REDACTED] was transferred out of the SICU to the surgical floor. His liver lesions and clinical case was discussed during a multi-disciplinary hepatic tumor conference. It was determined he would benefit from biopsy of his lesions, with possible systemic therapy to be determined as an outpatient. Mr. [REDACTED] future outpatient care was coordinated with the hematology-oncology service, and he was discharged on [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Metformin / Glipizide <ATTENDING> ___. <CHIEF COMPLAINT> Headaches <MAJOR SURGICAL OR INVASIVE PROCEDURE> Brain Biopsy <HISTORY OF PRESENT ILLNESS> ___ y/o female with history of HIV and worsening headaches, found to have non specific white matter changes on CT with a negative medical work up. <PAST MEDICAL HISTORY> NIDDM HIV - since ___, on HAART until 4 days ago, CD4 699 in ___ Migraine HIV meningitis and encephalopathy ___ - presented with 3 months of headache, CD4 down to 193, HIV viral load ___, negative for Tb, toxoplasma IgG, histoplasma Ag at that time) - dx "viral rebound" secondary to d/cing HAART for 2 months or leptomeningeal lymphoma Menorragia <SOCIAL HISTORY> ___ <FAMILY HISTORY> DM2 in mother and father, now deceased <PHYSICAL EXAM> Awake and Alert Oriented x 3 CN ___ grossly intact PERRL ___ strength throughout Wound: dressing C/D/I with no drainage. <PERTINENT RESULTS> Pathology on Brain biopsy: pending. <MEDICATIONS ON ADMISSION> 1. Abacavir 300 mg tablet, two tablets by mouth daily. 2. Atazanavir 150 mg capsule, two capsules by mouth daily. 3. Gabapentin 300 mg two capsules by mouth at bedtime. 4. Glipizide 5 mg extended release one tablet by mouth daily. 5. Lamivudine 300 mg tablet, two tablets by mouth daily. 6. Morphine 50 mg tablet sustained release every 12 hours as needed. 7. Ritonavir 100 mg capsule one capsule by mouth daily. <DISCHARGE MEDICATIONS> 1. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Unknown, pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General Instructions -Have a friend/family member check your incision daily for signs of infection. -Take your pain medicine as prescribed. -Exercise should be limited to walking; no lifting, straining, or excessive bending. -You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. -You may shower before this time using a shower cap to cover your head. -Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. -Clearance to drive and return to work will be addressed at your post-operative office visit. -Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING -New onset of tremors or seizures. -Any confusion or change in mental status. -Any numbness, tingling, weakness in your extremities. -Pain or headache that is continually increasing, or not relieved by pain medication. -Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. -Fever greater than or equal to 101° F.
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Ms. [REDACTED] was admitted to the Neurosurgery service to undergo an elective right frontal brain biopsy after a long hospitalization previously where a work up of the enhancing white matter was non diagnostic. Operative course was uncomplicated. Post operatively she was admitted to the neurosurgical floor and on POD #1 she was eating, voiding and ambulating independently.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "I'm hearing voices of the mafia and CIA" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None. <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ year old man with a self-reported history of schizophrenia who was brought to the ___ ED by EMS and police with paranoid delusions and auditory hallucinations. Psychiatry was consulted for a safety evaluation. Mr. ___ says that he is hearing voices of the mafia and CIA. Looking over the interviewer's shoulder, he says "there are people all over here watching you with guns. He made several threatening comments, such as, you better what out what you ask me in here, people are watching you. He says that he is always watched by satellites, and he endorsed delusions of thought broadcast. He denies depression, but he says that he has been thinking of shooting himself in the head to join his father. He says that he has access to guns. He says that he lives in an apartment in ___, and he could not explain how he got to ___. He says that he has been taking medications but could not list them. . Collateral from BEST: No record of the patient. <PAST MEDICAL HISTORY> None. <SOCIAL HISTORY> <SOCIAL HISTORY> Born and raised in: Says he was born in ___ until he was kidnapped Family/Support: Never knew his father. Mother lives in ___. No siblings. Has a wife and ___ year old daughter. Wife has custody of daughter. ___: Lives in an apartment in ___ Education: Finished high school Employment/Income: Receives SSDI. Has worked as a ___ in the past. Spiritual: Muslim Trauma history: Pt reports h/o sexual abuse in late teens and more recently this year. Substance Abuse History: Tobacco: ___ cigarettes/day currently. Alcohol: Denies issues with abuse in the past. Last drink was day of admission when pt had 1 beer. Illicit drug use: Marijuana last smoked ___ years ago. Cocaine last used ___ year ago. Pt guarded on this topic. FORENSIC HISTORY: Arrests: denies Convictions and jail terms: denies Current status (pending charges, probation, parole): N/A <FAMILY HISTORY> Unknown if there is a h/o psychiatric illness in pt's family. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM EXAM: *VS: 98.6 76 132/78 18 100% Neurological: *station and gait: normal station and gait *tone and strength: normal tone, strength ___ throughout cranial nerves: abnormal movements: frontal release: Cognition: Wakefulness/alertness: awake and alert *Attention (digit span, MOYB): refused to attempt *Orientation: ___, ___" *Memory: ___ registration *Fund of knowledge: ___ wrote: doesn't know. ___ ___ wrote: Keep your head up Executive function (go-no go, Luria, trails, FAS): Calculations: Abstraction: Visuospatial: *Speech: normal rate, rhythm, volume, and prosody *Language: fluent without paraphasic errors Mental Status: *Appearance: a young man with buzzed hair, appears calm, appears stated age, wearing hospital gown Behavior: cooperative and appropriate, good eye-contact *Mood and Affect: "OK"/euthymic, reactive *Thought process / *associations: linear, goal-directed, no LOA *Thought Content: auditory and visual hallucinations of the CIA and men with guns in the ED, delusions that satellites are watching him, thought broadcasting, SI with plan and intent, no HI *Judgment and Insight: poor <PERTINENT RESULTS> LABS ___ BLOOD WBC-4.3 RBC-5.13 Hgb-14.9 Hct-44.8 MCV-87 MCH-29.0 MCHC-33.3 RDW-12.7 RDWSD-40.8 Plt ___ ___ BLOOD Neuts-36.8 ___ Monos-10.8 Eos-2.8 Baso-0.5 Im ___ AbsNeut-1.57*# AbsLymp-2.09 AbsMono-0.46 AbsEos-0.12 AbsBaso-0.02 ___ BLOOD Plt ___ ___ BLOOD Glucose-107* UreaN-15 Creat-1.1 Na-139 K-4.2 Cl-101 HCO3-28 AnGap-14 ___ BLOOD ALT-28 AST-17 AlkPhos-61 TotBili-0.4 ___ BLOOD Calcium-9.3 Phos-5.2* Mg-2.1 ___ BLOOD Ammonia-49 MICRO ___ RAPID PLASMA REAGIN TEST NEGATIVE IMAGING None. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q6H: PRN tooth pain <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN tooth pain 2. Benztropine Mesylate 1 mg PO BID RX *benztropine 1 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills: *0 3. Divalproex (DELayed Release) 750 mg PO BID RX *divalproex ___ mg 3 tablet(s) by mouth twice a day Disp #*84 Tablet Refills: *0 4. HydrOXYzine 50 mg PO BID: PRN anxiety/insomnia RX *hydroxyzine HCl 50 mg 1 by mouth twice a day Disp #*28 Tablet Refills: *0 5. RISperidone 3 mg PO BID RX *risperidone 3 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills: *0 6. ZIPRASidone Hydrochloride 80 mg PO BID RX *ziprasidone HCl 80 mg 1 capsule(s) by mouth twice a day Disp #*28 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Schizoaffective Disorder <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. *Appearance: Young, well appearing ___ male who appears states age. Wearing a sweatshirt and black jeans. Fair grooming. Sitting up in chair, in no acute distress *Behavior: Calm and cooperative, answers questions appropriately. Good eye contact. No PMA/PMR *Mood and Affect: 'I'm good' / Affect seems overall euthymic, less irritable and more friendly, normal range, not overly expansive today *Thought process (including whether linear, tangential, circumstantial and presence or absence of loose *associations): Less tangential today *Thought Content (including presence or absence of hallucinations, delusions, homicidal and suicidal ideation, with details if present): Denies AVH, denies SI, denies HI. *Judgment and Insight: Limited but improved / limited but improved Cognition: *Language: Native ___ speaker, fluent without paraphrasic errors *Speech: Normal rate, rhythm, volume, tone. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Discharge Instructions -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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SAFETY: The pt. was initially placed on q5 minute checks and was restricted from sharps on admission. He consistently remained in good behavioral control, and was advanced to q15 minute checks. He was unit-restricted. There were no acute safety issues, and he required no physical or chemical restraints during this hospitalization. . LEGAL: [REDACTED] PSYCHIATRIC: #).Schizoaffective Disorder: On admission interview, patient demonstrated clear paranoia and delusions. He talked at length about concerns that he was being monitored by the CIA, and expressed concerns that there could be ninjas hiding among the hospital staff. Patient endorsed clear AVH on discharge, reporting that he saw snipers outside of the building. Patient had also made suicidal statements, stating that he had been thinking about eventually shooting himself at some point in the future in order to protect the President of the [REDACTED]. Patient also demonstrated some mood lability and expansiveness, and was at times hypersexual, verbally flirting with females on the unit, but notably was redirectable and maintained behavioral control overall. In turn, patient's clinical presentation was most consistent with a decompensation of his schizoaffective disorder, likely in the setting of medication noncompliance. . From a psychopharmacological standpoint, patient was restarted on risperidone, which was gradually uptitrated to 3mg po BID. Patient was also written for Cogentin 1mg po BID to prevent EPS, as well as hydroxyzine 50mg po BID prn anxiety, insomnia. To target mood lability, patient was started on Depakote, which was uptitrated to 750mg po BID. Patient continued to demonstrate some paranoia and delusions on risperidone alone, so risperidone was augmented with ziprasidone, which was slowly uptitrated to ziprasidone 80mg po BID. Patient tolerated this medication regimen well, and reported no adverse effects. Platelets were somewhat low on admission at 144, and patient reported that this has been a chronic problem in the past. Platelets were rechecked several times while on Depakote, and remained stable, last platelet count was 132 on [REDACTED]. Patient's outpatient provider should continue to monitor CBC as appropriate. On this regimen, patient demonstrated much less paranoia. He no longer reported any AVH, and did not appear to be internally preoccupied. He reported that his overall mood was "better," more balanced, and demonstrated less mood lability. Patient denied SI and HI consistently for several days prior to discharge. Again, on day of discharge, patient denied SI, denied HI, denied AVH, and remained future oriented, with plans to clean up his apartment in [REDACTED] and go shopping for groceries with his PACT team. Patient was actively engaged in the therapeutic process, meeting with treatment team daily for individual therapy, and also participating in some group and milieu therapy as tolerated. Upon discharge, patient was provided with prescriptions for benztropine 1mg po BID, Depakote 750mg po BID, Vistaril 50mg po BID prn anxiety/insomnia, risperidone 3mg po BID, and ziprasidone 80mg po BID. Patient's PACT team was contacted during this hospitalization and again prior to discharge to coordinate aftercare. On discharge, patient was sent via ambulance to his PACT team, and patient's PACT team case manager planned to meet with patient on each day of weekend following discharge. Patient was also scheduled for a follow-up appointment with his PACT team psychiatrist on [REDACTED]. Patient was in good understanding and agreement with this aftercare plan. . GENERAL MEDICAL CONDITIONS: #).Chronic tooth pain: Patient did complain of some chronic tooth pain, for which he had been taking ibuprofen. Patient remained afebrile, hemodynamically stable, and demonstrated no signs of infection during this hospitalization. Patient was continued on ibuprofen 600mg po q6h prn pain. Patient should continue to follow-up with his PCP and dentist upon discharge for ongoing management. . PSYCHOSOCIAL: #) GROUPS/MILIEU: Pt was encouraged to participate in units groups/milieu/therapy opportunities as appropriate. Patient was at times noted to be somewhat intrusive in milieu, but ultimately was responsive to staff redirection. He was more visible in the unit as the hospitalization progressed, and had conversations with peers. He attended groups as tolerated. He never engaged in any unsafe behaviors. He ate all meals in the milieu, slept well, and cooperated with group rules. . #) COLLATERAL CONTACTS: Patient's PACT team and PACT team psychiatrist, Dr. [REDACTED] contacted by the primary treatment team for collateral information, and were provided with clinical updates on this hospitalization. PACT team was contacted by our social worker prior to discharge in order to coordinate aftercare plans. As detailed above, at time of discharge, patient was sent via ambulance to his PACT team, at which time PACT team case manager will resume coordinating outpatient care. . #) INTERVENTIONS: - Medications: risperidone, ziprasidone, Depakote, Vistaril - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: coordinated in conjunction with patient's PACT team as detailed above - Behavioral Interventions (e.g. encouraged DBT skills, ect): Patient was encouraged to continue to participate in groups as tolerated, with particular emphasis on identifying positive coping mechanisms . INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting these medications, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. . RISK ASSESSMENT: #) Chronic/Static Risk Factors: -history of chronic mental illness with many prior hospitalizations -history of numerous failed medication trials, including failures on IM depot medications #) Modifiable Risk Factors: -chronic history of medication noncompliance and poor follow-up with established aftercare plans -reported history of self injury and suicide attempts #) Protective Factors: -patient has established outpatient treatment through his PACT team -patient is currently medication compliant . PROGNOSIS: Overall, patient has a very guarded longterm prognosis, given his history of numerous prior hospitalizations, numerous failed medication trials, and history of not following through with established after care plans. However, protective factors at this point include the fact that the patient has very comprehensive, involved outpatient treatment though his PACT team, he is currently medication compliant, and upon discharge from this hospitalization, he is being sent by ambulance directly into the care of his PACT team, who will continue to monitor him. Patient will continue to require longterm intensive outpatient follow-up as facilitated via his PACT team, in order to help him manage his psychopharmacology regimen, to provide him with outpatient therapy, and to help provide him with additional outpatient supports in the community. .
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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> food stuck in throat <MAJOR SURGICAL OR INVASIVE PROCEDURE> EGD <HISTORY OF PRESENT ILLNESS> ___ yo male with a PMHx of reflux disease who presents with a sensation of food being stuck in his throat after eating a sausage at ___ this evening. He reports having 2 bites of the sausage and then having a senstation that food was stuck in his chest. Since then, the patient has not been able to drink or swallow his secretions without vomiting. He reports vomiting secretions approximately every 5 minutes since he ingested the sausage. He reports ___ chest pain in the area of the xiphoid process with some radiation up to his neck. He denies dysphagia or odynophagia, similar episodes previously, or hematemesis. He has never had an EGD or history of strictures or esophageal webs. He denies any shortness of breath, cough or wheezing. . In the ED, initial vs were: T 98.8 P ___ BP 151/101 26 R O2 sat 99% ra. Patient was given nitroglycerin 0.4 SL & glucagon 1 mg IM without any improvement in his symptoms. In addition, he was given 500ml NS. GI was consulted and they plan to perform an EGD to remove the foreign body tonight in the ICU. . On the floor, the patient is vomiting and reports feeling very fatigued. He is breathing comfortably otherwise stable. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache cough, shortness of breath. Denies palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits. No dysuria. Denied arthralgias or myalgias. . <PAST MEDICAL HISTORY> # gastroesophageal reflux disease - symptoms for past ___ years, on prevacid for approximately ___ year. # Lt foot surgery complicated with compartment syndrome at age of ___ y/o. # s/p tonsilectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Grandmother with h/o PUD. <PHYSICAL EXAM> Vitals: T: 99.7 BP: 156/95 P: 98 R: 21 O2: 98% General: Alert & oriented x3 vomiting intermittently, diaphoretic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: rapid rate, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops. CP non-reproducible. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema <PERTINENT RESULTS> ADMISSION LABS: ___ 09: 30PM WBC-8.7 RBC-4.86 HGB-13.5* HCT-39.7* MCV-82 MCH-27.8 MCHC-34.1 RDW-12.8 ___ 09: 30PM NEUTS-71.8* ___ MONOS-3.2 EOS-3.9 BASOS-0.4 ___ 09: 30PM PLT COUNT-248 ___ 09: 30PM GLUCOSE-109* UREA N-18 CREAT-1.1 SODIUM-144 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-15 . EGD REPORT ___ Impression: Esophageal ring Esophagitis in the lower third of the esophagus No food bolus present in the esophagus. Ring was widely patent. Otherwise normal EGD to gastro-esophageal junction Recommendations: Protonix or Nexium or Omeprozole 40mg bid Outpt followup with GI for repeat EGD with biopsy in ___ wks Soft solids until followup EGD. . EKG: NSR 96, no ST or TW changes. <MEDICATIONS ON ADMISSION> Prevacid - dose unknown, takes PRN <DISCHARGE MEDICATIONS> 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp: *60 Capsule, Delayed Release(E.C.)(s)* Refills: *2* 2. ___ 200-25-400-40 mg/30 mL Mouthwash Sig: Thirty (30) ML Mucous membrane TID (3 times a day) as needed for throat pain. Disp: *200 ML(s)* Refills: *0* 3. Oxycodone-Acetaminophen ___ mg/5 mL Solution Sig: ___ MLs PO every six (6) hours as needed for pain. Disp: *100 ML(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Food impaction GERD with esophagitis and esophageal ring <DISCHARGE CONDITION> stable. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You were admitted with a likely food bolus impaction in you lower esophagus. You underwent an EGD and it was found that the food bolus had cleared. You were found to have changes in your esophagus consistent with acid reflux and it was recommended that you start omeprazole 40 mg by mouth twice daily. You do not need to continue to take prevacid. Please follow up with the ___ clinic as below.
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This is a [REDACTED] yo healthy male with history of GERD presented with the sensation that food was stuck in lower esophagus and suffered from vomiting. # food impaction - The patient likely had a food bolus obstructing his lower esophagus and causing persistent vomiting. He did vomit a small amount of the food bolus in the ED, but continued to be unable to swallow his secretions or other liquids. Glucagon and NTG SL did not improve his symtpoms. The patient was admitted to the ICU for urgent EGD. EGD was performed and not food bolus was found in the esophagus. The patient was noted to have esophagitis and an esophageal ring. It was recommend that he be started on omeprazole 40mg PO daily. The patient was advised to eat soft solids and follow up with gastroenterology in [REDACTED] weeks. He remained hemodynamically stable during this admission.
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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> cough <MAJOR SURGICAL OR INVASIVE PROCEDURE> catheter exchange G-tube placement <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ man with a past medical history of MSA, COPD, chronic respiratory failure s/p tracheostomy, Afib (on Eliquis), CAD, HFpEF, bilateral RAS s/p stenting, s/p suprapubic catheter, who presents with cough. The patient was recently admitted ___ for aspiration pneumonitis and respiratory failure. He initially required ICU admission for hypotension. Over the past 3 days, the patient's wife has noticed him coughing at night, and he has required more frequent trach suctioning (up to every 1hr) with dark brown sputum. He also endorsed dyspnea and night sweats. At baseline he does not require suctioning overnight and has white secretions. He has not been noted to have fever, chills, N/V, chest pain, abd pain, suprapubic pain, diarrhea or bleeding issues. He has selectively been eating soft cooked foods cut into small pieces at home, but has not had any witnessed episodes of aspiration. He is due for suprapubic catheter exchange next week. In the ED, initial VS: 99.4, P 93, BP 119/66, R 20, O2 Sat 98% on RA. Kabs were notable for ABG: 7.4/___, TnT 0.1, lactate 1.5, Cr 1.3, proBNP 5773, WBC 10.4, HCT 33.5. CXR was notable for mild cardiomegaly and fullness in the central pulmonary vasculature. The patient was started on vancomycin/Zosyn for empiric coverage of PNA. Currently, the patient reports feeling well, without chest pain, dyspnea or other discomfort. REVIEW OF SYSTEMS: Complete 10-point ROS obtained and is otherwise negative. <PAST MEDICAL HISTORY> # Multi-system Atrophy (previously followed by neurologist at ___ # AFib on Apixaban # CAD s/p IMI - Coronary angiography (___): LAD 80%, occluded after D2, LCx: Occluded OM1, OM2, RCA: Occluded, fills via L-R collaterals # HFpEF (LVEF >60%) # Tracheobronchomalacia - s/p ___ silver trach most recently placed in ___ # PVD s/p bl CIA stents in ___ # Bilateral renal artery stenosis s/p stenting in ___ # OSA # h/o GIB # h/o adenomatous polyp in ___ (poor prep) # Obstructive lung disease: - PFT (___): Moderate <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. His mother has ___ disease. Father died at age ___ of heart failure. <PHYSICAL EXAM> PHY VITALS: T 98.3, BP 100/65, P 75, R 24, O2 Sat 100%RA GENERAL: Chronically ill-appearing man in NAD HEENT: PERRL, dry MM NECK: No JVD. No bruits. CARDIAC: RRR. No MRG. LUNGS: Trace crackles at bases. ABDOMEN: Soft NTND. +suprapubic catheter in place. EXTREMITIES: Thin extremities without edema. NEUROLOGIC: AAO. ___ severely weak (chronic). Moving UE without asymmetry. DISCHARGE PHYSICAL EXAM: Vitals reviewed - please see eflowsheet GENERAL: Alert and in no apparent distress, trach in place, EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart irregularly irregular, no murmur, no S3, no S4. No JVD. RESP: No labored breathing. No longer has anterior lung wheezes, no crackles in bases GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. G-tube in place with no erythema or bleeding. No HSM GU: Suprapubic catheter in place. No suprapubic fullness or tenderness to palpation <PERTINENT RESULTS> Discahrge labs: ___ 05: 10AM BLOOD WBC-4.7 RBC-3.26* Hgb-9.5* Hct-31.5* MCV-97 MCH-29.1 MCHC-30.2* RDW-14.6 RDWSD-51.4* Plt ___ ___ 05: 10AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-148* K-4.1 Cl-103 HCO3-33* AnGap-12 ___ 05: 16AM BLOOD CK-MB-3 cTropnT-0.14* proBNP-___* CXR: IMPRESSION: Mild cardiomegaly and fullness of central pulmonary vasculature in keeping with volume overload. No frank pulmonary edema CT chest: IMPRESSION: Mild pulmonary edema, left atrial enlargement, should be evaluated by echocardiography. Extensive primarily basilar pulmonary consolidation, in the setting of a severely dilated upper esophagus is attributable to chronic aspiration. No tracheoesophageal fistula was demonstrated on a barium swallow in ___. Nodular right lower lobe lesions could be other foci of chronic aspiration changes or infection, but will need to be monitored with a repeat chest CT in 3 months to exclude malignancy, including lymphoma. No evidence of pulmonary fibrosis. Moderate reactive central adenopathy. Severe atherosclerotic coronary, moderate head and neck calcification. Possible chronic lower aortic dissection not fully evaluated on the noncontrast study, but with no evidence of progression. RECOMMENDATION(S): Monitor esophageal patency and function. CXR ___: In comparison with the study of ___, the tracheostomy tube is unchanged. Continued substantial enlargement of the cardiac silhouette with stable or increasing pulmonary vascular congestion. Bilateral pleural effusions are again seen with underlying compressive atelectasis. In view of the extensive changes described above, it would be impossible to exclude superimposed aspiration/pneumonia in the appropriate clinical setting, especially in the absence of a lateral view. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Calcium Carbonate 500 mg PO DAILY 3. melatonin 6 mg oral HS 4. MethylPHENIDATE (Ritalin) 2.5 mg PO DAILY 5. Bumetanide 1 mg PO QHS 6. Acetylcysteine 20% ___ mL NEB TID 7. AcetaZOLamide 250 mg PO Q12H 8. Albuterol Inhaler 2 PUFF IH Q4H: PRN SOB 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H <DISCHARGE MEDICATIONS> 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*4 Tablet Refills: *0 2. AcetaZOLamide 250 mg PO Q12H 3. Acetylcysteine 20% ___ mL NEB TID 4. Albuterol Inhaler 2 PUFF IH Q4H: PRN SOB 5. Apixaban 2.5 mg PO BID 6. Artificial Tears ___ DROP BOTH EYES TID: PRN dry eyes 7. Bumetanide 1 mg PO QHS 8. Calcium Carbonate 500 mg PO DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 10. melatonin 6 mg oral HS 11. MethylPHENIDATE (Ritalin) 2.5 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> pneumonia aspiration New g-tube placement atrial fib HFpEF anemia CAD suprapubic catheter <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 Mr. ___, You were admitted for evaluation of shortness of breath and increased sputum production and treated for pneumonia. You were also found to have evidence of aspiration so, after discussions with you and your wife, a feeding tube was placed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Your "dry weight" should be around 168 lbs. Sincerely, Your ___ Team
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[REDACTED] man with a past medical history of MSA, COPD, chronic respiratory failure s/p tracheostomy, Afib (on Eliquis), CAD, HFpEF, bilateral RAS s/p stenting, s/p suprapubic catheter, who presents with cough, dyspnea and increased sputum production, found to have significant aspiration. # PNA # Aspiration # Chronic Respiratory Failure The patient had significant cough and dyspnea. Initial CXR without clear PNA but this was difficult to exclude. Although no overt fever, he has had sweats and increased secretions. Tm in ED 99.4 and leukocytosis present. Overall picture was concerning for PNA. Flu negative in ED. Legionella neg. Sputum cx initially contaminated; repeat cx with yeast. CT chest with pulm edema, consolidation concerning for aspiration. Video swallow with aspiration and strict NPO recommended. The patient was placed on vanc/CTZ/azithro for CAP. However, vanc was ultimately d/c'ed given low suspicion for PNA. Given high aspiration risk, G-tube was placed by [REDACTED]. Pt was treated with CTX and Azithro and is discharged on 2 more days of Cefpodoxime. Blood cx negative x5 days. Cont home neb therapy, including duonebs and acetylcystiene. G-tube placed on [REDACTED] (indication = high aspiration risk). Tube feeds started. The patient will likely need tube feeding via G tube at least for 3 months, SLP may re-evaluate and determine If he may resume swallowing again. He will remain NPo till then. # Afib: The patient has a history of AF. CHADVASC score is 5. Patient was previously on anticoagulation, held due to concern for GIB. However, his PCP has since resumed a low-dose apixaban. Although he does not technically meet criteria for reduced dose apixaban, given borderline age and renal function (EGFR significantly reduced by cystatin c), as well as concern for bleeding, will maintain low dose apixban going forward. He was bridged with heparin gtt while NPO. Apixaban was resumed after G tube placed. # Acute on Chronic HfpEF: On admission, appeared euvolemic though cxray concerning for some vascular congestion. He was briefly off of PO diuretic [REDACTED] NPO status. Following trigger on [REDACTED] for tachypnea, it was noted that he was net fluid positive, pro BNP was elevated and increased form before, CXR showed vascular congestion. He was aggressively diuresed and responded well. His weight was around 168 lbs at the time of discharge # H/o Anemia and GIB: Per rehab record, Apixaban was previously held in [REDACTED] due to +guaiac stools and drop in HCT. Last colonoscopy in [REDACTED] with adenomatous polyp and poor prep. Patient was re-scheduled for repeat CS but was felt to be a poor candidate for colonoscopy given multiple comorbidities, per rehab notes. Iron studies c/w ACD. Stools have been guaiac negative here. H/H stable. # s/p suprapubic Foley: Urology came and changed on [REDACTED]. # CAD: Severe 3VD. Currently asymptomatic. ASA switched to apixaban by PCP. Statin also recently discontinued. Given hx of HLD and severe 3VD, would favor resuming statin. TnT slightly elevated in setting of demand and CKD.
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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> ___. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Colonoscopy (___) attach <PERTINENT RESULTS> DISCHARGE EXAM: -== Patient examined on day of discharge. AVSS, otherwise unchanged from admission. ADMISSION LABS: -= ___ 12: 30AM BLOOD WBC-8.8 RBC-3.84* Hgb-10.4* Hct-34.8 MCV-91 MCH-27.1 MCHC-29.9* RDW-14.0 RDWSD-46.6* Plt ___ ___ 12: 30AM BLOOD ___ PTT-31.3 ___ ___ 12: 30AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-25 AnGap-11 ___ 12: 30AM BLOOD ALT-13 AST-17 AlkPhos-49 TotBili-0.3 ___ 07: 30AM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.4 Mg-1.9 DISCHARGE LABS: -= ___ 04: 36AM BLOOD WBC-8.6 RBC-2.65* Hgb-7.3* Hct-24.4* MCV-92 MCH-27.5 MCHC-29.9* RDW-14.3 RDWSD-48.1* Plt ___ ___ 05: 21AM BLOOD ___ PTT-86.4* ___ UA: tr bld, otherwise neg UCx (___): mixed flora IMAGING: ======== Colonscopy (___): Diverticulosis of descending colon and sigmoid colon. Small, non-bleeding internal hemorrhoids. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Cephalexin 500 mg PO ASDIR 2. Oxybutynin 5 mg PO BID 3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID 4. Warfarin 4 mg PO 2X/WEEK (___) 5. Warfarin 3 mg PO 5X/WEEK (___) 6. Simvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Ureacin-20 (urea) 20 % topical ASDIR 9. Furosemide 20 mg PO DAILY 10. Acetaminophen w/Codeine 1 TAB PO Q6H: PRN Pain - Mild 11. diclofenac sodium 1 % topical QID: PRN pain 12. nystatin 100,000 unit/gram topical BID 13. Vitamin D ___ UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Enoxaparin Sodium 100 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 100 mg/mL 100 mg SC every twelve (12) hours Disp #*20 Syringe Refills: *0 2. Acetaminophen w/Codeine 1 TAB PO Q6H: PRN Pain - Mild 3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID 4. Cephalexin 500 mg PO ASDIR 5. diclofenac sodium 1 % topical QID: PRN pain 6. Ferrous Sulfate 325 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. nystatin 100,000 unit/gram topical BID 9. Oxybutynin 5 mg PO BID 10. Simvastatin 40 mg PO QPM 11. Ureacin-20 (urea) 20 % topical ASDIR 12. Vitamin D ___ UNIT PO DAILY 13. Warfarin 4 mg PO 2X/WEEK (___) 14. Warfarin 3 mg PO 5X/WEEK (___) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Gastrointestinal bleeding Diverticulosis Hemorrhoids History of pulmonary embolism Hypertension <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 hospital for rectal bleeding. You underwent a colonoscopy that showed some outpouchings of the colon and some hemorrhoids, either which could have caused your bleeding. You required one blood transfusion while you were here, but your bleeding seemed to have stopped by the time of your discharge. You will need to take a medicine called Lovenox along with your Coumadin until your INR is back within a therapeutic range. Your primary care doctor ___ monitor your ___ levels as she has been doing. Please continue the Lovenox until she instructs you to stop. Please take the remainder of your medications as prescribed and follow up with your outpatient doctors as ___. With best wishes, ___ Medicine
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[REDACTED] y/o female with w/ hx of massive PE ([REDACTED]) on coumadin, ischemic colitis with hematocheiza ([REDACTED]), lacunar infarct, HTN, HLD presenting with 1 day of painless hematochezia, s/p colonoscopy [REDACTED] showing diverticulosis and small internal hemorrhoids without active bleeding. # Hematochezia: # Acute blood loss anemia: # Hx of ischemic colitis: Hx of ischemic colitis with hematochezia in [REDACTED]. Presented this admission with one day of painless hematochezia, with Hgb 10.4 on admission --> 6.5 without HD instability or end-organ ischemia. INR of 2.8 was reversed on admission with FFP x 2 and vitamin K 10mg IV. She received 1u pRBCs. Underwent colonoscopy [REDACTED] revealing only diverticulosis of the descending/sigmoid colon and small internal hemorrhoids - both possibly explanatory - without evidence of active bleeding. No e/o recurrent ischemic colitis per GI. Her diet was advanced and a heparin gtt was initiated without evidence of recurrent bleeding. Given her hx of a massive PE in [REDACTED], the decision was made to bridge her back to coumadin with lovenox. She will be discharged with lovenox [REDACTED] BID along with coumadin 4 mg, with INR monitoring through her PCP (confirmed). Next INR to be drawn on [REDACTED]. Hgb 7.4 on discharge. # Hx of massive PE & RLE DVT: RLE DVT and massive PE [REDACTED]. Treated with Coumadin (managed by PCP, [REDACTED] and followed by cardiology (Dr. [REDACTED] and previously by hematology (Dr. [REDACTED] [REDACTED]. INR 2.8 on admission and was reversed with FFP x 2 and vit K. Once bleeding had stopped, a heparin gtt was initiated along with home coumadin. Her PE, while remote, was massive, and cardiology and hematology have both previously recommended bridging. Decision was made to bridge her back to coumadin with lovenox, discussed with her PCP who is in agreement and will resume INR monitoring. She was discharged on warfarin with an enoxaparin bridge. Next INR to be checked on [REDACTED]. # Hx of lacunar stroke # Chronic small vessel ischemic disease: # Hyperlipidemia: Anticoagulation management as above. Home simvastatin was continued. # Hx of iron deficiency anemia: Home iron was resumed on discharge. # Overactive bladder? On oxybutynin as outpatient, but patient unclear of indication. Restarting on discharge, though patient should follow up with her PCP. # HTN: # Chronic b/l [REDACTED] edema from venous insufficiency: Cardiology note from Dr. [REDACTED] [REDACTED] indicates she is still on lisinopril, but this was stopped some time ago due to concern that BP meds were the cause of her ischemic colitis; she confirmed on admission she is no longer taking lisinopril and last fill date was [REDACTED]. Lisinopril was not resumed this admission. Home lasix (for [REDACTED] edema and HTN) was held in the hospital and restarted on d/c. ** TRANSITIONAL ** [ ] CBC and INR on [REDACTED] [ ] lovenox bridge to coumadin, to be managed by PCP (confirmed) > 30 minutes spent on discharge activities.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Iodinated Contrast Media - IV Dye <ATTENDING> ___. <CHIEF COMPLAINT> ESRD, failed AVF <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Left loop forearm atrioventricular graft. <HISTORY OF PRESENT ILLNESS> Per Dr. ___ preop note as ___ gentleman with end- stage renal disease currently dialyzed via a tunneled hemodialysis catheter on ___. A left brachiocephalic AV fistula failed to mature prior to the initiation of dialysis and is found to be not salvageable. He presents today for elective placement of hemodialysis access. <PAST MEDICAL HISTORY> CAD, s/p CABG ___ Aortic stenosis, s/p mechanical AVR ___ Systolic HF ESRD Type 2 diabetes complicated by retinopathy, neuropathy, nephropathy PAD, past foot ulcers, amputations to toes Dyslipidemia Hypertensive heart disease Mild obesity Scrotal Abscess I&D ___ Toe Amputation- Right ___ toe ___, Right ___ and ___ toe ___ Left loop forearm atrioventricular graft. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Paternal grandmother with DM. <PERTINENT RESULTS> Admission Labs: ___ 10: 27PM BLOOD WBC-7.3 RBC-3.57* Hgb-11.2* Hct-32.7* MCV-92 MCH-31.4 MCHC-34.3 RDW-13.7 RDWSD-45.3 Plt ___ ___ 10: 27PM BLOOD ___ PTT-37.2* ___ ___ 10: 27PM BLOOD Glucose-194* UreaN-22* Creat-5.1*# Na-136 K-4.0 Cl-95* HCO3-27 AnGap-18 ___ 10: 27PM BLOOD ALT-14 AST-18 AlkPhos-60 TotBili-0.4 ___ 10: 27PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1 ___ 10: 27PM BLOOD ___ PTT-37.2* ___ ___ 12: 05AM BLOOD ___ PTT-59.0* ___ ___ 06: 45AM BLOOD ___ PTT-66.6* ___ ___ 06: 10AM BLOOD ___ PTT-80.4* ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Calcitriol 0.25 mcg PO DAILY 3. Carvedilol 25 mg PO BID 4. Escitalopram Oxalate 20 mg PO DAILY 5. Gabapentin 200 mg PO QHS 6. LORazepam 0.5 mg PO QHS: PRN insomnia 7. Pantoprazole 40 mg PO Q12H 8. Prochlorperazine 10 mg PO Q8H: PRN nausea 9. Renagel 800 mg oral TID W/MEALS 10. Torsemide 100 mg PO 4X/WEEK (___) 11. Warfarin 4 mg PO DAILY16 12. Vitamin D ___ UNIT PO DAILY 13. Calcium Carbonate 1000 mg PO QID: PRN heartburn 14. Aspirin 81 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN Pain - Mild 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain - Moderate RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills: *0 3. TraZODone 25 mg PO QHS 4. Warfarin 6 mg PO 3X/WEEK (___) 5. Warfarin 4 mg PO 4X/WEEK (___) 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 1000 mg PO QID: PRN heartburn 10. Carvedilol 25 mg PO BID 11. Escitalopram Oxalate 20 mg PO DAILY 12. Gabapentin 200 mg PO QHS 13. LORazepam 0.5 mg PO QHS: PRN insomnia 14. Pantoprazole 40 mg PO Q12H 15. Renagel 800 mg oral TID W/MEALS 16. Torsemide 100 mg PO 4X/WEEK (___) 17. Vitamin D ___ UNIT PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> ESRD History of Aortic Valve replacement Legally blind <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call the access clinic at ___ if you have fevers or chills, your left hand has any pain, is cold, has blue fingers, has numbness or tingling this may be a medical emergency and you should call right away. Please also monitor for incisional redness, drainage or bleeding, arm swelling or increased pain at the access site or any other concerning symptoms. You should check the left arm access daily for a thrill (buzzing sensation) and if this is not present, you should call the access clinic right away and not wait until your dialysis session. The incisions may be left open to air. The arm may be gently washed but do not submerge or soak the arm. If there is a small amount of drainage you may cover with a dry dressing. Keep the arm elevated when you are sitting or laying down to help the swelling decease. Do NOT allow any blood pressures or lab draws from the left arm. No tight or constrictive clothing or jewelry to the left arm and no lifting more than 10 pounds. Continue outpatient hemodialysis per your outpatient ___, ___ schedule using the tunneled dialysis catheter already in place. Continue home medications, dietary and fluid restrictions as you have been instructed Please have an INR drawn on ___. Continue Coumadin (Warfarin) as directed and follow with your anticoagulation provider.
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On [REDACTED], he was admitted to the transplant service for heparin bridge as he was on coumadin for h/o AVR. On [REDACTED] he underwent left loop forearm atrioventricular graft. Surgeon was Dr. [REDACTED]. He was stable postop with positive bruit/thrill as well as a left radial pulse. Dressings were removed and incisions were without redness/drainage. He received a Heparin drip that was started 6 hours postop which continued until [REDACTED] when INR was 2.1. Coumadin was started postop at a higher dose of 6mg. INR ranged 1.4-1.6, therefore, Coumadin was increased to 8mg on [REDACTED] and [REDACTED]. Coumadin was decrease to his home dose of 4mg on [REDACTED]. [REDACTED] [REDACTED] clinic was contacted and will f/u on patient's INR on [REDACTED]. He will take Coumadin 6mg, 4 days a week and 4mg, 3 days a week on dialysis days. On the day of discharge,he was nauseated and vomited once. He was given Zofran with improvement. Per patient he experiences intermittent n/v at home. He was unsteady on ambulation, requiring nursing assist to prevent a fall. [REDACTED] evaluated noting deconditioning and impaired balance due to blindness. Home [REDACTED] was recommended. Caregroup [REDACTED] was contacted and planned to arrange a home visit to assess for skilled nursing and [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> syncope <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ transphenoidal of pituitary macroadenoma <HISTORY OF PRESENT ILLNESS> This is a ___ with no significant past medical history recently diagnosed with pituitary mass and admitted after a syncopal episode at the ___ clinic. Patient reports headache beginning on ___ and increasing to "the worst headache of [his] life" on ___. It is greatest intensity at the right temple currently, but it does move to other areas of his head. He presented to ___, where a CT head showed a pituitary mass. He has had steady worsening headache since that time which is moderately relieved with p.o. oxycodone. There is some associated nausea and he has had very poor PO intake. Today he was seen in the ___ clinic for evaluation of the mass after receiving an outpatient MRI. While in clinic had a syncopal event while talking to the MD. ___ that he felt dizzy and lightheaded and that he was told that his blood pressure dropped very low and that his eyes rolled back in his head. He was out for approximately 15 seconds and was cold, clammy and sweaty afterwards. No seizure activity witnessed. He reports that he has had decreased energy for the past few years. He also anxiety and panic attacks which are new for him over this amount of time, which involve feeling of lightheadedness. Also with decreased libido. During his most recent admission, he was found to have hyponatremia likely secondary to volume depletion in the setting of poor intake versus adrenal insufficiency. He was started on hydrocortisone 100mg IV Q8h. Endocrine was consulted who deterimined that the lesion was a non-secreting prolactinoma. He was evaluated by neurosurgery and endocrine for an elective transphenoidal pituitary adenoma reseaction. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: - anxiety/PTSD - pituitary adenoma <SOCIAL HISTORY> ___ <FAMILY HISTORY> father is ___, has afib. Mother is ___, has hypertension. Paternal grandmother with colon cancer. Sister with breast cancer. No other history of cancer. No history of autoimmune or endocrine issues. <PHYSICAL EXAM> Exam on Discharge The patient was neurologically intact. strength was full and no pronator drift noted, pupils were equal and reactive. there was no salty taste reported in the back of the throat. There was no dripping from the nare reported. <PERTINENT RESULTS> Radiology Report MR HEAD W/ CONTRAST Study Date of ___ 4: 58 AM IMPRESSION: Interval decrease in size of a suprasellar mass, likely due to involution of hemorrhage, with 1.6 cm residual heterogeneously enhancing mass. Findings discussed with Dr. ___ by Dr. ___ by phone at 15: 27 on ___ at the time of initial attending radiologist review. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 1: 03 ___ IMPRESSION: 1. Status post transsphenoidal resection of pituitary macroadenoma with postoperative soft tissue changes and postoperative air within the pituitary fossa. 2. No evidence of hematoma formation or postoperative pneumocephalus. Pathology Report Tissue: PITUITARY TUMOR Procedure Date of ___ Report not finalized. Logged in only. PATHOLOGY # ___ PITUITARY TUMOR <MEDICATIONS ON ADMISSION> 1. Hydrocortisone 10 mg PO QAM start ___ every morning until surgery 2. Hydrocortisone 20 mg PO QPM start ___ every afternoon at 1600 until surgery 3. OxycoDONE (Immediate Release) 10 mg PO Q4H: PRN pain 4. Sodium Chloride 1 gm PO Q6H <DISCHARGE MEDICATIONS> 1. Outpatient Lab Work LABORATORY WORK: serum sodum every ___ for 3 weeks on (___) serum TSH and Free T 4 on ___ please have these results FAXED every ___ to ___ attention ___, endocrinologist. 2. Acetaminophen 325-650 mg PO Q6H: PRN pain 3. Bisacodyl 10 mg PO DAILY RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth once a day Disp #*60 Tablet Refills: *0 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule,delayed ___ by mouth once a day Disp #*60 Capsule Refills: *0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*65 Tablet Refills: *0 6. Solu-CORTEF (hydrocorTISone Sod Succinate) 100 mg intramuscular x1 prn in case of emergency- in setting of nausea / vomiting and unable to take pill form of medication please present to Emergency Department for nausea and vomiting RX *hydrocortisone sod succinate [Solu-Cortef] 100 mg 100 mg IM x1 Disp #*2 Cartridge Refills: *0 7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 8. Hydrocortisone 20 mg PO QAM RX *hydrocortisone 20 mg 1 tablet(s) by mouth qam Disp #*30 Tablet Refills: *0 9. Hydrocortisone 10 mg PO 2 ___ DAILY RX *hydrocortisone 10 mg 1 tablet(s) by mouth daily at 2 pm Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pituitary macroadenoma <DISCHARGE CONDITION> alert and oriented to person, place, time. strength is full no pronator drift no salty taste or dripping form the nares of clear fluid <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -Take your pain medicine as prescribed. -Exercise should be limited to walking; no lifting, straining, or excessive bending. -Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. -Clearance to drive and return to work will be addressed at your post-operative office visit. -Continue SINUS PRECAUTIONS for an additional two weeks. This means, no use of straws, forceful blowing of your nose, or use of your incentive spirometer. -You have been discharged on Hydrocortisone,DO NOT MISS ___ DOSE. take it daily as prescribed. If on any day, you are ill, take the Hydrocortisone as you have been instructed by the endocrine team. -YOU are required to take hydrocortisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Hydrocortisone should also be taken with a glass of milk or with a meal. *** IF YOU EXPERIENCE nausea or vomiting and cannot take FOOD by mouth.....please present to Emergency Department as you may be showing signs of have ADRENAL insufficiency. IF YOU can NOT TAKE your pill form of hydrocortisone YOU MUST give yourself Hydrocortisone 100 mg intramuscular injection as was intructed to you by nursing prior to your discharge. IF YOU NOTICE an INCREASE in thirst, or DROP in urine, or EXCESS in urine please notify the endocrine service right away or return to the emergency department if this is over the weekend or overnight. LABORATORY WORK: serum sodum every ___ for 3 weeks on (___) serum TSH and Free T 4 on ___ please have these results FAXED every ___ to ___ attention ___, endocrinologist. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING -New onset of tremors or seizures. -Any confusion or change in mental status. -Any numbness, tingling, weakness in your extremities. -Pain or headache that is continually increasing, or not relieved by pain medication. -Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. -It is normal for feel nasal fullness for a few days after surgery, but if you begin to experience drainage or salty taste at the back of your throat, that resembles a dripping sensation, or persistent, clear fluid that drains from your nose that was not present when you were sent home, please call. -Fever greater than or equal to 101° F. -If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist.
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Mr. [REDACTED] was taken to the operating room on the day of admission on [REDACTED] and underwent a transphenoidal for removal of a pituitary macroadenoma. Intraoperatively, he was given 100mg of hydrocortisone as stress prophylaxis. He tolerated the procedure well and was extubated in the operating room. He was transferred to the Neuro step down post-operatively. He underwent a post-operative non-contrast head CT which showed post-operative changes. His diet as advanced as tolerated. Endocrine was consulted who recommended strict monitoring of input and output and to put in labratory work should his levels become unbalanced. In itially the patient urine output was stable. The patient post operative serum sodium was Na 142 and serum osmoality was 292. The patient urine output was increased and the patient was in dibetes insipidus overnight. He was administered 0.1mg of DDAVP. He was gven Lopressor for tachycardia and hypertension. On [REDACTED], The patient nasal packing was left in place for another 24 hours. The patient had some small amount nasal drainage. From 10 am to 1200 noon the patient began having elevated urine outputs of 250 cc hr. The patient was given DDavp at 3 pm. The patient urine output at 4 pm was 350cc, at 5pm it was 225cc, at at 6pm it was 225cc. Endocrine was made aware and decision was made to follow urine output. At 7 pm the urine output slowed to 7 pm. The serum potassium was repleated with 60 meq. The patient was neurologically intact. On [REDACTED], Mr. [REDACTED] nasal packing was removed by ENT. There were no complications thereafter. His urine and serum values were closely monitored. Due to increasing urine output along with decreasing specific gravity levels, an oral dose of DDAVP was administered as recommended by Endocrinology. On [REDACTED] Mr [REDACTED] was moved out of the step down unit. His sodiums remained in the 140 range, he was drinking to thirst. His activity was increased and he did not need any further DDAVP. on [REDACTED], The patient was neurologically intact and final recommendations were provided by endocrine. The patient was cleared for home and the patient was provided with written and verbal discharge intructions all questions were answered.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Bactrim / Vicodin / Lasix <ATTENDING> ___. <CHIEF COMPLAINT> right lower extremity ischemia with non healing ulcer on right foot bunion <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ 1. Ultrasound-guided puncture of the left common femoral artery. 2. Contralateral third-order catheterization of the right superficial femoral artery. 3. Abdominal aortogram. 4. Serial arteriogram of the right lower extremity. No intervention <HISTORY OF PRESENT ILLNESS> This is a ___ female with severe peripheral arterial disease and a nonhealing ulceration of her right foot. She is scheduled to undergo resection with podiatry, and she was consented for a right lower extremity arteriogram with possible angioplasty and stenting. <PAST MEDICAL HISTORY> PMH: CAD, DM, HTN, Hyperlipidemia, Carotid artery stenosis, Chronic atrial fibrillation (anticoag),Peripheral arterial disease, prolapsed uterus, History of GI bleed PSH: CABG <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> VSS Afebrile Gen: elderly female in nad Lungs: CTA bilat no w/r/r Card: Irreg rate/rhythm Abd: soft no m/t/o Extremities: mild ___ edema. There is a large bunion of the right leg with a quarter-sized ulcer on the medial aspect. Pulses fem dp pt right p d d left p d d <PERTINENT RESULTS> ___ 06: 44AM BLOOD WBC-7.6 RBC-3.96* Hgb-10.6* Hct-31.5* MCV-79* MCH-26.8* MCHC-33.7 RDW-15.3 Plt ___ ___ 06: 35AM BLOOD ___ ___ 06: 44AM BLOOD ___ ___ 06: 44AM BLOOD Glucose-92 UreaN-24* Creat-1.1 Na-140 K-3.8 Cl-102 HC___ AnGap-13 ___ 06: 44AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.7 Cardiology Report ECG Study Date of ___ 12: 56: 08 ___ ECG interpreted by ordering physician. Please see corresponding office note for interpretation. Intervals Axes Rate PR QRS QT/QTc P QRS T 51 0 86 402/386 0 3 -162 <MEDICATIONS ON ADMISSION> Amlodipine 5'', Furosemide 10',Glipizide 5'', Isosorbide Mononitrate 30',Lisinopril 20'', Mesalamine 400'',Metoprolol Tartrate 50'', Omeprazole 20', Simvastatin 20', Warfarin 2mg ___ 4day, 3mg ___, Acetaminophen 500prn, Aspirin 81', Vitamin D3 1,000 unit', MVI, otc laxatives <DISCHARGE MEDICATIONS> 1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: one-half Tablet PO every six (6) hours as needed for pain. Disp: *10 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO QMWF (). 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QTUTHSASU (). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Right lower extremity ischemia with ulceration. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). - pt at her baseline - <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Division of Vascular and Endovascular Surgery Lower Extremity Angiogram Discharge Instructions Medications: -Take Aspirin 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 slight 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, you may resume sexual activity -After 1 week, gradually increase your activities and distance walked as you can tolerate -No driving until you are no longer taking pain medications -Keep your f/u appt in the ___ clinic. Be sure to see your primary care doctor for ___ check 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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Ms. [REDACTED] was admitted for a RLE angio prior to a planned debridement by the podiatry team. Ms. [REDACTED] was preoped and consented and taken to the agnio-suite for RLE angiogram. ANGIOGRAPHIC FINDINGS: 1. Her distal abdominal aorta had moderate diffuse disease, but no flow-limiting stenosis or aneurysm. Her right renal artery was patent. Her left renal artery had a critical stenosis, and the nephrogram on the left was absent. 2. Bilateral common iliac arteries had moderate diffuse disease, but were patent. 3. Her internal and external iliac arteries were patent. Her internal iliac arteries were heavily diseased. 4. The right common femoral and profunda femoris arteries were patent. 5. The superficial femoral artery was heavily calcified and diseased along its entire length. The distal portion of the artery was occluded for 7-10 cm. We did attempt to cross this in a subintimal fashion with a combination of a stiff angled Glidewire and a Quick-Cross catheter, but we were unable to regain entry to the lumen in the popliteal artery despite using several different wires. 6. The above- and below-knee popliteal artery were patent, however, very small in size and with severe diffuse disease. 7. The anterior tibial artery was occluded and did not reconstitute. 8. The peroneal artery was patent, but small in size and heavily diseased. It gave off an anterior and a posterior branch at the ankle which supplied multiple collaterals supplying the foot. The posterior tibial artery was occluded proximally, but did reconstitute at the level of the ankle and proceeded into the foot. The dorsalis pedis artery pulse also did reconstitute through an anterior branch of the peroneal artery and was patent in the foot. Given her severe disease, we were unable to intervene with angioplasty and/or stent as we had hoped. After the diagnostic angio, she was taken to the PACU for further recovery. She remained hemodynamically stable and was then transfered to the VICU. She was monitored closely. Given that her arterial disease was so severe, and intervention was failed, the podiatry team decided surgical debridement would not be beneficial at this time. On POD 0, her coumadin was restarted. Her foley was d/c'd on POD 1 and she voided without difficulty. She worked with physical therapy and while she needed assistance, she was found to be at her baseline. By POD 2 she was tolerating a regular diet and felt well. She was ambulating at her baseline as well. She was deemed stable for discharge home with daughter, with [REDACTED] and [REDACTED] services .
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Worsening SOB <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo male with COPD p/w worsening dyspnea, SpO2 86% on room air per EMS. Recently discharged on ___ with diagnosis of COPD flare, sent home on prednisone taper and azithromycin x 5 days. Went to Dr. ___ PCP appointment two days after discharge, and no changes in medication and was feeling well. He was doing well until day prior to admission when he reports worsening dyspnea with exertion, barely able to ambulate from room to room today. He slept overnight with 3 pillows and wife reports that he had labored breathing with wheezing. He awoke from afternoon nap with acute dyspnea, was reported white in face by son, and wife called EMS. Denies fevers, but reports some lightheadness. In the ED, pt's vitals were 97.9, 79, 156/84, 22, 99% 4L. He was given combivent, solumedrol, and levofloxacin 750 mg IV, and EKG showed normal sinus rhythm at rate of 73. He was transfered to the medicine floor. This is his second hospitalization (first being the discharge on ___. On the floor, patient complained of shortness of breath, cramps in the legs that is chronic, and productive cough and x1 bought of watery diarrhea without blood; but denies chest pain, palpitations, fever, chills, nausea, vomitting, constipation, dysuria, muscle, or swelling in legs. <PAST MEDICAL HISTORY> -Hypertension -Tobacco abuse -COPD -s/p AAA repair in ___ c/b brief postoperative atrial fibrillation -Chronic Kidney Disease (seconary to vascular disease) -Prostate cancer s/p radiation therapy and leupron -Skin cancer <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> VS 97.2, 132/68, 72, 96% RL, 72.4 kg Gen: lying flat in bed, dyspenic, with oxygen, "puckered" breathing HEENT: NCAT, EOMI, PEERLA, no LAD, MMM CV: s1, s2 appreciated, no MRG Lungs: use of accessory muscles when breathing, harsh breath sounds, wheezing heard throughout, hyperinflation Abd: ventral hernia, vertical scar, soft, NTND, +BS Ext: WWP, no CCE Neuro: A&O x3, moves all extremities, normal tone, follow commands <PERTINENT RESULTS> CXR: PA AND LATERAL CHEST RADIOGRAPHS: The heart size remains normal and the aorta is mildly unfolded. Again, there is hyperinflation of the lungs. Increased interstitial markings, particularly in the perihilar region likely represent interstitial pulmonary edema in this patient with underlying COPD. There is no evidence of pneumothorax and no definite pleural effusions seen. The osseous structures appear unremarkable. IMPRESSION: Interstitial pulmonary edema in the setting of COPD. EKG: Cardiology Report ECG Study Date of ___ 5: 07: 04 ___ Sinus rhythm. Non-specific septal T wave changes. Compared to the previous tracing of ___ there is no significant diagnostic change. ECHO: The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate pulmonary artery systolic hypertension. <MEDICATIONS ON ADMISSION> 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO at bedtime. 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule, Delayed Release(E.C.)(s) 10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp: *4 Tablet(s)* Refills: *0* 11. Prednisone 10 mg Tablet Sig: see below Tablet PO once a day for 5 days: Please take 5 pills (50mg) on ___, 4 pills (40mg) on ___, 3 pills (30mg) on ___, 2 pills (20mg) on ___, 1 pill (10mg) on ___, then STOP. Disp: *15 Tablet(s)* Refills: *0* <DISCHARGE MEDICATIONS> 1. Oxygen Oxygen 2L continuous for portability, pulse dose system. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 weeks: please take 2 pills for two days, then one pill for two days, than a half a pill for two days and then stop. Disp: *7 Tablet(s)* Refills: *0* 9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp: *30 Tablet Sustained Release 24 hr(s)* Refills: *2* 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation every ___ hours as needed for shortness of breath or wheezing. Disp: *30 Nebs* Refills: *0* 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp: *30 Neb* Refills: *0* 13. Nebulizer & Compressor For Neb Device Sig: One (1) Device Miscellaneous every ___ hours as needed for shortness of breath or wheezing. Disp: *1 Device* Refills: *0* 14. Combivent ___ mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. Disp: *1 INH* Refills: *3* <DISCHARGE DISPOSITION> Expired <DISCHARGE DIAGNOSIS> Pneumonia COPD exacerbation Atrial Fibrillation Tobacco use <DISCHARGE CONDITION> Expired <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> None indicated.
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[REDACTED] y/o male with COPD exacerbation and PNA, died of hypotension and MSOF. The patient was initially admitted to the hospital on [REDACTED]. He had been recently discharged on [REDACTED] with diagnosis of COPD flare, sent home on prednisone taper and azithromycin x 5 days. He was thought to have COPD exacerbation/ PNA and was treated with Levaquin PO and long steroid taper, and remained on [REDACTED] NC. On [REDACTED] because of low grade fevers and unimproved oxygen requirement a CT chest, non contrast was done that showed diffuse peribronchovascular and periperhal parenchymal opacities with associated bronchial wall thickening, as well as centrilobular emphysema, concerning for fungal infection. For this reason, pulmonary consult was called for bronchoscopy, as well as ID. On [REDACTED], he was found to be in afib with RVR. He was started on heparin gtt and rate control with increasing doses of metoprolol and diltiazem. He continued to be in a fib with RVR and on [REDACTED] triggered for tachycardia. He was digoxin loaded an started on daily dig. On [REDACTED], he desatted on 2L NC, diaphoretic and dyspneic. The patient reports sudden onset of shortness of shortness of breath when getting up to go to the bathroom. He was evaluated by the [REDACTED] consult service for a bronch and was thought to not be stable enough, and they intiated a MICU transfer to stabilize him for bronch. An ABG was done which was: 7.49/34/48/27. He was transferred to the MICU for further stabilization of respiratory status. He was satting 95% on high flow max 95%, tachy to the 120s, with BP 116/61. Also described choking on food the day prior to transfer. The pt's condition rapidly deteriorated in the MICU. He was intubated due to increasing respiratory distress. A central line was successfully placed. Mr. [REDACTED] became hypotensive and was bolused 2L NS, which were ineffective. He was placed on phenylepherine and vasopressin. He had progressively increasing O2 requirements on the vent, set at AC with high O2, TV, and PEEP. Vancomycin and Cipro were added to the voriconazole and cefepime to broaden antibiotic coverage. In the afternoon of [REDACTED], Mr. [REDACTED] continued to [REDACTED] fluid resuscitation with NS and LR, to mild effectiveness. As the pt's underlying condition was unclear, he was bronched, which showed pulmonary macrophages, inflammatory cells and fungal forms suggestive of aspergillus (results returned postmortem). As pt continued to be hypotensive and tachycardic, LR was continued at 500cc/hr. An ABG showed severe acidosis, so the pt was given bicarb. Nebulizer treatments were continued. A family meeting was held, during which the decision was made to make the patient DNR, but allow him to continue aggressive care while intubated. Overnight, the patient's hypotension became unresponsive to fluids and pressors, his sats dropped, he became increasingly tachycardic. He passed away on the morning of [REDACTED]. The underlying cause is unknown; aspergillus multilobar pneumonia is in the differential diagnosis but the cause is uncertain. . Pt's other issues were as follows: #. CKD Stage 3: Stayed near his baseline creatinine of 1.9 until respiratory failure. #. Tobacco Abuse: Counceled on smoking cessation. Nicotene patch started. #. HTN: Continued home meds lisinopril, HCTZ, atenolol until became hypotensive with respiratory distress. #. s/p AAA repair: Continued ASA, lipitor. #. Depression: Continued zoloft. #. Atrial Fibrillation: New AFib. Was on atenolol at home, but was changed to metoprolol 200 mg BID for rate control. Started on Heparin Drip.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> SURGERY <ALLERGIES> Nickel / Codeine / Dilantin / Seroquel / Hydromorphone / phenytoin <ATTENDING> ___. <CHIEF COMPLAINT> ESRD <MAJOR SURGICAL OR INVASIVE PROCEDURE> renal transplant <HISTORY OF PRESENT ILLNESS> ___ with ESRD (secondary to HTN) on HD x ___ years presents preoperatively for kidney transplant. He was discharged this AM from ___, where he was admitted following LUE fistulagram/thrombectomy yesterday. He was dialyzed this morning. He denies any recent illnesses. No fevers, chills, nausea, vomiting, abdominal pain, or diarrhea. <PAST MEDICAL HISTORY> - ESRD: secondary to hypertension on HD x ___ years with LUE fistula. Frecenius dialysis in ___ ___, ___. Peripheral neuropathy (pain in hands, feet, shooting down lateral L leg) started ___ year ago.Renal transplant ___ - hypertension - hypercholesterolemia - Gastroesophageal reflux disease: asymptomatic on PPIs - migraine headaches: ___ per year - polysubstance abuse including cocaine, ethanol, marijuana - history of depression: says he no longer feels depressed; not on antidepressants; previously prescribed prozac <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother has end stage renal disease, diabetes and RA. Cousins also have renal disease. Grandparents have hypertension. <PHYSICAL EXAM> PE: 97.5 50 93/60 18 100%RA Gen: NAD ___: RRR Pulm: CTA b/l Abd: soft, NT, ND, +BS, inc c/d/i Ext: LUE AV fistula w/ palpable thrill, radial pulse palpable b/l <PERTINENT RESULTS> On Admission: ___ WBC-6.5 RBC-4.19* Hgb-13.8* Hct-43.2 MCV-103* MCH-32.9* MCHC-31.9 RDW-15.0 Plt ___ PTT-32.1 ___ UreaN-32* Creat-7.9*# Na-135 K-6.3* Cl-97 HCO3-26 AnGap-18 ALT-15 AST-17 Albumin-4.8 Calcium-8.5 Phos-3.2 Mg-2.1 ___ PTH-90* ... At Discharge: ****************** <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Omeprazole 40 mg PO BID 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. traZODONE 200 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) 7. Lidocaine 5% Patch 1 PTCH TD DAILY 8. OxycoDONE (Immediate Release) 15 mg PO Q4H: PRN pain 9. Calcium Carbonate ___ mg PO DAILY <DISCHARGE MEDICATIONS> 1. Calcium Carbonate ___ mg PO QID RX *calcium carbonate 500 mg calcium (1,250 mg) 4 tablet(s) by mouth four times a day Disp #*480 Tablet Refills: *3 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 3. Omeprazole 40 mg PO BID RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills: *1 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 5. traZODONE 100 mg PO HS: PRN insomnia RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*20 Tablet Refills: *0 6. Acetaminophen 650 mg PO Q6H: PRN Pain or premedication 7. Calcitriol 0.5 mcg PO DAILY RX *calcitriol 0.5 mcg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills: *3 8. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *3 9. Mycophenolate Mofetil 1500 mg PO BID 10. Nystatin Oral Suspension 5 ml PO QID 11. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60 Tablet Refills: *3 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 13. ValGANCIclovir 450 mg PO 2X/WEEK (___) 14. Lidocaine 5% Patch 1 PTCH TD DAILY 15. Simvastatin 40 mg PO DAILY RX *simvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills: *1 16. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth Weekly Disp #*4 Capsule Refills: *3 17. Sodium Polystyrene Sulfonate 15 gm PO ASDIR Take only as directed by the transplant clinic for high potassium level on your labs 18. Tacrolimus 10 mg PO Q12H Duration: 2 Doses please check trough regularly and dose appropriately. You should have your tacrolimus level checked on ___ <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___: ESRD s/p cadaveric renal transplant Delayed graft function RA GERD <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Partners ___ has been arranged Please call the Transplant Office ___ if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, indigestion, increased abdominal pain, incision redness/bleeding/drainage, decreased urine output, weight gain of 3 pounds in a day, edema, constipation or diarrhea. -You will need to have blood drawn twice weekly for lab monitoring at ___ Lab, ___ ___ Office Building - Take only medications listed on your transplant card. Update medication doses and always bring the card with you to your clinic visits. -No heavy lifting/straining. Nothing heavier than 10 pounds -No driving while taking pain medication -You may shower. Do not scrub incision or apply powder/lotion/ointment -Weigh yourself every morning, call MD if weight goes up more than 3 lbs.
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On [REDACTED], he underwent donor after cardiac death kidney transplant. Surgeon was Dr. [REDACTED]. After venous and arterial anastomoses, the kidney pinked up over [REDACTED] minutes. The ureteral anastomosis was created and a double J stent was placed. A 19 [REDACTED] drain was place in the retroperitoneum around the anastomoses. Please refer to operative note for complete details. PACU stay was notable for low urine output and hyperkalemia requiring hemodialysis. Urine output was low via the foley. IV fluid replacements were stopped. Vital signs were stable. Pain was controlled with a Morphine PCA. He experienced pruritus during ATG administration. Extra Benadryl was given with decreased pruritus. ATG infusion was slowed down over 8 hours. Oliguria persisted with potassium of 5.7 on postop day 2. Hemodialysis was repeated, and continued on a [REDACTED] schedule. Given delayed graft function, he was set to receive 4 doses of ATG. However, WBC decreased to 2.4 on postop day 2. Half dose of ATG was administered (75mg)and infused over 10 hours. On postop day 3, the [REDACTED] half dose of ATG was due, but was held given further decrease in WBC to 1.1. On postop day 4, that dose (75mg)was administered completing his [REDACTED] full dose. On postop day 5, WBC was 1.7. ATG was held. Fourth and last dose of ATG (125mg)was administered on [REDACTED]. He received steroid taper over 5 days, and completed this on [REDACTED]. Cellcept was well tolerated. Prograf was begun on postop day 1 with doses adjusted up for low trough levels to 8mg bid. Diet was advanced and tolerated. Colace and Senna were given bid. He was passing flatus and had a BM on [REDACTED]. RLQ incision was intact with staples without redness or drainage. JP drain outputs were serosanguinous and down to 60cc/day by postop day 5. JP was removed on [REDACTED]. He remained afebrile with stable vital signs. He was assisted OOB and was ambulating with a walker and then progressed to a cane for discharge. [REDACTED] assessed him and felt that he would be safe for home with [REDACTED] thru the [REDACTED]. Medication teaching went well. He was ready for discharge on [REDACTED]. He will continue on hemodialysis at his outpatient dialysis unit, who have been notified of his return. He was sent home on Tacro [REDACTED], with instructions to have next level checked on [REDACTED] [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate <ATTENDING> ___. <CHIEF COMPLAINT> I need a colonoscopy <MAJOR SURGICAL OR INVASIVE PROCEDURE> Endoscopy Colonoscopy <HISTORY OF PRESENT ILLNESS> ___ with PMH of CAD s/p CABG, recurrent symptomatic polymorphic VT with syncope, DM, HTN, PVD, s/p L CEA, RA, Factor V Leiden, recent dx of thyroid cancer (___), interstitial lung disease, restless leg syndrome, and iron deficiency anemia admitted to the medical service for cardiac and anesthesia evaluation prior to colonoscopy. Patient states she feels in her usual state of health, with no complaints of chest pain, palpitations, dyspnea on exertion, orthopnea, PND, or lower extremity edema. She does admit to intermittent black stools, but cannot comment on frequency or duration. No recent diarrhea, constipation, nausea, vomiting, or abdominal pain. ROS: Ten point review of systems performed and negative except as noted above. <PAST MEDICAL HISTORY> Syncope due to recurrent polymorphic ventricular tachycardia CAD s/p CABG Diabetes HTN PVD Left CEA for carotid stenosis Rheumatoid arthritis Factor V ___ Depression Iron def anemia Hypothyroidism Failure to thrive Cholecystectomy Urinary incontinence Interstitial lung disease Restless leg syndrome Seizure ___ years ago Recurrent Anemia requiring multiple tranfusions as per son, details unknown (possible GI losses w/negative work-up) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Patient denies family history of IBD, GI bleeds. <PHYSICAL EXAM> VS: T=98 BP=155/56 HR=57 RR=16, 100% on RA Gen: Awake, alert, NAD HEENT: NCAT, EOMI, anicteric CV: RR, bradycardic, ___ systolic murmur Pulm: CTA B Abd: Soft, NTND, + bowel sounds Ext: No edema Neuro: Oriented x 3, conversant, fluent speech, confused when asked details of medical history but clear on reason for admission <PERTINENT RESULTS> ___ 06: 35PM GLUCOSE-114* UREA N-20 CREAT-1.0 SODIUM-139 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-31 ANION GAP-10 ___ 06: 35PM estGFR-Using this ___ 06: 35PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-3.2* ___ 06: 35PM WBC-7.6 RBC-3.46* HGB-8.4* HCT-26.2* MCV-76* MCH-24.1* MCHC-31.9 RDW-18.2* ___ 06: 35PM PLT COUNT-335 . Discharge labs: ___ 07: 55AM BLOOD WBC-6.0 RBC-3.37* Hgb-7.8* Hct-25.2* MCV-75* MCH-23.3* MCHC-31.1 RDW-17.4* Plt ___ ___ 07: 55AM BLOOD Glucose-77 UreaN-12 Creat-1.0 Na-140 K-4.1 Cl-102 HCO3-28 AnGap-14 . Endoscopy/colonoscopy: reports not available yet. <MEDICATIONS ON ADMISSION> (Patient not aware of medications and no list sent from ___ ___. Verified with covering physician ___ on ___. Lasix 20mg Daily Lisinopril 10mg daily Aspirin 81mg daily Simvastatin 20mg daily Prednisone 5mg daily Tylenol ___ Q6H: prn pain Albuterol neb QID Atrovent 0.025 QID Trazadone 50mg qHS Amiodarone 200mg QOD Levoxyl 125 daily Novolin N 8 unit qAM Remeron 7.5 mg qhs Aricept 10mg qhs Multivitamin tab Cyanocobalamin 1000mcg q month on ___ Calcium with Vit D 600mg/400 IU BID Simethicone ___ QID Cepacol lozenges TID PRN Fosamax 70mg Q Weekly Cepcaol lozenge PRN <DISCHARGE MEDICATIONS> 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain, fever. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO every other day. 12. Novolin N 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous once a day. 13. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) ml Injection once a month. 14. Calcium with Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 16. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding scale units Subcutaneous QAC and QHS. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Arteriovenous malformations of colon Gastrointestinal bleeding Coronary artery disease, stable Insulin dependent diabetes mellitus Chronic CHF without exacerbation Polymorphic VT, history Thyroid cancer, newly diagnosed. <DISCHARGE CONDITION> Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair (at baseline) <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Weigh yourself every morning, call MD if weight goes up more than 3 lbs. . You were admitted and underwent colonoscopy for bleeding in your stool. This showed some blood vessels that might be the cause of the bleeding. There was no evidence of active bleeding. . Medication changes: Given risk of continued bleeding, your aspirin was continued at only 81 mg daily.
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1. Iron deficiency anemia: Patient noted to be guaiac positive at last admission; plan is for mag citrate tonight and colonoscopy tomorrow pending anesthesia evaluation. She underwent colonoscopy and EGD after evaluation by anesthesia. The colonoscopy showed AVMs. Her hct was stable. She did not require transfusion. She should be started on iron as an outpatient. Her aspirin was decreased back to 81 mg daily given risk of bleeding. She may require push enteroscopy if she continues to have a drifting down of her hct, or may require intermittent transfusions. She was given the information to follow up with Dr. [REDACTED] as needed, and Dr. [REDACTED] in 1 month. . 2. h/o polymorphic VT: Appears to have been in setting of electrolyte abnomalities. Currently in sinus rhythm. She was continued on amiodarone. . 3. CAD s/p CABG: Continued home regiment of Lisinopril, Atorvastatin. Aspirin as above decreased to 81 mg daily. 4. Diabetes II, uncontrolled, without complications: Continued NPH at decreased dose while NPO, and restarted back at home dose at discharge. 5. Interstitial Lung Disease: Continued Prednisone, Albuterol, Atrovent. 6. Mild Dementia: Continued Remeron, Aricept, Trazodone.
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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> Right ankle pain and discomfort <MAJOR SURGICAL OR INVASIVE PROCEDURE> R ankle radial tendon repair and lateral ankle spur excision <HISTORY OF PRESENT ILLNESS> ___ year old women with right ankle pain after falling in ___. She has no relief from conservative treatment. <PAST MEDICAL HISTORY> 1. Sleep apnea 2. C-section ___ years prior 3. Kidney stone @ ___ years old 4. BTL ___ years ago 5. L sided back pain x ___ years following epidural <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> General: AOx3. NAD Heart: RRR, No M/R/G Lungs: CTA-B Abdomen: Soft, NTND, NABS Right Ext: Splint clean dry intact, Positive cap refill <MEDICATIONS ON ADMISSION> ambien, diclofenac, lorazepam, omeprazole, paroxetine, MVI, topiramate <DISCHARGE MEDICATIONS> 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. Disp: *21 syringe* Refills: *0* 2. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: Take AFTER completing Lovenox. Disp: *42 Tablet(s)* Refills: *0* 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for depression. 6. topiramate 25 mg Tablet Sig: Two (2) Tablet PO DAILY AT 1800 (). 7. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 10. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp: *75 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> R ankle pain <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> 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your cast clean. You may shower afer covering your cast completely with plastic to keep it dry. The cast will be changed at your follow-up visit. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in two (2) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. ___ STOCKINGS x 6 WEEKS on your left leg. 10. WOUND CARE: Please keep your cast clean and dry. Check skin around cast regularly for signs of infection such as redness or thick yellow drainage. Your cast will be changed at your follow-up visit in two (2) weeks. 12. ACTIVITY: Non-weight bearing at all times on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment.
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The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The patient was seen daily by physical therapy. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact. The patient is non-weight-bearing on the right lower extremity. Ms. [REDACTED] is discharged to home in stable condition with prescriptions for dilaudid and lovenox.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> aneurysm <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ Coil embolization of Right superior hypophyseal aneurysm <HISTORY OF PRESENT ILLNESS> Ms. ___ was having episodes of right sided weakness which were consistent with transient ischemic attacks. She had a finding of a right superior hypophyseal aneurysm and presented for an elective coiling. <PAST MEDICAL HISTORY> Dyslipidemia Appendectomy Sigmoid Colectomy Transient ischemic attacks <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> PHYSICAL EXAMINATION ON DISCHARGE: Alert and oriented. PERRL bilaterally. ___, but conversing fluently with her daughter. CN ___ grossly intact. Motor strength ___ throughout bilateral UE and ___. Groin site: soft, non-tender. No hematoma. <PERTINENT RESULTS> Diagnostic and Interventional Cerebral Angiogram: ___ Final report pending. <MEDICATIONS ON ADMISSION> ASA, Atorvastatin, Plavix, Esidrix <DISCHARGE MEDICATIONS> 1. Atorvastatin 20 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q6H: PRN fever or pain 3. Hydrochlorothiazide 25 mg PO DAILY 4. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth daily. Disp #*30 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right superior hypophyseal aneurysm <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Activity -You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. -Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. -You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. -Do not go swimming or submerge yourself in water for five (5) days after your procedure. -You make take a shower. Medications -Resume your normal medications and begin new medications as directed. -You may be instructed by your doctor to take one ___ a day. If so, do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. -You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. -If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site -You will have a small bandage over the site. -Remove the bandage in 48 hours by (___) soaking it with water and gently peeling it off. -Keep the site clean with soap and water and dry it carefully. -You may use a band-aid if you wish. What You ___ Experience: -Mild tenderness and bruising at the puncture site (groin). -Soreness in your arms from the intravenous lines. -Mild to moderate headaches that last several days to a few weeks. -Fatigue is very normal. -Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: -Severe pain, swelling, redness or drainage from the puncture site. -Fever greater than 101.5 degrees Fahrenheit -Constipation -Blood in your stool or urine -Nausea and/or vomiting -Extreme sleepiness and not being able to stay awake -Severe headaches not relieved by pain relievers -Seizures -Any new problems with your vision or ability to speak -Weakness or changes in sensation in your face, arms, or leg
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On [REDACTED], Ms. [REDACTED] was taken to the angio suite on the day of admission and underwent a oil embolization of a right superior hypophyseal aneurysm. The groin site was sealed with angioseal. She tolerated the procedure well and was transferred to the Neuro ICU post-operatively while on a heparin drip which was started intra-angio. Her diet as advanced as tolerated. [REDACTED], the Heparin gtt was discontinued. She started Aspirin 325mg daily. The A-line and foley catheter was removed. She was ambulating independently, tolerating a diet, and voiding without difficulty. It was determined she would be discharged to home.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> Apple / Peach <ATTENDING> ___. <CHIEF COMPLAINT> Headaches and arm numbness <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnositic Cerebral Angiogram unable to coil residual aneursym <HISTORY OF PRESENT ILLNESS> ___ well known from our dept for s/p SAH, coiling acom aneurysm in ___. Had been doing well but recent imaging showed partial recanalization of the aneurysm and he was scheduled for angio on ___. He now c/o of progressive tension in his neck, pressure in back of head, pressure/pain around vertex and 2 episodes of rigth leg + arm numbness/tingling. Feels overall tired and heavy. Has taken fiorcet and received morphine in ED He denies any sudden onset of symptoms as symptoms started at noion and progressed throughout the day. he has had prior similar episodes but of lesser intensity. <PAST MEDICAL HISTORY> DVT x2 Diverticulitis Fatty Liver Congenital hydrocephalus Upper ventral herniaInguinal hernia as a child Retinal surgery PE x 1 VPS / non functioning LPS / functioning <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father - GERD Mother - ___ <PHYSICAL EXAM> 111/69 66 12 100% Awake and alert, cooperative with exam. NAD. Orientation: Oriented to person, place, and date. Speech intact. II: Pupils R 5->2, L 3->2 (baseline) III, IV, VI: Extraocular movements intact, Rt beating nystagmus. V, VII: very discreete Rt facial assymetry; sensation intact and symmetric. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Neck soft supple, non tender, no ROM limitation. <PERTINENT RESULTS> ___ 02: 57AM BLOOD Hct-34.9* ___ 11: 15PM BLOOD Neuts-63.6 ___ Monos-6.7 Eos-3.4 Baso-0.8 ___ 04: 36AM BLOOD Plt ___ ___ 04: 36AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-142 K-3.5 Cl-105 HCO3-26 AnGap-15 ___ 04: 36AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2 <MEDICATIONS ON ADMISSION> Lisinopril, Amlodipine and Amitriptyline <DISCHARGE MEDICATIONS> 1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for h/a: No more than 6 tablets in one day. Disp: *25 Tablet(s)* Refills: *0* 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for h/a. 3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for tension h/a. Disp: *15 Tablet(s)* Refills: *0* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Work Note To Whom it ___ Concern Mr ___ was admitted to ___ on ___ <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> A-Comm Aneursym <DISCHARGE CONDITION> Neurologically stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> --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 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, you may resume sexual activity. -After 1 week, gradually increase your activities and distance walked as you can tolerate. -No driving until you are no longer taking pain medications What to report to office: -Changes in vision (loss of vision, blurring, double vision, half vision) -Slurring of speech or difficulty finding correct words to use -Severe headache or worsening headache not controlled by pain medication -A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg -Trouble swallowing, breathing, or talking -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 our office. If bleeding does not stop, call ___ for transfer to closest Emergency
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Mr [REDACTED] had a planned coiling scheduled for later this week but came in early due to his progressive tension in his neck, pressure in back of head, pressure/pain around vertex and 2 episodes of rigth leg + arm numbness/tingling. Feels overall tired and heavy. He underwent a diagnositic angiogram with attempted coiling which was unable to be done. Post operatively he was neurologically intact with his unchanged surgical pupils and beating nystagmus in his right eye. He had issues with hypotension on his first post operative night. He was given fluids and his antihypertensive were held. On day of discharge his BP was in low 100's he was symptomatic, not feeling as tired, tolerating a regular diet and ambulating. His groin was without hematoma and he was neurologically intact.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Codeine / Prochlorperazine / Remicade <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ pt of Dr. ___, ___ abdominal wound w/ poor healing, ECF s/p ileostomy resiting ___ parastomal hernia, now p/w several days of malaise, abdominal pain, fever to 102.5, vomiting starting 1 day PTA. Pain has been crampy followed by increased ostomy output. <PAST MEDICAL HISTORY> 1. Crohns disease diagnosed ___ 2. Rheumatoid arthritis diagnosed ___ 3. s/p colectomy/ileostomy 4. s/p multiple abd surgeries (___) ___ procedure and Parks reversal. ___ - Wound opening and debridement of devitalized skin and subcutaneous tissues; Irrigation of the wound; Debridement of devitalized fascia and removal of some mesh and suture; Placement of VAC. ___ - VAC change and debridement 5. depression <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory. <PHYSICAL EXAM> Gen: NAD Chest: no respiratory distress Abdomen: soft, appropriately tender, non distended, wound viable, granulating, with unchanged fistulae, viable ostomy w/ appliance in place. no peritoneal signs. Ext: wnl <PERTINENT RESULTS> ___ 01: 25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01: 25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04: 37AM PLT COUNT-373 ___ 04: 37AM WBC-14.3* RBC-4.03* HGB-11.7* HCT-35.6* MCV-88 MCH-29.1 MCHC-32.9 RDW-15.6* ___ 04: 37AM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.9 ___ 04: 37AM GLUCOSE-124* UREA N-10 CREAT-0.7 SODIUM-139 POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-22 ANION GAP-11 <MEDICATIONS ON ADMISSION> Amoxicillin-Pot Clavulanate [Augmentin] 875 mg-125 mg Tablet 1 BID 1 Tablet(s) by mouth twice a day ___ B12 injection Folic Acid 1 mg Tablet one Tablet(s) by mouth once a day Lorazepam [Ativan] 0.5 mg Tablet 1 Tablet(s) by mouth every 6 hours as needed for anxiety Methocarbamol 750 mg Tablet two Tablet(s) by mouth twice a day ___ Omeprazole [Prilosec] 20 mg Capsule, Delayed Release(E.C.) 20 mg Capsule(s) by mouth once a day Oxycodone-Acetaminophen [Percocet] 5 mg-325 mg Tablet one to two Tablet(s) by mouth four times a day as needed for pain (Dose adjustment - no new Rx) ___ Prednisone 10 mg Tablet one Tablet(s) by mouth once a day taper to 7.5 mg and then to 5 mg (Dose adjustment - no new Rx) ___ Sertraline [Zoloft] 25 mg Tablet two Tablet(s) by mouth once a day ___ Tacrolimus [Protopic] Dosage uncertain Trimethoprim-Sulfamethoxazole [Bactrim DS] 800 mg-160 mg Tablet 1 Tablet(s) by mouth twice a day. Vit A Dosage uncertain <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp: *30 Tablet(s)* Refills: *0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 4. Methocarbamol 750 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Sertraline 25 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> cellulitis/crohn's disease <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please resume your normal diet, activity as tolerated, continue ostomy/wound care as before. Please call Dr. ___ ___ or come to the emergency department for fevers, inability to tolerate oral intake, nausea/vomiting, no ostomy output, or other issues.
Output:
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On presentation to the ER the patient was febrile, with abdominal pain and possible pSBO on CT scan. The patient was initially admitted to the ICU, but was transferred to the floor the same day. Her diet was gradually advanced, she was started on octreotide, and she was pan-cultured. Broad spectrum antibiotic coverage was continued for the duration of her hospital stay. On [REDACTED] she is afebrile, stable, is tolerating a regular diet and is ready for discharge home. She will complete a 2 week course of Augmentin and will see Dr. [REDACTED] in clinic on [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Codeine <ATTENDING> ___. <CHIEF COMPLAINT> nausea and coffee ground emesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> This is an ___ with a history of bladder cancer s/p cystectomy/urostomy, CCY, appendectomy, and TAH, now presenting with nausea and coffee ground emesis x 5 days. Her last BM and flatus were 3 days ago. She reports minimal abdominal pain in the RLQ that presents only with coughing. She was seen at ___ today, where a CT abd/pelvis showed an SBO. She was transferred to ___ for further management given her complicated anatomy. NGT in the ___ ED put out 1L immediately. Of note, this is her first episode of obstruction. <PAST MEDICAL HISTORY> PMH: bladder cancer s/p resection PSH: cystectomy/urostomy ___ years ago, CCY, appendectomy, and TAH <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Temp 98.7 HR 91 BP 154/87 RR 18 O2 sat 93% Gen NAD, AAOx3 CV RRR Pulm CTAB, no w/r/r Abd soft, mildly distended and tympanic, NT, well healed incisions; healthy urostomy with light yellow urine, no appreciable hernia Ext wwp, no edema <PERTINENT RESULTS> ___ 06: 20PM WBC-6.1 RBC-4.49 HGB-14.5 HCT-41.5 MCV-92 MCH-32.4* MCHC-35.0 RDW-13.5 ___ 06: 20PM NEUTS-47* BANDS-18* ___ MONOS-8 EOS-0 BASOS-1 ATYPS-6* ___ MYELOS-0 ___ 06: 20PM PLT COUNT-223 ___ 06: 20PM GLUCOSE-121* UREA N-35* CREAT-1.0 SODIUM-141 POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-27 ANION GAP-17 ___ 6: 10 pm URINE Site: CLEAN CATCH URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R <MEDICATIONS ON ADMISSION> Centrum silver 1 tab daily Fish Oil 1 tab daily <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 4. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 5. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. <DISCHARGE DISPOSITION> Home With Service Facility: ___ ___ Diagnosis: Small bowel obstruction UTI <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> * You were admitted to the hospital with abdominal pain due to a small bowel obstruction. * Your symptoms improved with gastric decompression and bowel rest. * You are now able tolerate a regular diet and should continue to do so. You should also drink enough to stay well hydrated. * Make sure that your bowel movements are regular and if needed use a stool softener or gentle laxative to stay regular. * If you develop any more abdominal pain or vomiting, call your doctor or return to the Emergency Room.
Output:
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Ms. [REDACTED] was evaluated by the Acute Care service in the Emergency Room and admitted to the hospital for further management of her small bowel obstruction. A nasogastric tube was placed for decompression and she was hydrated with IV fluids. Following transfer to the Surgical floor she was comfortable, without abdominal pain or nausea. Her gastric drainage decreased over the next [REDACTED] hours and was removed on [REDACTED]. At that time she was able to tolerate a liquid diet without difficulty. Her diet was gradually advanced to regular and tolerated well. She remained free of abdominal pain or nausea. She also had some diarrhea which resolved with discontinuing Reglan. She had 2 stool cultures which were negative for C difficile. Of note, a urine culture was done on admission and grew > 100K E Coli and > 10K enterococcus. The specimen was taken from her [REDACTED] ostomy bag but due the count of E Coli and the strong odor of her urine she was treated with 3 days of Keflex. She was up and walking with her cane and able to care for all of her ADL's. After a short stay with resolution of her SBO she was discharged to home on [REDACTED] and will follow up with her PCP [REDACTED] 1 week. She will probably need an EGD to follow up on the findings on her chest CT at [REDACTED] which noted esophageal wall thickening possibly inflammatory vs neoplastic. That can be done after she has fully recovered from the recent SBO.
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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> Mr ___ is a ___ year old male who complains of L sided chest pain for the last 5 days which comes and goes. He has not taken anything for the pain and has never had this type of pain before. He describes it as a sharp stabbing pain that is worse with deep inspiration or activity. It is currently keeping him from sleeping and he is very concerned about it. <PAST MEDICAL HISTORY> Hyperlipidemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Parents and siblings alive and healthy. No significant medical problems. No history of blood clots, bleeding, or sudden death in the family. <PHYSICAL EXAM> Admission physical Exam -====== Vitals: 98.4 | 149 / 84 | 81 | 20 | 100% RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Slightly diminished breath sounds in lower lobes, improved from yesterday. Otherwise clear to auscultation. No wheezes, rhonchi or rales. BACK: Skin intact, no rashes or lesions. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 1+ edema in right leg with trace in left. No cords felt. No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Gait is normal. Discharge Physical Exam -====== Vitals: 98.7 | 113/69 | 78 | 20 | 97% RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Slightly diminished breath sounds in lower lobes, improved from yesterday. Otherwise clear to auscultation. No wheezes, rhonchi or rales. BACK: Skin intact, no rashes or lesions. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 1+ edema in right leg with trace in left. No cords felt. No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Gait is normal. <PERTINENT RESULTS> ___ 01: 30AM BLOOD D-Dimer-3900* ___ 01: 30AM BLOOD cTropnT-<0.01 ___ 08: 00AM BLOOD Glucose-97 UreaN-11 Creat-1.2 Na-141 K-4.3 Cl-104 HCO3-24 AnGap-17 ___ 08: 00AM BLOOD WBC-7.4 RBC-5.57 Hgb-14.1 Hct-43.9 MCV-79* MCH-25.3* MCHC-32.1 RDW-12.2 RDWSD-34.5* Plt ___ <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H: PRN Pain - Mild Take over the counter Tylenol or acetaminophen as written on the bottle. 2. Rivaroxaban 15 mg PO BID Please take with food. Follow up with your PCP ___ 1 week. RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth Twice a day Disp #*14 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary Diagnosis - Pulmonary embolism - provoked <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You came to the hospital with chest pain and were found to have blood clots in your lung. This is a serious condition which could have been life threatening. The clots are likely caused by your truck driving which involves sitting for a long period of time. During your driving, we recommend that you take frequent breaks to move your legs and promote the flow of blood. To treat your condition, we are starting you on a blood thinning pill that will help keep the clots small and help your body get rid of them. You are starting on rivaroxaban (Xarelto) which is a pill that you need to take twice per day for 3 weeks and then take a slightly larger pill once a day for another 9 weeks for a full 3 months of treatment. You will need to start this medication tomorrow morning. You will need to follow up with a primary care physician. An appointment will be made with you this week and you will be called with the day and time.
Output:
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Mr. [REDACTED] is an otherwise healthy [REDACTED] year old [REDACTED] driver who presented to the ED with chest pain and was found to have bilateral segmental PEs by CTA. They are likely secondary to immobilization during long trucking routes. He was admitted to medicine where he was educated on his illness and started on rivaroxaban prior to discharge with close followup this same week. # Pulmonary Embolism Mr. [REDACTED] had bilateral segmental pulmonary embolisms which are believed to be provoked by his long periods of sitting in his truck. He was educated on what these clots were and was told that he should try to get out of his truck more often than every 8 hours if possible, ideally every [REDACTED] hours. He still had some pain which was controlled with an additional dose of ketorolac and then tylenol. In hospital he was anticoagulated with lovenox initially in the ED at 1.5mg/kg dose and then the next morning with a 1 mg/kg dose. He was then switched to rivaroxaban in the evening with dinner. He was discharged home with a 1 week prescription and a plan for close followup scheduled the next day. # Lack of health insurance Around the time of discharge, it was discovered the Mr. [REDACTED] [REDACTED] did not have health insurance. He lost it almost a year prior when he was moved from a [REDACTED] to a [REDACTED]. He was given resources in the hospital including a coupon to help with the cost of rivaroxaban. Follow up was scheduled the next morning where it was confirmed that he was able to get the medication and was working on obtaining insurance. Financial [REDACTED] was notified of his situation and further follow up was arranged. Transitional Issues: - Initiation of rivaroxaban: 15mg/kg for 3 weeks [REDACTED] - [REDACTED] then complete the remaining weeks at 20mg per day taking with dinner (until [REDACTED] - Will need to establish care with PCP. He is agreeable to go to [REDACTED] and will be called with an appointment. - Patient does not have insurance at discharge. He will be calling his company and case management has already been alerted to the situation. He was willing to pay out of pocket for rivaroxaban until insurance can be obtained.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing <ATTENDING> ___. <CHIEF COMPLAINT> carotid stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Left carotid endarterectomy and bovine pericardial patch angioplasty. <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ patient of Dr. ___. Consultation is requested for treatment of a left carotid stenosis. Mrs. ___ relates three episodes of right-hand clumsiness one a year ago, which cleared spontaneously in five minutes and two more in the last three weeks. The last one was a week ago. In all three occasions, she lost motor control of her right hand transiently once when trying to write and most recently when trying to use remote control on the TV. These then responded spontaneously. After the first episode a year ago, she was seen at the ___. She underwent a fairly extensive neurological evaluation and no specific treatment recommendations were made. She has been on Aspirin, does not take Plavix, and has not been on the statin. She has a strong family history of atherosclerosis. Her sister recently had a right carotid endarterectomy at the ___ for similar symptoms. She has no history of stroke. She denies any amaurosis fugax or expressive aphasia <PAST MEDICAL HISTORY> carotid stenosis, hypertension, hypothyroidism, and degenerative arthritis PSH: cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> carotid stenosis; atherosclerosis <PHYSICAL EXAM> VSS Afebrile Gen: wdwn elderly female in nad Neck: supple, no jvd; incision c/d/i without swelling Card: RRR Lungs: CTA bilat Extremeties: warm, well perfused; Femoral, popliteal, and pedal pulses are all strongly palpable. <PERTINENT RESULTS> ___ 04: 44AM BLOOD WBC-10.0 RBC-3.96* Hgb-9.5* Hct-29.1* MCV-74* MCH-24.0* MCHC-32.6 RDW-16.0* Plt ___ ___ 10: 26AM BLOOD WBC-11.3* RBC-4.65 Hgb-11.2* Hct-33.0* MCV-71* MCH-24.0* MCHC-33.9 RDW-16.1* Plt ___ ___ 04: 44AM BLOOD Glucose-101* UreaN-18 Creat-0.8 Na-133 K-4.0 Cl-105 HCO3-22 AnGap-10 ___ 10: 26AM BLOOD Glucose-117* UreaN-22* Creat-0.7 Na-135 K-4.0 Cl-103 HCO3-22 AnGap-14 ___ 04: 44AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.9 ___ 10: 26AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0 <MEDICATIONS ON ADMISSION> Atenolol 50 qd, Levothyroxine 125qd, Nifedipine CR 90qd, omeprazole 20qd, asa 325qd, plavix 75qd(for carotid disease), simvastatin 20qd <DISCHARGE MEDICATIONS> 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for hr <55; sbp <100. 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. clobetasol 0.05 % Cream Sig: One (1) Appl Topical DAILY (Daily). 7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for discomfort. 8. oxycodone 5 mg Tablet Sig: 0.5 - 1 Tablet PO Q4H (every 4 hours) as needed for pain. 9. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily): hold for sbp<100. 10. Stop these medications: You may stop taking Plavix <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic Left Carotid Stenosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: -It is normal to have some swelling and feel a firm ridge along the incision -Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness -Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery -Try ibuprofen, acetaminophen, or your discharge pain medication -If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeons office 4. 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 -You may walk and you may go up and down stairs -Increase your activities as you can tolerate- do not do too much right away! 5. 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 What activities you can and cannot do: -No driving until post-op visit and you are no longer taking pain medications -No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit -You may shower (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 -Take all the medications you were taking before surgery, unless otherwise directed -Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed -You can stop taking Plavix What to report to office: -Changes in vision (loss of vision, blurring, double vision, half vision) -Slurring of speech or difficulty finding correct words to use -Severe headache or worsening headache not controlled by pain medication -A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg -Trouble swallowing, breathing, or talking -Temperature greater than 101.5F for 24 hours -Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions
Output:
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Ms. [REDACTED] underwent preop [REDACTED] and was taken for a Left carotid endarterectomy on [REDACTED]. She was monitored closely and was maintained on a nitro gtt overnight for blood pressure control. On POD 1 the nitro was weaned off and her home blood pressure meds were initiated. She remained stable; her foley was removed and she voided without difficulty; and she tolerated a regular diet. Later that morning she ambulated in the hallways without assistance and her blood pressure was well controlled on her home regimen. She was deemed stable for discharge to home. Of note, we did stop her plavix.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Percocet <ATTENDING> ___. <CHIEF COMPLAINT> left hip pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ORIF left hip <HISTORY OF PRESENT ILLNESS> ___ y.o. male with Alzheimer's dementia and ___ disease who presents with left hip pain after unwitnessed fall. Patient reports that he fell yesterday while at his SNF. He had plain films performed yesterday that were inconclusive and so he was sent to the ED for additional films. He reports continued pain, but denies striking his head or LOC. He further denies chest pain, SOB, fevers/chills/sweats, abdominal pain. <PAST MEDICAL HISTORY> 1. chronic low back pain secondary to lumbar spinal stenosis. He is status post lumbosacral surgery a couple of times, one in ___ and one in ___. 2. Status post prostate cancer and surgery. Persistent urinary incontinence after the prostate surgery 3. Alzheimer's dementia or a parkinsonism such as ___ body dementia 4. orthostatic hypotension 5. High blood pressure, 6. Deep venous thrombosis 7. Osteoporosis 8. Multifactorial gait disorder 9. Problems with sleep secondary to neuropathic pain in his lower extremities 10. CRF 11. Anemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of heart disease or neurological disease. <PHYSICAL EXAM> General Evaluation Exam Sensorium: Awake () Awake impaired (x) Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable (x) Unstable () Circulation: Stable (x) Unstable () Musculoskeletal Exam Neck Normal (x) Abnormal () Comments: Spine Normal (x) Abnormal () Comments: Clavicle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Shoulder R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Arm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Elbow R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Forearm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Wrist R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Pelvis R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: mild ttp on lateral compression Hip R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: increased pain with flexion and internal rotation. Thigh R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Knee R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Leg R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Ankle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Foot R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Vascular: Radial R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Ulnar R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Femoral R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Poplitea R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () DP R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () ___ R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Neuro: Deltoid R (5) L (5) Biceps R (5) L (5) Triceps R (5) L (5) Wrist Flx R (5) L (5) Wrist Ext R (5) L (5) Finger Flx R (5) L (5) Finger Ext R (5) L (5) Thumb Ext R (5) L (5) ___ DIP R (5) L (5) Index Abd R (5) L (5) Thumd Add R (5) L (5) Quad R (5) L (not tested secondary to pain) Ant Tib R (5) L (not tested secondary to pain) ___ R (5) L (5) Peroneal R (5) L (5) ___ R (5) L (5) <PERTINENT RESULTS> ___ 09: 40PM GLUCOSE-101* UREA N-21* CREAT-1.4* SODIUM-133 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-12 ___ 09: 40PM WBC-5.4 RBC-3.43* HGB-11.1* HCT-32.0* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.8 ___ 09: 20PM ___ PTT-26.7 ___ <MEDICATIONS ON ADMISSION> (1) Metamucin 1.7 gram PO daily (2) Fosamax 70mg PO weekly (3) MVI i tab PO daily (4) Miralax 17gm PO prn constipation (5) Namenda 10mg PO BID (6) Effexor XR 75mg PO daily (7) Colace 100mg PO BID (8) carbidopa-Levodopa 25mg-100mg, 1.5 tabs PO TID (9) Flomax 0.4mg PO daily (10) oxycodone 2.5 PO prn (11) acetaminophen 650mg PO prn (12) senokot ii tabs prn (13) Heparin 5000 units SC TID <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> left hip fracture <DISCHARGE CONDITION> Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <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 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 ___ 2. 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. If you have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room.
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Mr. [REDACTED] as evaluated in the emergency room by the orthopaedic trauma service and found to have a left hip fracture. He was admitted to ortho and prepped for surgery. On HD 2, he was taken to the OR. See operative report for full details. He tolerated the procedure well without complication. After a brief stay in PACU, he was transferred to the floor. He arrived to the floor and was transitioned to a regular diet and PO meds for pain. He was started on lovenox daily for DVT prophylaxis. At the time of discharge, he was afebrile with stable vital signs, tolerating a regular diet, voiding spontaneously, and with his pain well controled.
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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> COUGH <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Mr. ___ is an ___ year old man with medical history notable for COPD, HTN, HLD, CAD s/p MI, stroke s/p recent treatment for pneumonia who presented to the ED with cough, nausea, and weakness and admitted for further work-up. Per patient, approximately 1 week ago he was seen by his PCP for productive cough, subjective fevers, concerning for pneumonia. He was started on a Z pack. Throughout the week, his symptoms persisted and he developed worsening cough, nausea, and weakness. He endorsed a few episodes of non-bloody, non-bilious vomiting and decreased PO intake. Due to his ongoing symptoms, he presented to the ED for further management. In the ED, initial vitals were: 99.8 55 128/55 18 96% RA Work-up was notable for: flu negative, leukocytosis to 16, normal lactate, CXR without acute findings. Patient received: ___ 06: 22 IVF NS ___ 06: 37 IV CefTRIAXone ___ 07: 23 IV Azithromycin ___ 07: 23 IH Albuterol 0.083% Neb Soln ___ 07: 23 IH Ipratropium Bromide Neb ___ 07: 59 PO/NG amLODIPine 2.5 mg Decision was made to admit for management of pneumonia. VS on transfer: 98.6 84 104/54 18 97% RA On the floor, he reports that he is currently feeling somewhat improved. He describes a history of one week of feeling malaise, fatigue and cough. This did not improve with a Z-pack which he completed. He has continued to feel increasingly unwell, with one episode of vomiting at home. He reports poor appetite over this week. He denies chest pain, shortness of breath, abdominal pain, diarrhea, lower extremity swelling. <PAST MEDICAL HISTORY> COPD HYPERTENSION HYPERLIPIDEMIA CAD s/p MI CVA S/p GUN SHOT WOUND <SOCIAL HISTORY> ___ <FAMILY HISTORY> None reported <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: VS: 98.3 PO 114 / 57 74 18 95 Ra GEN: elderly gentleman in NAD, sitting up in bed HEENT: anicteric sclerae, adentulous, NC/AT CV: Regular rate and rhythm, normal S1 + S2, no murmurs LUNGS: clear to auscultation but with poor air movements at the bases Abdomen: Soft, non-tender, non-distended EXT: Warm, well perfused, 2+ pulses, no edema NEURO: CNII-XII intact, A+O X 3 DISCHARGE PHYSICAL EXAM: VS: 97.8 PO 116 / 62 5616 97% on RA GEN: well-appearing elderly gentleman in NAD, lying in bed HEENT: anicteric sclerae, adentulous, NC/AT CV: RRR, normal S1 + S2, no murmurs LUNGS: clear to auscultation Abdomen: soft, non-tender, non-distended EXT: warm, well perfused, no edema or ulcers NEURO: CNII-XII intact, A+O X 3 <PERTINENT RESULTS> ADMISSION LABS: ___ 05: 00AM WBC-16.8* RBC-4.35* HGB-13.8 HCT-39.0* MCV-90 MCH-31.7 MCHC-35.4 RDW-13.0 RDWSD-42.8 ___ 05: 00AM NEUTS-84.6* LYMPHS-6.1* MONOS-8.4 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-14.24* AbsLymp-1.02* AbsMono-1.42* AbsEos-0.00* AbsBaso-0.03 ___ 05: 00AM PLT COUNT-227 ___ 05: 00AM ___ PTT-27.2 ___ ___ 05: 00AM ALBUMIN-4.2 ___ 05: 00AM LIPASE-36 ___ 05: 00AM ALT(SGPT)-31 AST(SGOT)-63* ALK PHOS-77 TOT BILI-1.0 ___ 05: 00AM GLUCOSE-109* UREA N-14 CREAT-0.9 SODIUM-136 POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-22 ANION GAP-12 ___ 06: 26AM LACTATE-1.8 ___ 12: 26PM URINE MUCOUS-RARE* ___ 12: 26PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 12: 26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 12: 26PM URINE COLOR-Yellow APPEAR-Clear SP ___ CHEST X-RAY IMPRESSION: No acute cardiopulmonary abnormality. DISCHARGE LABS ___ 05: 46AM BLOOD WBC-7.5 RBC-3.99* Hgb-12.6* Hct-36.2* MCV-91 MCH-31.6 MCHC-34.8 RDW-13.2 RDWSD-43.8 Plt ___ ___ 05: 46AM BLOOD Plt ___ ___ 05: 46AM BLOOD Glucose-89 UreaN-9 Creat-0.7 Na-140 K-4.1 Cl-101 HCO3-23 AnGap-16 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN shortness of breath 2. amLODIPine 2.5 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Gabapentin 100 mg PO TID 5. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 6. Aspirin 81 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY <DISCHARGE MEDICATIONS> 1. Benzonatate 100 mg PO TID RX *benzonatate 100 mg 1 capsule(s) by mouth three times per day Disp #*21 Capsule Refills: *0 2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice per day Disp #*4 Tablet Refills: *0 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 unit neb every 6 hours Disp #*28 Ampule Refills: *0 4. Albuterol Inhaler ___ PUFF IH Q4H: PRN shortness of breath 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Gabapentin 100 mg PO TID 9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 10. Vitamin D 1000 UNIT PO DAILY 11.NEBULIZER DME: NEBULIZER MACHINE DIAGNOSIS: COPD ICD-10: J44.9 DURATION: 99 MONTHS (LIFETIME) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary Diagnosis: Upper Respiratory Infection Secondary Diagnosis: COPD, Coronary Artery Disease, Hypertension, Hyperlipidemia <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 to care for you during your hospitalization at ___. You were admitted due to cough, shortness of breath and fatigue. We believe this was caused by an infection in your lungs. You were treated with antibiotics and breathing treatments and your symptoms improved. Please complete your course of antibiotics (Cefpodoxime 200mg twice daily for 2 more days) and continue to use the medicine for cough and breathing treatments until your symptoms improved. Also be sure to follow-up with your PCP. We wish you the best! Your ___ Team
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Mr. [REDACTED] is a [REDACTED] with COPD, HTN, HLD, CAD s/p MI, hx of stroke who presented to the ED with cough, nausea, and weakness, likely due to upper respiratory infection and clinically improved with ceftriaxone/azithromycin, duonebs and symptomatic treatment of his cough. UPPER RESPIRATORY INFECTION WITH LEUKOCYTOSIS/COUGH: Patient presented with fatigue/malaise, leukocytosis to 16.8 and cough, making upper respiratory infection most likely. His Flu A/B, CXR and UA were all negative on [REDACTED]. Though his imaging and exam were less consistent with a bacterial process and clinical picture more suggestive of a viral infection, his leukocytosis improved with ceftriaxone and azithromycin so were continued inpatient. His cough and shortness of breath also improved with symptomatic treatment including tesslon perles and duonebs. He completed 3 days of ceftriaxone and azithromycin in-house and was discharged on cefpodoxime 200mg Q12H for 2 additional days as he had received a full course of azithromycin prior to admission. He also was discharged with plan for a new nebulizer machine, duonebs and tessalon perles at home. #NAUSEA: Patient reported nausea that improved on admission but this improved inpatient without intervention. #COPD: No evidence of exacerbation. Plan for outpatient PFTs in [REDACTED]. He was given duonebs in house with reported improvement in symptoms. Also was continued on home Symbicort. #HTN: Continued home amlodipine 2.5mg daily #HL: Continued home atorvastatin #CAD s/p MI + HX OF CVA: Patient with CAD s/p MI and Hx of CVA without residual focal neurologic deficits. Continued home aspirin and atorvastatin. TRANSITIONAL ISSUES - Patient will complete two additional days of cefpodoxime 200mg Q12H due to concern for community acquired pneumonia. - Patient being discharged on tessalon perles for cough and new duonebs. He will have nebulizer machine delivered to his home. He felt symptomatic relief with nebs inpatient so will encourage until this illness resolves. - Please follow-up final blood cultures - Patient may benefit from further nutritional counseling and/or supplements in the outpatient setting. - Please consider whether patient may benefit from additional (elder
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> hydrochlorothiazide <ATTENDING> ___ <CHIEF COMPLAINT> L1 fracture <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: T11-L3 posterior fusion <HISTORY OF PRESENT ILLNESS> ___ s/p fall on ___ resulting in L1 fracture. Since then, he is doing ok in a TLSO, which he has been competent to. However, he still has some back pain, but no neurologic issues including bowel/bladder issues, tingling or weakness. XR on ___ showed the fracture collapsed with 30% more loss of height and kyphotic angulation increased for another ~15 degrees. Plan for T11-L3 fusion to avoid more collapse. <PAST MEDICAL HISTORY> -Atrial fibrillation - rate controlled on metoprolol and digoxin, apixaban for thromboembolic prophylaxis -Left bundle branch block -Hypertension -Chronic pain -Hyperlipidemia -PUD -HFpEF -Mild aortic regurgitation, mild mitral regurgitation, aortic valve sclerosis outside hospital echo ___ -CHF -OSA -OA left knee -s/p total right knee replacement (___) -chronic headaches -Obesity -PUD -Reflux -Barretts Esophagus -Right arm tendon surgery (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> None <PHYSICAL EXAM> ON DISCHARGE: ------------- Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch Wound: [x]Clean, dry, intact [x]Staples <PERTINENT RESULTS> Please see OMR for pertinent results. <MEDICATIONS ON ADMISSION> Medications - Prescription APIXABAN [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth twice a day (per surgeon stop 1 week preop) - (Prescribed by Other Provider; Dose adjustment - no new Rx) DIGOXIN - digoxin 250 mcg tablet. 1 tablet(s) by mouth once a day FUROSEMIDE - furosemide 40 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1.5 tablet(s) by mouth twice a day OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1 CAPSULE BY MOUTH ONCE A DAY OXYCODONE - oxycodone 5 mg tablet. 1 tablet by mouth up to qid as needed for severe breakthrough pain from spine fracture OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 7.5 mg-325 mg tablet. 2 tablet(s) by mouth three times a day SILVER SULFADIAZINE - silver sulfadiazine 1 % topical cream. apply to affected areas twice a day SIMVASTATIN - simvastatin 40 mg tablet. TAKE 1 TABLET BY MOUTH EVERY DAY AT BEDTIME FOR CHOLESTEROL Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALTRATE 600 + D] - Caltrate 600 + D 600 mg (1,500 mg)-800 unit chewable tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by Other Provider; Dose adjustment - no new Rx) DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 (One) capsule(s) by mouth twice a day <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H Do not exceed 4g/day. 2. Bisacodyl 10 mg PO/PR DAILY 3. Gabapentin 300 mg PO Q8H 4. OxyCODONE (Immediate Release) ___ mg PO Q6H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Q6H PRN Disp #*10 Tablet Refills: *0 5. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H RX *oxycodone 30 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills: *0 6. Senna 8.6 mg PO BID 7. Tamsulosin 0.4 mg PO DAILY 8. Digoxin 0.25 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Furosemide 40 mg PO DAILY 11. Metoprolol Succinate XL 75 mg PO BID 12. Omeprazole 20 mg PO DAILY 13. Simvastatin 40 mg PO QPM <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> L1 fracture <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> Surgery -Your incision is closed with staples. You will need staple removal. -Do not apply any lotions or creams to the site. -Please keep your incision dry until removal of your staples. -Please avoid swimming for two weeks after staple removal. -Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity -You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. -You must wear your brace while showering. -We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. -You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. -No driving while taking any narcotic or sedating medication. -No contact sports until cleared by your neurosurgeon. -Do NOT smoke. Smoking can affect your healing and fusion. Medications -Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. -Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. -You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. -It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: -Severe pain, swelling, redness or drainage from the incision site. -Fever greater than 101.5 degrees Fahrenheit -New weakness or changes in sensation in your arms or legs.
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[REDACTED] who presented [REDACTED] for elective T11-L3 posterior fusion. A hemovac drain was placed intraop. Please see separate operative report by Dr. [REDACTED] more information. Patient was extubated and recovered in the PACU before being transferred to the floor. He was evaluated by the chronic pain service, who initially managed his pain with PCA. On POD1, CPS d/c'd PCA, started oxycontin/oxycodone with morphine for breakthrough, along with Tylenol and gabapentin. On POD2, CPS d/c'd morphine and diazepam. His foley was removed and he voided independently. He worked with [REDACTED] and became slightly orthostatic. Hemovac drain was removed on [REDACTED] without event. Xray was done post-pull and showed expected post-op changes. He remained neurologically intact and was discharged to rehab on [REDACTED].
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> PLASTIC <ALLERGIES> Sulfa(Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> ___ with right breast ca desiring bilateral mastectomy and reconstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1) Left modified radical mastectomy and right prophylactic mastectomy. 2) Immediate bilateral tissue expander breast reconstruction. <HISTORY OF PRESENT ILLNESS> ___ with right breast ca desiring bilateral mastectomy and reconstruction <PAST MEDICAL HISTORY> Afib with TIA on coumadin <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/a <PHYSICAL EXAM> On discharge the patient was afebrile with normal vital signs, her incisions were clean/dry/intact without evidence of infection, the JP drains were serosanguinous in quality, the mastectomy skin flaps were viable. <PERTINENT RESULTS> ___ INR 1.1 <MEDICATIONS ON ADMISSION> atenolol, coumadin <DISCHARGE MEDICATIONS> 1. Atenolol 25 mg PO DAILY 2. cefaDROXil *NF* 500 mg Oral Q12h Duration: 7 Days RX *cefadroxil 500 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*14 Capsule Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 4. HYDROmorphone (Dilaudid) ___ mg PO Q3H: PRN Pain RX *hydromorphone 2 mg ___ tablet(s) by mouth Q4-6h Disp #*60 Tablet Refills: *0 5. Enoxaparin Sodium 40 mg SC QD RX *enoxaparin 40 mg/0.4 mL 1 injection subcutaneous once a day Disp #*10 Syringe Refills: *0 6. Warfarin 5 mg PO ONCE ___ Duration: 1 Doses 7. Warfarin 5 mg PO ONCE ___ Duration: 1 Doses 8. Warfarin 3.75 mg PO DAILY16 ___ and forward 9. Gabapentin 300 mg PO TID RX *gabapentin [Neurontin] 300 mg 1 capsule(s) by mouth three times a day Disp #*42 Capsule Refills: *0 10. Sarna Lotion 1 Appl TP BID: PRN dry skin/itch <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Left invasive carcinoma of the breast. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Personal Care: 1. Leave any dressings in place for 48-hours after surgery and then they may be removed and incisions left 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 each drain should be brought to every follow-up appointment. your drains 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. ___. . 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. 3. Take your antibiotic as prescribed. 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. 6. You should take coumadin 5mg on ___ and on ___ then return to your normal dosing of 3.75 mg daily. You should go to your ___ clinic on ___ for a repeat INR. If you cannot get there on ___, then please go on ___ ___. Your nurse, ___, will be there both days. You must continue the lovenox injection until your INR becomes therapeutic (between ___. . 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 oF 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.
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The patient was admitted to the plastic surgery service following bilateral mastectomy and tissue expander reconstruction. She recovered uneventfully in PACU and was transfered to the regular surgical floor later that day in stable condition. Her hospital course was unremarkable. Coumadin was resumed on POD#2. She was kept on a lovenox bridge throughout her hospitalization and discharged on lovenox until her INR is therapeutic. At the time of discharge the patient was afebrile with normal vital signs, her incisions were clean/dry/intact without evidence of infection, the JP drains were serosanguinous in quality, the mastectomy skin flaps were viable. Her pain was well controlled on oral medication, she was ambulating independently and voiding good amounts of urine. She expressed her readiness to return home.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Hydrochlorothiazide <ATTENDING> ___. <CHIEF COMPLAINT> Abd pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic converted to open cholecystectomy. <HISTORY OF PRESENT ILLNESS> The patient presented with a somewhat suggestive history of biliary colic but caution was expressed prior to surgery that removal of her gallbladder might not address all of her clinical issues. With this understanding, the patient elected to undergo cholecystectomy. <PAST MEDICAL HISTORY> Hypertension ; Endometrial cancer <SOCIAL HISTORY> ___ <FAMILY HISTORY> Unknown <PHYSICAL EXAM> A and O x 3 V.S.S RRR no m/r/g LSCTA bilat soft, nt, nd, + bs no c/c/e <PERTINENT RESULTS> ___ 06: 50AM BLOOD WBC-7.8 ___ 09: 46AM BLOOD WBC-11.6* RBC-3.35* Hgb-11.3* Hct-31.2* MCV-93 MCH-33.9* MCHC-36.3* RDW-12.4 Plt ___ ___ 06: 50AM BLOOD Glucose-116* UreaN-8 Creat-0.5 Na-140 K-3.7 Cl-101 HCO3-32 AnGap-11 ___ 08: 10AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-138 K-3.7 Cl-100 HCO3-29 AnGap-13 ___ 06: 50AM BLOOD ALT-37 AST-30 AlkPhos-51 Amylase-22 TotBili-1.4 ___ 08: 10AM BLOOD ALT-49* AST-50* AlkPhos-55 Amylase-28 TotBili-1.9* ___ 06: 50AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2 ___ 08: 10AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8 <MEDICATIONS ON ADMISSION> Simvastatin, Enalapril; Atenolol; Omeprazole; Amlodipine <DISCHARGE MEDICATIONS> 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. 6. Codeine Sulfate 30 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cholelithiasis. <DISCHARGE CONDITION> Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within ___ hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow up appointment. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. .
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Mrs. [REDACTED] was admitted to general surgery from the pacu. She was maintained as NPO with IVF/NGT. Her NGT was removed with the return of bowel function and decreased output. Her diet was slowly advanced as tolerated and medications were converted to oral. She has an uncomplicated post-op course. She will f/u with Dr. [REDACTED] in [REDACTED] weeks.
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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> Diarrhea, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ man with recent ORIF of right arm at ___ presented with adominal pain and diarrhea. The patient presented to ___ for ORIF of "broken bones" in right arm about 10 days ago. He was given "antibiotics" and then before discharge developed diarrhea. Stool samples were taken. He went home 4 days ago, and the diarrhea became worse, more frequent up to 10 nonbloody, loose stools a day with diffuse abdominal pain. Two days ago, his wife called ___ to report on the diarrhea and was reportedly told that the patient had C. diff and was prescribed oral metronidazole, which he has taken since. He has experienced poor appetite, nausea, but no vomiting. Not wanting to return to ___, he presented to ___. On presentation to ___ ED, T 98.8, BP 123/83, HR 94, RR 16, 96%RA. Labs were notable for WBC 7.9 with 22% bands, ALT 172, AST 108, AP 246. Lipase was normal, and Cr was 0.7. Abd CT showed pancolitis with mural thickening and mucosal hyperenhancement, consistent with C.diff; no evidence of perforation or megacolon. He was given levofloxacin 750 mg IV x 1, oxycodone 10 mg PO x 1, morphine 2 mg IV x 1 and admitted to medicine. On review of systems, patient reports persistent right arm pain. No fevers, chills, headache, visual changes, chest pain, dyspnea, dysuria, hematuria, melena, BRBPR, rash. <PAST MEDICAL HISTORY> CVA Right arm fracture(s) s/p ORIF <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> T 99.1, BP 112/76, HR 80, RR 18, 97%RA Gen: middle-aged muscular man in discomfort from arm pain, awake, alert, appropriate HEENT: EOMI, conjunctivae clear, sclerae anicteric Neck: supple Lungs: CTAB CV: no JVD, regular rhythm, normal rate, normal S1/S2, no murmur Abd: soft, diffusely tender, bowel sounds present, no rebound tenderness, no guarding Ext: no c/c/e; right arm in cast <PERTINENT RESULTS> C.diff toxin POSITIVE GLUCOSE-122* UREA N-12 CREAT-0.7 SODIUM-134 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-17 ALT(SGPT)-172* AST(SGOT)-108* ALK PHOS-246* TOT BILI-0.3 WBC-7.9 RBC-4.47* HGB-13.5* HCT-39.9* MCV-89 MCH-30.3 MCHC-33.9 RDW-13.7 CT ABD: 1. Severe circumferential pancolonic mural thickening with hyperenhancing mucosa, most consistent with known C. diff colitis and much less likely ischemic in etiology given distribution. Small amount of right lower quadrant pericecal and perihepatic free fluid is likely reactive/inflammatory in nature. No extraluminal gas seen. No evidence of megacolon. 2. Mild splenomegaly. <MEDICATIONS ON ADMISSION> atorvastatin unknown dose clopidogrel 75 mg daily metronidazole unknown dose <DISCHARGE MEDICATIONS> 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 11 days. Disp: *44 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Clostridium difficile colitis Transaminitis <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 clostridium difficile colitis. Please be sure to complete the antibiotics, as prescibed. Your liver function tests were slightly elevated while here; please stop taking your atorvastatin (LIPITOR) until you see your primary care doctor.
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1 Clostridium difficile colitis: Toxin positive with CT abdomen significant for severe pan-colitis, without evidence of toxic megacolon. Initiated on both oral vancomycin and IV flagyl initially; IV flagyl was stopped after his symptoms began to improve and he was continued on the PO vancomycin to complete a 14-day course. His abdominal pain improved and his diet as advanced as tolerated. 2. History of CVA: Continued clopidogrel 75 mg 3. Transaminitis: Unclear if acute or not. Patient has been on atorvastatin, which was discontinued on admission with plan for repeat LFTs as an outpatient before resuming statin.
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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> ampullary adenoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP with ampullectomy and pancreatic stent removal <HISTORY OF PRESENT ILLNESS> Pt is a ___ y.o female with h.o FAP s/p colectomy, h.o bowel obstructions requiring surgery, RA, osteoporosis who presented for ERCP for ampullectomy due to presence of a polyp. Pt denies any problems prior to admission including fever, chills, headache, dizziness, URI, CP, sob, palpitations, nausea, vomiting, diarrhea, constipation, melena, brbpr, dysuria, hematuria, paresthesias, weakness, change weight or appetite, rash. She does report chronic unchanged joint pain due to RA. She reports current ST after ERCP. In addition, she reports ___ upper epigastric "achy" pain after ERCP. <PAST MEDICAL HISTORY> rheumatoid arthritis dx ___ FAP dx ___ colectomy ___ bowel obstruction ___ bowel obstruction ___ with surgery bowel obsruction ___ osteoporosis tested NEGATIVE for the ___ gene <SOCIAL HISTORY> ___ <FAMILY HISTORY> HL HTN osteoporosis grandfather with CVA ___ mutation <PHYSICAL EXAM> GEN: well appearing, NAD, lying comfortably in bed vitals: T 98.2 BP 131/82, HR 82, RR 18, sat 100% on RA HEENT: ncat eomi anicteric MMM neck: supple, no LAD, chest: b/l ae no w/c/r heart: s1s2 rr no m/r/g abd: +bs, +several healed surgical scars, soft, NT, ND, no guarding or rebound ext: no c/c/e 2+pulses skin: no rash neuro: non-focal, speech fluent, face symmetric psych: calm, cooperative <PERTINENT RESULTS> . ERCP ___: Impression: Polypoid tissue was noted at the ampulla measuring approximately 8 mm, consistent with known adenoma An ampullary resection was performed using a snare Successful cannulation of pancreatic duct (cannulation) Normal pancreatic duct A 7cm by ___ ___ single pigtail pancreatic stent was placed successfully. Otherwise normal ercp to third part of the duodenum . Recommendations: Admit overnight for observation and evaluation. NPO overnight with aggressive IV hydration with LR at 200 cc/hr. If no abdominal pain in the AM, advance diet to clear liquids and then advance as tolerated. No aspirin, plavix, NSAIDS, coumadin for 5 days Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call (___) Repeat ERCP in 2 weeks for stent removal. Repeat EGD with side viewing scope in 6 months for surveillance . ___ 05: 25AM BLOOD WBC-10.5 RBC-4.36 Hgb-12.6 Hct-39.9 MCV-92 MCH-28.8 MCHC-31.5 RDW-14.1 Plt ___ ___ 08: 10AM BLOOD WBC-9.7 RBC-5.18 Hgb-15.3 Hct-46.3 MCV-90 MCH-29.6 MCHC-33.1 RDW-14.4 Plt ___ ___ 08: 10AM BLOOD Neuts-66.4 ___ Monos-5.9 Eos-0.6 Baso-0.4 ___ 05: 25AM BLOOD Plt ___ ___ 08: 10AM BLOOD Plt ___ ___ 08: 10AM BLOOD ___ PTT-27.0 ___ ___ 08: 10AM BLOOD ESR-12 ___ 05: 25AM BLOOD Glucose-58* UreaN-6 Creat-0.6 Na-139 K-4.0 Cl-101 HCO3-27 AnGap-15 ___ 08: 10AM BLOOD UreaN-10 Creat-0.8 Na-142 K-3.8 Cl-101 HCO3-26 AnGap-19 ___ 05: 25AM BLOOD ALT-27 AST-20 AlkPhos-63 TotBili-1.2 ___ 08: 10AM BLOOD ALT-33 AST-19 AlkPhos-83 Amylase-59 TotBili-0.5 DirBili-0.2 IndBili-0.3 ___ 05: 25AM BLOOD Lipase-174* ___ 08: 10AM BLOOD Lipase-25 ___ 08: 10AM BLOOD ___ ___ 08: 10AM BLOOD CRP-16.0* ___ 08: 10AM BLOOD RO & ___ ___ 08: 10AM BLOOD SM ANTIBODY-PND <MEDICATIONS ON ADMISSION> methotrexate 17.5mg weekly prednisone 2mg QId hydrochloroquine 200mg BID citrical 600/400 BID vit D 1000IU daily 27mg ferric gluconate BID immodium 2mg QID 4 psyllium QId MVI OCP <DISCHARGE MEDICATIONS> 1. prednisone 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 2. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 6. ferrous gluconate 236 mg (27 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 7. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. psyllium husk 0.52 g Capsule Sig: Four (4) Capsule PO four times a day. 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 11. methotrexate sodium 25 mg/mL Solution Sig: 17.5 mg Injection once a week. 12. Aviane 0.1-20 mg-mcg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ampullary adenoma s/p resection h.o FAP s/p colectomy rheumatoid arthritis <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 observation following an ERCP ampullectomy. The procedure was successful and a stent was placed in your pancreatic duct. A biopsy of this area was taken and is still PENDING at the time of discharge. Your gastroenterologist will follow up on this result. You had some abdominal pain after the procedure that improved. Your diet was successfully advanced. . You will need to have a repeat ERCP in 2 week's time for stent removal (see below for appointment). In addition, you will need to have a repeat EGD in 6 months for routine surveillance. . Medication change: 1.please avoid all aspirin, ibuprofen, naproxen products for 5 days . Please take all of your medications as prescribed and follow up with the appointments below.
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Pt is a [REDACTED] y.o female with h.o FAP s/p colectomy, h.o bowel obstructions requiring surgery, RA on steroids/MTx, osteoporosis who presents for observation s/p ampullectomy given presence of adenoma. . #ampullary adenoma-H.O FAP and is s/p colectomy for FAP. She was found to have an adenoma at the ampulla and therefore underwent an ERCP with ampullectomy and pancreatic stent placement. A biopsy of the ampullary area was taken and results are PENDING at the time of discharge. Pt did have some epigastric pain post ERCP that resolved. She was initially given bowel rest, IV fluids and IV dilaudid for pain. her abdominal pain resolved and her diet was successfully advanced to regular without any complications. She was advised to avoid NSAIDs for 5 days. She is already scheduled for a repeat ERCP in 2 weeks for stent removal. She was advised to have a repeat EGD in 6 month's time for surveillance. . #h.o FAP s/p colectomy with pouch. Pt was continued on her outpt regimen of psyllium and loperamide. She will follow up with her gastroenterologist after discharge. . #rheumatoid arthritis- pt can continue her outpt regimen of prednisone, methotrexate, hydroxychloroquine and follow up with her rheumatologist after discharge. . #osteoporosis-continue citrical, vitamin D . #ppx-ambulation, pneumoboots . Transitional care: -f/u ampullary biopsy -pending [REDACTED], anti Ro and La, SM antibody-ordered by Dr. [REDACTED] .
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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> none attach <PERTINENT RESULTS> Admission Labs: -== ___ 03: 47AM BLOOD WBC-13.1* RBC-3.25* Hgb-8.8* Hct-29.6* MCV-91 MCH-27.1 MCHC-29.7* RDW-15.2 RDWSD-51.4* Plt ___ ___ 03: 47AM BLOOD Neuts-86.0* Lymphs-4.8* Monos-8.0 Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.24* AbsLymp-0.63* AbsMono-1.05* AbsEos-0.00* AbsBaso-0.01 ___ 06: 50AM BLOOD ___ PTT-31.9 ___ ___ 03: 47AM BLOOD Glucose-154* UreaN-36* Creat-2.1* Na-142 K-4.1 Cl-111* HCO3-18* AnGap-13 ___ 03: 47AM BLOOD Calcium-7.4* Phos-2.5* Mg-1.4* ___ 03: 53AM BLOOD Lactate-0.8 BCx (___): no growth UCx (___): < 10,000 CFU/mL. ___ cultures: UCx (___): Urine Culture Final ___ Organism 1 Enterobacter cloacae complex Colony Count: >100,000 CFU/mL E clo cpx M.I.C. Inter ------ ----- Amox/Clav >=32 R Aztreonam 2 S Cefazolin >=64 R Cefepime <=1 S Ceftriaxone 16 R Ciprofloxacin >=4 R Ertapenem <=0.5 S Gentamicin <=1 S Imipenem <=0.25 S Levofloxacin >=8 R Meropenem <=0.25 S Nitrofurantoin 64 I Pip/Tazo 16 S Tetracycline 8 I Trimeth/Sulfa >=320 R Imaging: ======== CT Abd/Pelvis: IMPRESSION: 1. Status post neobladder ileal conduit formation without evidence of inflammatory change or discrete obstruction. Mild bilateral hydronephrosis to the level of the conduit with severe chronic right renal atrophy. 2. Cholelithiasis without evidence of cholecystitis for technique. Discharge Labs: -== ___ 07: 35AM BLOOD WBC-6.8 RBC-4.15* Hgb-11.2* Hct-36.5* MCV-88 MCH-27.0 MCHC-30.7* RDW-15.0 RDWSD-48.2* Plt ___ ___ 07: 35AM BLOOD Glucose-160* UreaN-31* Creat-1.7* Na-139 K-4.5 Cl-102 HCO3-23 AnGap-14 ___ 07: 35AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 DISCHARGE EXAM: ___ 0746 Temp: 98.0 PO BP: 127/67 L Sitting HR: 76 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: Alert, NAD EYES: Anicteric ENT: mmm RESP: breathing room air comfortable ABD/GI: Soft, ND, NTTP, normoactive bowel sounds, urostomy in place with bag draining clear yellow urine GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs VASC/EXT: No ___ edema SKIN: No rashes or lesions noted on visible skin NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, moves all limbs PSYCH: pleasant, appropriate affect <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires further investigation. 1. MetFORMIN (Glucophage) Dose is Unknown PO BID 2. GlipiZIDE XL Dose is Unknown PO DAILY 3. Metoprolol Tartrate Dose is Unknown PO BID 4. Gabapentin Dose is Unknown PO BID 5. Pravastatin Dose is Unknown PO QPM 6. TraZODone Dose is Unknown PO QHS: PRN insomnia 7. LORazepam Dose is Unknown PO QHS: PRN anxiety 8. Citalopram Dose is Unknown PO DAILY 9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID <DISCHARGE MEDICATIONS> 1. ertapenem 1 gram injection DAILY RX *ertapenem 1 gram 1 gram IV once a day Disp #*4 Vial Refills: *0 2. Citalopram 20 mg PO DAILY 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 4. Gabapentin 100 mg PO TID 5. GlipiZIDE XL 5 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Metoprolol Tartrate 25 mg PO BID 10. Pravastatin 20 mg PO QPM 11. TraZODone 200 mg PO QHS: PRN insomnia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary: Complicated UTI <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Mr. ___, You came to the hospital with abdominal pain and fevers. We found that you had another urinary tract infection. We treated you with antibiotics and your infection improved. You were also seen by the urologists who felt that your ileal conduit was working well. However, the recommended that you have a loopogram of the ileal conduit after returning to ___. It will be important to continue taking antibiotics after leaving the hospital. It was a pleasure taking care of you, and we are happy that you're feeling better!
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Mr. [REDACTED] is a [REDACTED] male from [REDACTED] with no records available here with a history of an ileal conduit for bladder cancer [REDACTED] years ago with recurrent UTIs who presented with right-sided abdominal pain and fever secondary to a UTI. # Abdominal pain # Multidrug resistant Enterobacter cloacae UTI # Right and Left hydronephrosis # Possible partial obstruction of the ileal conduit Patient presented with symptoms consistent with prior UTIs. Per patient has had resistant organisms in the past, and is often treated with cefepime, which he also received in the ED at [REDACTED]. He was started on cefepime on [REDACTED]. His urine culture grew multidrug-resistant Enterobacter cloacae which is covered by cefepime. Infectious disease was consulted. Due to fluctuating creatinine clearance which may require adjustment in cefepime dosing, they recommended changing to ertapenem on discharge. He was given a dose prior to discharge. He will continue ertapenem through [REDACTED] to complete a 10 day course. Urology was consulted. They recommended outpatient loopogram when he returns to [REDACTED] to eval the ureteroileal anastamosis. # [REDACTED] on CKD: Cr 2.6 at BIP, improved to 2.1 following IVF suggesting prerenal etiology. Unknown baseline, but per discussion with patient's PCP he believes his baseline is around 1.8. As above no evidence of obstructive etiology on CT. Creatinine improved to 1.7 by discharge. # Thrombocytopenia: platelets 122 on admission, likely mildly low in the setting of sepsis. Resolved with treatment of infection # HTN: Continued home Metoprolol 25 mg PO BID and home HCTZ 12.5 mg daily. Initially held home lisinopril 20 mg daily in the setting [REDACTED] but this was resumed on discharge. # DM: held home glipizide and metformin. Placed on ISS while hospitalized # Mood disorder: continued home citalopram, lorazepam, trazodone # HLD: continued home pravastatin >30 minutes spent on complex discharge
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> Vomiting blood <MAJOR SURGICAL OR INVASIVE PROCEDURE> Upper endoscopy <HISTORY OF PRESENT ILLNESS> ___ M with history of DM, HTN, depression, anxiety who presented to ED with vomiting small amounts of dried blood in vomitus. He woke up this morning with nausea and dizziness and difficulty walking as he was bumping into things. he checked his sugar which was 180. Baseline fasting sugars are in the 110's usually. Soon after, he vomited which contained specks of dried blood. Of note, three days ago he had a mechanical fall where he hit his back and R leg and started taking ibuprofen 600mg tid for pain. In the ED VS: 98.1 104 112/66 18 99%. NGL with ___ dark brown material with no BRB. Dark color cleared with lavage. He received IV PPI. GI was consulted and plan made for EGD in the morning. EKG was unchanged from prior. Labs remarkable for acute renal failure to 1.9. Hct was 37 from baseline of 40. WBC was 16 with a left shift. A T&S was sent. On my evaulation on the floor he reported some 'aches and pains' where he fell, but otherwise had no complaints. ROS: (+) 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 diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. <PAST MEDICAL HISTORY> * B 12 deficiency * Diabetes * h/o ataxia and falls * s/p MVA ___ with chronic low back pain * hx of herpez zoster * past hx of Hep B, cleared infection <SOCIAL HISTORY> ___ <FAMILY HISTORY> His father died of pancreatic cancer in age ___. Mother died of an MI suddenly at age ___. <PHYSICAL EXAM> DISCHARGE: Vitals: 98 124/67 76 15 100% RA General: Well appearing M in NAD, alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear, no conjunctival pallor Neck: supple, Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild TTP epigastrically, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: raised, rough, dark plaque on back, may be SK vs AK <PERTINENT RESULTS> LABS: - CBC: WBC-16.2 HGB-14.3 HCT-37.4 PLT-181 - DIFF NEUTS-81* BANDS-1 LYMPHS-7* MONOS-9 EOS-1 BASOS-0 ___ METAS-1* MYELOS-0 - LFT's: ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-58 TOT BILI-0.5 - cTropnT-<0.01 - LIPASE-40 - CHEM 7: GLUCOSE-183* UREA N-25* CREAT-1.9*# SODIUM-143 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15 IMAGING: HEAD CT (prelim): No acute intracranial process EGD: Grade D esophagitis (biopsy) Ulcer in the stomach antrum Antral gastritis (biopsy) Duodenitis Otherwise normal EGD to third part of the duodenum <MEDICATIONS ON ADMISSION> clonazepam 1 mg Tablet duloxetine 60 qam 120 qpm fluticasone 50 mcg Spray, 2 sprays each nostril, qam hydrochlorothiazide 25 mg qd metformin 500 mg bid pregabalin 150 mg Capsule zolpidem 12.5 mg Tablet,Ext Release Multiphase aspirin 81 mg <DISCHARGE MEDICATIONS> 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 8 weeks. Disp: *120 Capsule, Delayed Release(E.C.)(s)* Refills: *2* 2. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO qam. 3. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO qpm. 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal BID (2 times a day). 5. pregabalin 150 mg Capsule Sig: One (1) Capsule PO once a day. 6. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for back pain. 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. zolpidem 12.5 mg Tablet,Ext Release Multiphase Sig: One (1) Tablet,Ext Release Multiphase PO at bedtime as needed for insomnia. 11. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Upper GI bleed from gastritis/esophagitis likely from NSAIDs Diabetes Hypertension Depression <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 vomiting blood. You had an EGD which showed severe stomach and esophagus irritation probably from acid and the ibuprofen you were taking. You should not take any ibuprofen (Advil, Motrin) or aspirin. You can take acetaminophen (Tylenol) for pain as it doesn't irritate the stomach. The following medication changes were made: ADDED: - Omeprazole 40mg twice a day, this is to help treat your stomach irritation. Continue this until after your EGD and GI appointment. STOPPED: - Aspirin, please stop this as it causes stomach irritation. You PCP or GI doctor may restart it. No other medication changes were made, please continue all your other home medications as previously directed. You should also avoid alcohol as it can worsen your stomach irritation. It was a pleasure meeting you and participating in your care.
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#. Upper GIB: EGD showing severe gastritis and esophagitis likely from NSAID use and GERD. HCT dropped to low 30's and remained stable. Discharged on BID omeprazole and follow up with PCP and GI from repeat endoscopy in 6 weeks. Aspirin also held until repeat EGD and patient counseled on not taking any NSAIDs or drinking alcohol. # [REDACTED]: Pre-renal as resolved with IVF. Back to baseline on discharge. # Diabetes: Held metformin while in house and covered with SSI. Restarted metformin on discharge. # HTN: Initially held hydrochlorothiazide given [REDACTED], but restarted on discahrge. TRANSITION OF CARE: 1. GI follow up with EGD on [REDACTED], continue PPI until then
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Erythromycin Base / morphine / Codeine <ATTENDING> ___. <CHIEF COMPLAINT> ventricular tachycardia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None this hospitalization. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo woman with history of hypertension, recent admission to ___ for monomorphic ventricular tachycardia controlled on outpatient metoprolol and diltiazem, presented to ___ with dizziness and palpitations this morning, found to be in ___ and converted on amiodarone, now transferred to ___ for further management. Ms. ___ was recently admitted to ___ (discharged ___ with ventricular tachycardia. She underwent unremarkable TTE and exercise tolerance test (complete results below). She was discharged on metoprolol and diltiazem in NSR with cardiology followup. Outpatient notes from Dr. ___ that patient remained in sinus rhythm on her med regimen but would likely require ablation if VT returned. Per patient she has been well controlled on these medications and completely asymptomatic. She has been taking them daily. She was in usual state of health when she got out of the shower this morning and felt lightheaded with palpitations. She denies any known triggers including recent illnesses.. At ___ she was given amiodarone bolus and then transitioned to amiodarone drip at 1 mg/min. After 6 hours amiodarone decreased to 0.5 mg/min. Vital signs prior to transfer were reportedly BP 125/65, HR ___ sinus rhythm with no ectopy, temperature 97.2, RR 18, O2 sat 97% on room air. <PAST MEDICAL HISTORY> Idiopathic monomorphic VT Hypertension Hyperlipidemia Psoriasis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with MI at age ___ and subsequent arrhythmias requiring ablation, all after his MI, Sister with HTN. No other family history of heart disease. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: VS: 98.6 139/75 71 18 97%RA Weight 88.5 kg GENERAL: WDWN very pleasant woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT, MMM. Sclerae anicteric. NECK: Supple with no JVD CARDIAC: RRR. Normal S1, S2. No murmurs/rubs/gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Lungs clear without crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: No c/c/e SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted. DISCHARGE PHYSICAL EXAM: VS: 98.6 ___ 60-71 18 96-98% RA Weight 88.5 kg Telemetry: Sinus rhythm GENERAL: WDWN very pleasant woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT, MMM. Sclerae anicteric. NECK: Supple with no JVD CARDIAC: RRR. Normal S1, S2. No murmurs/rubs/gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Lungs clear without crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: No c/c/e SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted. <PERTINENT RESULTS> ADMISSION LABS ___ 07: 38PM BLOOD WBC-6.3 RBC-4.26 Hgb-11.7 Hct-37.3 MCV-88 MCH-27.5 MCHC-31.4* RDW-14.4 RDWSD-45.3 Plt ___ ___ 07: 38PM BLOOD ___ PTT-26.3 ___ ___ 07: 38PM BLOOD Glucose-97 UreaN-13 Creat-0.5 Na-139 K-3.6 Cl-101 HCO3-24 AnGap-18 ___ 07: 38PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.1 DISCHARGE LABS ___ 06: 50AM BLOOD WBC-5.1 RBC-3.98 Hgb-10.8* Hct-36.9 MCV-93 MCH-27.1 MCHC-29.3* RDW-14.6 RDWSD-49.2* Plt ___ ___ 06: 50AM BLOOD Glucose-106* UreaN-12 Creat-0.6 Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 ___ 06: 50AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1 ECG Sinus rhythm <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Diltiazem Extended-Release 360 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Ibuprofen 400-600 mg PO Q8H: PRN pain 5. DiphenhydrAMINE 25 mg PO Q6H: PRN allergy 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY: PRN indigestion <DISCHARGE MEDICATIONS> 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg Take 1 tablet by mouth daily Disp #*30 Tablet Refills: *0 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY: PRN indigestion 5. Diltiazem Extended-Release 360 mg PO DAILY 6. DiphenhydrAMINE 25 mg PO Q6H: PRN allergy 7. Ibuprofen 400-600 mg PO Q8H: PRN pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary Diagnosis: - Monomorphic Ventricular Tachycardia Secondary Diagnosis: - Hypertension - Hyperlipidemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to the hospital with ventricular tachycardia. You were started on amiodarone and you converted to normal sinus rhythm. You were evaluated by the Electrophysiology doctors. Your metoprolol dose was increased. Please follow-up with Dr. ___ planning ablation as an outpatient. All the best, Your ___ Team
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Ms. [REDACTED] is a [REDACTED] yo woman with history of hypertension, recent admission to [REDACTED] for monomorphic ventricular tachycardia controlled on outpatient metoprolol and diltiazem, presented to [REDACTED] with dizziness and palpitations this morning, found to be in [REDACTED] and converted on amiodarone, now transferred to [REDACTED] for further management. # Idiopathic monomorphic ventricular tachycardia: Patient admitted with second episode of monomorphic ventricular tachycardia. Reports full adherence to outpatient metoprolol and diltiazem. Prior workup including echo and stress test have been unrevealing. Converted with amiodarone prior to transfer to [REDACTED] and remained in sinus rhythm here. Her home metoprolol was increased to 100 mg daily. She will schedule outpatient follow up with her cardiologist Dr. [REDACTED] with plan for outpatient ablation. # Hypertension: Blood pressure within normal limits. COntinued home lisinopril. # CODE: FULL # CONTACT: Sister [REDACTED] [REDACTED] # TRANSITIONAL ISSUES: - Patient's metoprolol XL was increased to 100mg daily. Please continue to monitor her heart rate. - Patient will follow-up with Cardiologist Dr. [REDACTED] to schedule outpatient ablation.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> ORTHOPAEDICS <ALLERGIES> Motrin / Nsaids / Vicodin <ATTENDING> ___. <CHIEF COMPLAINT> Bilateral hand weakness and sensory changes <MAJOR SURGICAL OR INVASIVE PROCEDURE> Anterior cervical discectomy and fusion C4/C5 <HISTORY OF PRESENT ILLNESS> This is a patient with a C4-C5 adjacent segment degeneration with cervical myelopathy from significant cervical stenosis with myelomalacia. Please see my previous notes for details. His symptoms have only worsened with now ___ function in his left hand, wrist flexors and wrist extensor as well as right lower extremity significant weakness with significant weakness of his ___, quadriceps. His last MRI since ___ shows significant and worsening myelomalacia at C4-C5. I discussed the risks and benefits of surgical intervention with him. I reviewed his CT scan, which showed no significant osteophyte formation in his canal, which means this is a soft disc, which is consistent with his previous MRI. He saw ENT because he has some dysphonia. Dr. ___ some right focal hypomobility, there was not a contraindication from approach from should not be a problem. <PAST MEDICAL HISTORY> Hypertension Hyperlipidemia Cervical spinal stenosis Depression/cyclothymia Sciatica Pulmonary nodule hx Nephrolithiasis Diverticulosis Pre-Diabetes Mellitus H. pylori s/p treatment ___ Past Surgical History: Bilateral Knee arthroscopy Left wrist surgery C5/6 and C6/7 Discectomy Right shoulder arthroscopic flap repair, subacromial decompression, distal claviculectomy ___ Cystoscopy, bladder biopsies, selective, bilateral retrograde pyelogram ___ Right knee partial medial meniscectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions but with significant decrease and paresthesias BUE: ___ Del/Tri/Bic 3+/5 WE/WF/FF/IO BUE: Tone normal, positive ___ bilaterally <PERTINENT RESULTS> ___ 06: 15AM BLOOD WBC-18.5*# RBC-4.69 Hgb-14.6 Hct-43.6 MCV-93 MCH-31.1 MCHC-33.5 RDW-13.2 RDWSD-45.0 Plt ___ ___ 06: 15AM BLOOD Plt ___ ___ 06: 15AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-137 K-4.3 Cl-101 HCO3-25 AnGap-15 ___ 06: 15AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H: PRN Shortness of breath 2. ARIPiprazole 10 mg PO DAILY 3. Diazepam ___ mg PO Q6H: PRN Spasm or anxiety 4. Lisinopril 5 mg PO DAILY 5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Oxybutynin 5 mg PO TID 9. Polyethylene Glycol 17 g PO DAILY 10. Pravastatin 40 mg PO QPM 11. Tiotropium Bromide 1 CAP IH DAILY 12. Aspirin 325 mg PO DAILY 13. Nicotine Patch 14 mg TD DAILY <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 2 PUFF IH Q6H: PRN Shortness of breath 2. ARIPiprazole 10 mg PO DAILY 3. Diazepam ___ mg PO Q6H: PRN Spasm or anxiety 4. Metoprolol Tartrate 50 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. Oxybutynin 5 mg PO TID 7. Polyethylene Glycol 17 g PO DAILY 8. Pravastatin 40 mg PO QPM 9. Tiotropium Bromide 1 CAP IH DAILY 10. Acetaminophen 650 mg PO Q6H: PRN Pain 11. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hous Disp #*90 Tablet Refills: *0 12. Senna 17.2 mg PO QHS 13. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 14. Aspirin 325 mg PO DAILY 15. Lisinopril 5 mg PO DAILY 16. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY <DISCHARGE DISPOSITION> Home with Service Facility: ___ <DISCHARGE DIAGNOSIS> C4/C5 disc herniation and spinal stenosis. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You have undergone the following operation: Anterior Cervical Decompression and Fusion Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. Rehabilitation/ Physical Therapy: ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. Diet: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful however, please limit your movement of your neck if you remove your collar while eating. Cervical Collar / Neck Brace: You have been given a hard collar. You may remove the collar to take a shower or eat. Limit your motion of your neck while the collar is off. You should wear the collar when walking, especially in public Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. Medications: You should resume taking your normal home medications. You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. 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. Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline x rays and answer any questions We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Physical Therapy: -Activity as tolerated with C-collar in place -Ambulation as much as tolerated -Weight bearing as tolerated -Gait, balance training -No lifting >10 lbs Treatments Frequency: Daily dressing changes with dry gauze until wound is dry Daily ___ for mobilization (encourage ambulation) Collar on at all times except hygiene and eating
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He was admitted to the [REDACTED] Spine Surgery Service and taken to the Operating Room for the above procedure (please refer to the dictated operative note for further details). The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis, in addition to encouraging early ambulation. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Diet was advanced as tolerated. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Stock Ragweed Pollen Mixture <ATTENDING> ___. <CHIEF COMPLAINT> rupture of membranes, concern for euglycemic DKA <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary C-section <HISTORY OF PRESENT ILLNESS> ___ G1P0 at ___ with T1DM who arrived as transfer from ___- ___ with rupture of membranes and concern for euglycemic DKA. Pt initially presented to ___ yesterday with nausea, vomiting, abd pain. Was given IV fluids, zofran and discharged home. She experienced a gush of clear fluid at ___ and had continued nausea, vomiting and thus presented again to ___. At ___ she was confirmed SROM grossly. Given her history of T1DM, electrolytes were checked which were as follows: Na 132, K 4.2, Cl 103, HCO3 11, BUN 8, Cr 1.14, glucose 119. Anion gap =8. Venous blood gas pH 7.33, pCO2 29.1, Bicarb 14.4, PO2 68.7, CO2 15. Urine with 3+ ketones. Pt was seen by Internal Medicine. Started on insulin gtt and D5NS + 40K. I/O at ___ 1750 IVF, UOP 1550, emesis 600 mL. Transferred to ___ due to concern for DKA. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ ultrasound - Labs Opos /Abs neg/Rub ___ NR/HBsAg neg/HIV neg/GBS UNKNOWN - Screening: not done - FFS: normal - U/S ___ 3475gm (78%ile) - Issues: -- T1DM, f/b ___, most recent hgbA1C 6.2. Baseline creatinine 0.5. Takes levemir 26 units qAM/qPM and novolog insulin sliding scale -- Hepatitis C, most recent viral load on ___ no current meds OBHx: - G1 GynHx: denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: T1DM as above; Hep C as above PSH: liver biopsy, wisdom teeth <SOCIAL HISTORY> denies T/E/D. Lives with parents. FOB not involved. <PHYSICAL EXAM> T 98.6 HR 122 BP 133/82 Gen: A&O, vomiting CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness SVE: deferred, ___ by outside hospital and grossly ruptured TAUS: Adequate pelvis Toco q5-10min FHT 140/moderate varability/+accels/-decels <PERTINENT RESULTS> ___ 09: 02PM GLUCOSE-121* UREA N-9 CREAT-0.7 SODIUM-140 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-20* ANION GAP-14 ___ 09: 02PM ALT(SGPT)-20 AST(SGOT)-18 ___ 09: 02PM CALCIUM-8.7 PHOSPHATE-1.4* MAGNESIUM-1.5* ___ 04: 45PM URINE HOURS-RANDOM ___ 04: 45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04: 45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG ___ 04: 45PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 04: 45PM URINE HYALINE-6* ___ 04: 45PM URINE MUCOUS-RARE ___ 03: 45PM GLUCOSE-128* UREA N-11 CREAT-0.9 SODIUM-139 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-18* ANION GAP-20 ___ 03: 45PM CALCIUM-9.0 PHOSPHATE-2.0* MAGNESIUM-1.5* ___ 03: 45PM WBC-10.1# RBC-3.61*# HGB-11.3*# HCT-30.4*# MCV-84 MCH-31.3 MCHC-37.2* RDW-14.0 ___ 03: 45PM NEUTS-72.0* ___ MONOS-8.0 EOS-0.2 BASOS-0.2 ___ 03: 45PM PLT COUNT-205 <MEDICATIONS ON ADMISSION> PNV, levemir 26units qAM/qPM; novolog with I: C ratio 1: 6, goal 120. <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6hrs Disp #*40 Tablet Refills: *0 3. NIFEdipine CR 30 mg PO BID RX *nifedipine [Procardia XL] 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q3H: PRN Pain RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s) by mouth Q4hrs Disp #*40 Tablet Refills: *0 5. Glargine 5 Units Breakfast Glargine 0 Units Bedtime ** Insulin Carb Counting Scale ** RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 5 units SC 5 Units before BKFT; 0 Units before BED; Disp #*1 Syringe Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p primary C-section for arrest of labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest, nothing in vagina, no heavy lifting
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Ms. [REDACTED] is a [REDACTED] G1 now P1 who was admitted at 37w 3d and was transferred from [REDACTED] with spontaneous rupture of membranes and euglycemic diabetic ketoacidosis. She was transferred for management of euglycemic diabetic ketoacidosis which was managed with IV insulin and IV D5 half-normal saline, as well as potassium repletion and IV fluid boluses with normal saline. Her labor was induced with Pitocin secondary to inadequate contractions. She arrived to us 3 cm dilated and progressed to 6 cm, and continued to be 6 cm for 6 hours prior to surgery. Her Pitocin was turned off twice during her labor course secondary to fetal deceleration, which was prolonged with good return to baseline. However, given the inability to augment her labor secondary to fetal intolerance of Pitocin, the patient was offered a primary cesarean section, and the patient decided at this time that she desired a primary cesarean section rather than continued augmentation of labor. She delivered a liveborn female infant with now APGARS. Her postpartum course was complicated by pre-eclampsia without severe features dignosed on PPD#3. PIH labs were significant for P/C ratio 0.4 and uric acid 5.9. She was started on nifedipine CR 30mg daily. On [REDACTED], she developed a HA and visual changes. Her BPs were persistently in 150/80s. She received 12 hours of magnesium and her HA responded to compazine and benadryl. For her T1DM, [REDACTED] was following her and by time of discharge, she was on lantus 5u Qam. By time of discharge, she was ambulating, voiding, pain controlled, BP and glucose controlled. She was discharged on POD#5 in stable condition with follow up scheduled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Weakness <MAJOR SURGICAL OR INVASIVE PROCEDURE> L1/2 Decompressive Lumbar Laminectomy Intubation Tracheostomy EGD <HISTORY OF PRESENT ILLNESS> ___ year old ___ speaking female transferred from ___ ___ facility for ___ of progressively worsening lower extremity weakness and a constellation of other symptoms. Per reports, patient had a questionable CVA 3 weeks ago, and at that time, was also reported to have developed bilateral lower extremity weakness. The weakness has progressed to the point where she can no longer walk or move her legs. She also reports pain and numbness to her L leg, as well a as "dullness" to her thoracic/abdominal region. She denies urinary or bowel incontinence, other than her usual stress urinary incontinence, and also denies any saddle anesthesia. <PAST MEDICAL HISTORY> PMHx: 1. Diabetes Type II 2. Arthritis 3. Cervical Spondylosis 4. Degenerative disc disease 5. Hyperlipidemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family Hx: Father with ___ <PHYSICAL EXAM> PHYSICAL EXAM: O: T: 98 BP: 156/68 HR: 73 R: 18 O2Sats: 99% Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic, Atraumatic. Pupils: PERRLA. ___ bilaterally EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and place only. Motor: D B T IP Q H AT ___ G R 4 4 4 ___ ___ ___ ___ ___ ___ L 5 5 5 ___ ___ ___ ___ ___ ___ Sensation: Patient reports "dullness" to abdominal area without a specific sensory level or dermatomal distrubution deficit. Was able to feel anterior pinprick, but describes it as dull. Reflexes: Pa Ac Right N/A(knee replacement) 0 Left N/A (knee replacement) 0 Toes downgoing bilaterally - Negative Babinski Rectal exam normal sphincter control <PERTINENT RESULTS> Admission Labs: . CSF Analysis: wbc 1, rbc 24, poly 1, lymph 87, mo 0, mac 12 TP 197, glu 77 . VZV: Neg HSV: Neg Oligoclonal Bands: Neg IMAGING . MRI from ___, ___: LUMBAR SPINE: L1-L2: There is a focal left paracentral disc protrusion and a broad based right paracentral to extraforaminal disc protrusion, with associated spondylitic ridging. Facet arthritis is asymmetrically moderate on the right and mild on the left. There is resultant severe spinal canal stenosis with complete effacement of SCF in the thecal sac, and severe foraminal encroachment which is worse on the right.L2-L3: The disc is severely degenerated with bulging of spondylitic ridging and there is moderate facet arthritis, with resultant moderate to severe canal stenosis, severe encroachment of the left neural foramen and moderate right foraminal encroachment.L3-L4, and L4-L5: There is a shallow broad based dorsal disc protrusion and moderate facet arthrisit causing moderate to canal stenosis which is asymmetrically most prominent along the left lateral recess, moderate foraminal encroachment on the right, and severe froaminal encroachment of the left. . CERVICAL MRI: Motion degraded study showing mild cervical spondylosis. . MRI HEAD: Results are unavailable <MEDICATIONS ON ADMISSION> 1. Metformin 500mg daily 2. Tylenol PRN 3. Vitamin D 4. ASA 81mg Daily <DISCHARGE MEDICATIONS> 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: Please give via PEG. 2. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please give via PEG. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: 100 mg PO BID (2 times a day) as needed for constipation: ___ give via PEG. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Please give via PEG. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep : Please give via PEG. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for dysesthetic leg pain: Please give via PEG. 9. Sodium Chloride 0.9% Flush 3 mL IV Q8H: PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 10. Lorazepam 0.5-1 mg IV Q8H: PRN anxiety 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 13. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR units Injection four times a day: sliding scale. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Acute Idiopathic Demyelinating Polyneuropathy (Guillain ___ Syndrome) <DISCHARGE CONDITION> Stable condition with trach. Neurologic exam notable for paraparesis with limited movement at proximal legs and none distally; moderate weakness of UEs but at least antigravity. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were transferred to ___ ___ ___ for ___ of progressively worsening lower extremity weakness. You underwent neurosurgery for a procedure called a laminectomy. Following diagnosis of Guillian ___ Syndrome, you were treated with IVIG. You are currently begin treated with Flagyl for a 14 day course for a previously postive C. diff toxin. Repeat C. diff toxin in negative. The last day of treatment with Flagyl will be on ___. With improving examination, you are now ready for transfer back to ___ for continued rehabilitation.
Output:
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Ms. [REDACTED] is a [REDACTED] year-old woman with a past medical history including obesity, DMII, hyperlipidemia, and cervical spondylosis who was admitted to the [REDACTED] [REDACTED] with with lower extremity weakness and was found to have stenosis at L1-2 for which she underwent laminectomy; she subsequently developed progressive weakness in the lower extremities, upper extremities, and face and was discovered to have evidence of AIDP. She was initially admitted to the Neurosurgery Service and subsequently transferred to the Neurology Service. . # NEURO: When the patient first presented, she was evaluated by both Neurosurgery and Neurology, where she was found to have diffuse weakness, R>L, a R sided facial palsy, decreased pinprick to the mid thighs, saddle anesthesia, brisk reflexes in the upper extremities, but no reflexes in her lower extremities. It was suspected that her inability to walk was due to her lumbar stenosis, and that her facial and upper extremity weakness were due to a lacunar stroke, that was too small to pick up on MRI. She was initially scheduled to go to the ER on [REDACTED] for laminectomy, however this was delayed for further work-up. She had a repeat MRI with DWI to rule out possible infarction to explain her symptoms, which was negative for infarct. On [REDACTED] she went to the OR for L1-L2 laminectomy. During surgery on [REDACTED], a CSF sample was obtained, which showed an elevated protein of 197, with 1 WBC and 24 RBCs. On [REDACTED], patient complained of increased pain and was observed to have progressive increase in weakness in her upper extremities as well as a bilateral facial droop, R>L. She also increased her requirement for O2 due to dyspnea. She was re-evaluted by Neurology, who found her facial weakness to be worse, with complaints of dysarthria, dysphagia, and mild dyspnea. Concern was raised for either GBS vs. CIDP vs. new stroke affecting her left side. As her respiratory status continued to decline, she was transferred to the ICU and intubated. An EMG was consistent with the concern for Guillain [REDACTED]. Accordingly, a five-day course of IVIG was prescribed. Thereafter the patient experienced gradual increases in strength and a return of reflexes, most notable in the left biceps. After transfer to the floor, her strength continued to improve, particularly in her upper extremities. # RESP: Because of worsening respiratory status, on [REDACTED] the patient was transferred to the ICU and intubated. On [REDACTED], after completing her course of IVIG, she underwent a successful SBT and was extubated. However, shortly after extubation she desaturated and had to be emergently reintubated. Ultimately, a tracheostomy was performed. She continued to receive oxygen supplementation via tracheostomy during the remainder of her hospital stay. . # ID In the course of the hospitalization, the patient developed a fever. Sputum culture demonstrated gram positive cocci in clusters for which IV vancomycin was begun ([REDACTED]) and subsequently switched to nafcillin after it was determined to be coagualase positive staph sensitive to nafcillin. Nafcillin was discontinued after one week. Stool was positive for c. difficile toxin for which flagyl was started ([REDACTED]). For a concurrent urinary tract infection, ciprofloxacin was initiated ([REDACTED]) and continued for a ten day course. It was determined that flagyl should be continued for a 14 day course. The last dose of flagyl should be given on [REDACTED]. . # GI Tube feeds were provided to ensure adequate nutritional intake throughout the hospitalization. Initial attempts to place a PEG in conjunction with the trach were thwarted as the patient was found to have "concretions" in the esophagus. A follow-up EGD demonstrated a clear esophagus, suggesting the concretions had spontaneously passed. As the patient seemed to attain improved attention and motor function following the IVIG treatments, the placement of a PEG was ultimately delayed with the hope she could begin oral intake. After transfer to the neurology floor, speech and swallow study was attempted but tracheostomy size was too large. On repeat study, she passed to receive NGT diet of ground consistency and nectar prethickend liquids. So that she could receive adequate nutritional support, she had a PEG tube placed on [REDACTED]. She is on goal tubefeeding of fiber full strength at 60 ml/hr and flush with 30 mL water q4h. Also, per repeat swallowing evaluation, she is permitted ground (dysphagia) consistency regular diet and nectar prethickened liquids, but the trach cuff must be deflated while feeding.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> PSYCHIATRY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "I had a vood spell cast on me a few years ago when I went to the traditional doctors... they told me to mix honey with some medication from trees." <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ domiciled, ___ woman without known psychiatric history who was BIBA after her family expressed concern that she was not eating or drinking food for several days. Psychiatry was consulted for evaluation of psychosis. Patient notes that she has been battling a voodoo spell that was placed ___ years ago. She said that she has seen some traditional doctors about the ___ and they told her to try to cure herself by mixing honey with some "medicine from trees." She said that the spell resulted in her having some "heaviness" in her right leg and arm. She said that lately she started trying to "speed up treatment" by listening to the Quran all night. She said that she would start feeling dizzy during this time, but then would have a little bit to drink before spending the night listening to the Quran. When asked for clarification about her religion (given that Voodoo and Islam are not typically associated), she irritably said, "You don't know anything about my religion." She denies having AVH, changes in sleep (notes that she sleeps about 6 hours per night), ideas of reference, paranoia, grandiosity, distractibility, risky/impulsive behaviors. Denies SI, HI, notes that her mood has been okay. No neurovegetative symptoms of depression. After providing an update on the plan and our concerns, the patient became quite upset and said that her sister and I were involved in a "set up," but she wasn't able to explain why we would be colluding. COLLATERAL: ___ (Sister, ___ & ___ (Mother) - Patient given verbal permission to provide update. They note that they started to notice a change about ___ years ago when the patient was attending college out in ___. They said that she started to call her mom daily and was very anxious about people being out to get her. They note that since she has moved back to ___, she has been acting even more strangely. They note that she spends almost all of her time in her room. She then started to make up stories where she was accusing her siblings of having a dark side. For instance, her sister reports that one of the stories that ___ made up about her was that there was a video of ___ being raped and that ___ was going to expose her sister if she ___ careful. They said that over the last few months, has started to require liquids and soft foods because she was chewing in a very unusual manner and was often looking to the side as if she was looking for permission to eat from something. They note that she has been self-dialoguing in her room and talking about things as if they were saying negative things about her. They also notes that she has been laughing randomly. They also report that the patient has started to become paranoid of her iPhone. Over the last four days, she hasn't been eating or drinking much and has been obsessing over the need to listen to the Quran. They note that the voodoo spell is not normal culturally. They note that prior to this she was very well-respected and social. ___ Records: Patient reported that she sees a PCP at ___ and thinks that there may have been a psychiatrist that she saw at one point, but no records of such a visit in ___. Patient gave verbal permission to access them. <PAST MEDICAL HISTORY> PAST PSYCHIATRIC HISTORY: Hospitalizations: Denies Current treaters and treatment: None Medication and ECT trials: None Self-injury: None, No history of suicide attempts Harm to others: None reported Access to weapons: None PAST MEDICAL HISTORY: Denies <SOCIAL HISTORY> SOCIAL HISTORY: -Born/Raised: ___ -Childhood: Grew up in ___, denies any childhood trauma. Moved to ___ in ___. -Education: Graduated from ___ and ___. -Employment: ___ -Housing: Lives with her mother and sister in ___. -Relationships/Children: No relationships or children. -Religiousity/Spirituality: Muslim -Trauma: Denies any history of trauma -Military: ___ SUBSTANCE ABUSE HISTORY: - Alcohol Use: Denies - Tobacco History: Denies - Illicit Substances: Denies. Patient was smoking a lot of hookah around the time that the symptoms started, but she no longer does this. FORENSIC HISTORY: Arrests: None Convictions and jail terms: None Current status (pending charges, probation, parole): None <FAMILY HISTORY> FAMILY PSYCHIATRIC HISTORY: No known family history of psychosis, mood disorder, suicide attempts, or substance abuse. <PHYSICAL EXAM> PHYSICAL EXAM: VS: HR: 132 bpm (was agitated while being taken) BP: 131/81 SpO2: 100% on RA Weight: 156 lbs HEENT: dried lips, MMM Heart: regular rate and rhythm, normal S1 and S2, no murmurs appreciated Lungs: clear to auscultation bilaterally, no wheezes, rales or rhonchi appreciated Abdomen: non-tender to palpation, normoactive bowel sounds x4, non-distended, no guarding, masses or rebound Extremities: warm and well perfused, no edema in bilateral lower extremities Neuro: pupils reactive to direct and near (3mm-2mm); EOMI; muscles of facial expression intact and symmetric bilaterally; shoulder-shrugs symmetric; light touch diffusely intact; strength ___ throughout UE and ___ ___ STATUS EXAM: *Appearance: wearing head wrap *Behavior: cooperative with interview *Speech: normal rate, volume, and tone *Language: fluent, occasional words that seemed to be in another language *Mood/Affect: "I'm affected by a voodoo spell," affect blunted *Thought process / *associations: tangential *Thought Content: as above, denies SI/HI, denies AH/VH, discusses feeling that there is a voodoo spell over her brought on by "fake people" *Judgment and Insight: poor/ poor Cognition: *Wakefulness/alertness: alert *Attention (digit span, MOYB): MOYB intact *Orientation: oriented x3 *Memory: intact to personal history *Fund of knowledge: average Neurological: *station and gait: within normal limits *tone and strength: within normal limits <PERTINENT RESULTS> ___: Normal BMP, Normal serum toxicology, normal CBC ___ 06: 27AM BLOOD WBC-5.6 RBC-3.63* Hgb-10.4* Hct-32.7* MCV-90 MCH-28.7 MCHC-31.8* RDW-13.1 RDWSD-43.2 Plt ___ ___ 06: 27AM BLOOD Glucose-84 UreaN-5* Creat-0.5 Na-138 K-4.0 Cl-104 HCO3-29 AnGap-9 ___ 06: 27AM BLOOD TotProt-5.1* Albumin-3.1* Globuln-2.0 Calcium-8.5 Phos-3.9 Mg-1.9 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> Patient to receive monthly dose of Invega sustena 156mg IM on ___ <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> schizophreniform disorder <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were hospitalized at ___ for disorganized thinking, feeling paranoid and not eating or drinking. While you were here we started you on medication and arranged outpatient treatment for you. You are now ready to be discharged home with ___ services for medication administration. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please do not misuse alcohol or 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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SAFETY: The patient was placed on Q5 minute checks on admission and was advanced to Q15 minute checks. Patient was unit-restricted. There were no acute safety or behavioral issues during this hospitalization. LEGAL: [REDACTED] PSYCHIATRIC: On admission to Deaconess 4, patient was significantly paranoid with a fixed delusion that she had been placed under a voodoo spell. She was offered PO risperidone but declined all psychotropic medications and "self-treated" by listening to recordings of the Quran on the internet and isolating in her room. She initially would only eat a specific brand of juice (Naked Juice) brought in by her mother and declined all other nutrition. Once the [REDACTED] was granted by the court, Haldol QHS was started and uptitrated (offered PO but patient declined and therefore received IM). She also received a Haldol Decanoate injection on [REDACTED]. The patient showed moderate clinical improvement on Haldol -- specifically reduction in paranoia, increased cooperation with team and better thought organization. However after approximately two weeks of treatment with Haldol, the patient was noted to have a new bilateral upper extremity tremor as well as facial swelling. There was no associated shortness of breath, throat swelling or rash. Haldol was stopped with improvement of swelling and tremor. Her psychiatric symptoms deteriorated after several days off antipsychotics, close to admission status, and began refusing to speak with the MDs on the team. She was transitioned to Abilify but showed little clinical improvement so she was switched to Olanzapine and dose was uptitrated. SHe did not show any improvement on the olanzapine so this medication was discontinued and patient was started on a medication vacation where patient did not receive psychiatric medications for a week. Afterwards patient was changed to Abilify Maintena was given a single dose however patient did not show any improvement on this medication. Therefor patient was changes to Invega sustena patient obtained 2 doses and tolerated well. Patient showed gradual improvement on Invega, she began to consume solid food and was able to maintain her weight while hospitalized. Patient began to become more agreeable to speak with the team and was less irritable, however delusional content persisted and patient remained extremely guarded and paranoid. Team applied for guardianship which were granted as temporary guardianship on [REDACTED] to patients sister. Family meeting was held on [REDACTED] in order to discuss patients final disposition with family. During family meeting, both mother and daughter agreed that patient could be discharged home since patients nutritional intake had normalized and her auditory hallucinations had decreased. Patients family agreed that they would have [REDACTED] services for patients monthly Invega sustena dose. Patients family also agreed to have patient see out-patient psychiatrist on a monthly basis for continued [REDACTED]. Patients family where educated on patients diagnosis and prognosis, family understood the importance of medication adherence and possible side effects. Family was also introduced to [REDACTED] services, because sister is the temporary guardian she may request D[REDACTED] services on behalf of her sister which was done on [REDACTED]. Though the [REDACTED] services patient will be able to obtain permanent PCP and psychiatric [REDACTED]. In the mean time Dr. [REDACTED] clinical director of the inpatient unit will be the referring physician for patient to be eligible to receive [REDACTED] services though [REDACTED]. Patients discharge was delayed due to difficulties finalizing paperwork for [REDACTED] application, however after second family meeting was held on [REDACTED] patient's guardian her sister [REDACTED] signed her [REDACTED] papers. Patient's family where re-educated on the services provided by [REDACTED], and how patient is not bound to receive their services once she is enrolled. Intermediate care search was stopped after agreement on final disposition was made by team and family, social work found outpatient [REDACTED] for patient in [REDACTED] once application can be processed. Where patient can both receive her primary care and out-patient psychiatry services. GENERAL MEDICAL CONDITIONS: # Poor PO intake/nutritional status: On admission patient refused to consume solid food, eventual agreed to accepted Naked Juices. BMP and CBC were wnl however patient was noted to be persistently tachycardic. Nutrition was consulted and provided recommendations about nutritional supplementation w/ protein powder and MVI which the patient refused. Over the course of admission the patient gradually accepted more foods including soup brought in by her mother and Ensure supplementation. Eventually patient began to consume solid food brought in by her family, nutrition service signed out since patient had stable weight gain and was no longer having intake problems. Weight and orthostatics were monitored weekly tachycardia improved, patient gained weight (admission 164.4, discharge 167.6) and orthostatics were negative. PSYCHOSOCIAL: #) GROUPS/MILIEU: Patient was encouraged to participate in the units groups/milieu/therapy opportunities however declined most of these opportunities. Use of coping skills and mindfulness/relaxation methods were encouraged. Therapy attempted to address family/social/work issues but was limited by the patient's clinical status (psychosis). #)COLLATERAL CONTACTS/FAMILY CONTACTS: Collateral was obtained from mother and sister. Several family meetings were held throughout the admission with the patient, her mother and sister and the treatment team which focused on psychoeducation and discharge planning. #) INTERVENTIONS: - Medications: Invega sustena - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: by social work, MDs, RNs and outpatient providers - Guardianship: Guardianship (mother and sister) was applied for and granted on [REDACTED]. - DMH Referral: The team submitted a DMH application for the patient to receive services which will be granted once application can be processed. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Haldol, aripiprazole and olanzapine, as well as the risks and benefits of possible alternatives, including not taking the medication, with this patient. Medication is included on [REDACTED]. Answered the patient's questions. The patient appeared able to understand. RISK ASSESSMENT: #) Chronic/Static Risk Factors: Chronic mental illness (family reports symptoms ongoing for several years) #) Modifiable Risk Factors: Persistent delusions and paranoia - modified by starting antipsychotics, providing therapy while admitted, connecting patient with outpatient treaters No connection to outpatient mental health treaters - modified by connecting patient with DMH services Poor PO intake [REDACTED] psychiatric illness - modified w/ antipsychotics, frequent redirection/encouragement and arranging guardianship #) Protective Factors: Strong social support (mother and sister), no suicidal ideation or homicidal ideation; high prior level of functioning PROGNOSIS: Patient presented with significant psychosis that interfered with psychosocial functioning. While admitted to the inpatient unit, she was started on antipsychotics and efforts were made to set up patient with DMH services, family was instructed on how to obtain these services when patient is amenable to participate, temporary guardianship was granted to sister during hospitalization. Prognosis is guarded given minimal symptomatic improvement, but is encouraged by connection with outpatient providers and support in the community. The patient was taught about warning signs and resources, including the emergency department that she can [REDACTED] with.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Macrolide Antibiotics / Phenergan / Doxycycline / Erythromycin Base / Zithromax / Tetracycline <ATTENDING> ___ <CHIEF COMPLAINT> Chest and back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ woman with history of IVDU, MRSA tricuspid endocarditis (___) s/p 4-wk course of IV daptomycin now being admitted for transthoracic echocardiogram. Per the ED history, patient was arrested earlier on evening of admission when she was caught using heroin with her boyfriend. She was then incarcerated, and upon discovering that the cost of bail was ___, she developed chest and back pain and was transferred to ___ emergency room. (Speaking with patient this morning, she denies heroin or cocaine use; she says that she had an unlabeled bottle of pills that contained gabapentin and "some Klonopin" and that this was the cause for her incarceration - she says that earlier in the day she was taking Klonopin but otherwise denies illicits yesterday; last heroin use was 3 days ago.) In the ED, initial vitals were T 98.6, HR 88, BP 117/69, RR 12, satting 100%RA. Labs showed a hct of 29.8, which is unchanged from her recent baseline. CBC and BMP were otherwise unremarkable. Cardiac enzymes were negative x1 set. EKG was unchanged. CXR showed no acute process. ED staff noted focal tenderness over her right lower back and was concerned about septic arthritis of the sacroiliac joint versus psoas abscess. For this reason, patient underwent CT scan of the ___ that showed no evidence of acute infection (see preliminary report below). Blood cultures were drawn. Patient was then admitted for a TTE that had been previously scheduled for ___. Of note, patient underwent a 4-week treatment course for MRSA tricuspid endocarditis with IV daptomycin that ended in mid ___. Previously, she had been evaluated by thoracic surgery as there was concern about tricuspid vegetations and ASD (both seen on her TEE), and the risk for paradoxical embolism. Thoracics had recommended for TTE in four weeks to re-evaluate valves (see note from ___. The original follow-up TTE had been scheduled for ___, and as it turned out patient had been re-admitted to ___ again on ___ for somnolence in the setting of urine tox positive for cocaine and opioids. During that admission, after she cleared from what was thought to be drug-related somnolence, patient insisted on leaving the hospital and refused to have the TTE done. She ended up leaving AMA. Patient is now being admitted to have the follow-up TTE done. Emergency room staff has confirmed that she is willing to undergo the study during this admission. Review of Systems: currently, patient complains of right lower back pain. Her chest pain, which she attributes to stress, has resolved. <PAST MEDICAL HISTORY> - h/o MRSA tricuspid endocarditis s/p 4-weeks daptomycin (___) - atrial septal defect (small) - untreated hepatitis C - asthma - ?Bipolar disorder - per pt, recent diagnosis of Shattack - ongoing IV heroin use and cocaine use <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of cardiac problems. <PHYSICAL EXAM> Vitals: Afebrile, normotensive, HR ___, satting high ___ on RA General: Young well-appearing woman, tearful, in no acute distress Heart: RRR, normal s1/s2, no murmurs Lungs: CTAB Abdomen: Soft, nontender, nondistended, BS+ Back: no supraspinal tenderness, masses, warmth or erythema; mild ttp over the right iliac crest without skin changes, warmth or masses Neurological: patient able to walk without need for support; no ataxia, no significant limp <PERTINENT RESULTS> Admission labs: ___ 01: 45AM WBC-8.1 RBC-3.48* HGB-9.7* HCT-29.8* MCV-86 MCH-28.0 MCHC-32.7 RDW-14.9 ___ 01: 45AM NEUTS-45.4* LYMPHS-47.9* MONOS-3.6 EOS-2.5 BASOS-0.6 ___ 01: 45AM PLT COUNT-513*# ___ 02: 10AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02: 10AM HCG-LESS THAN ___ 02: 10AM cTropnT-<0.01 ___ 02: 10AM GLUCOSE-80 UREA N-15 CREAT-0.7 SODIUM-144 POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-15 Studies: ___: CT Abdomen/Pelvis: 1. Cavitary nodule at the right lung base in keeping with patient's history of septic emboli. 2. Cystic structure in the pelvis measuring 5 cm similar to prior could be a paraovarian cyst; however cannot exclude endometrioma since no change in size about two months. Pelvic ultrasound is recommended to evaluate this finding further. Small amount of free fluid in the pelvis. D/w Dr. ___ at 10: 13 am on ___. 3. Hypodensity at the cervix, could be a Garthner's cyst. 4. Hypodensities in the right kidney too small to be characterized, likely simple cysts. 5. Small hypodensity at L1-L2 on the right could be a small perineural cyst. ___: CXR: 1. Stable blunting of the right costophrenic angle, likely scarring, with minimal blunting of the left costophrenic angle. 2. Opacity at the right lung base corresponds to the small cavitation seen on CT abdomen and pelvis from the same night. <MEDICATIONS ON ADMISSION> Per ___ discharge summary from ___: - clonidine 0.1mg bid - daptomycin (course completed) - dicyclomine 20mg tid - ibuprofen 400-800 q8h prn - morphine 15mg q6h prn - nystatin 100,000unit/g topical cream bid - omeprazole 20mg qday - zolpidem 5mg qhs prn (Note: patient denies taking most of these medications but left against medical advice prior to full medication reconciliation) <DISCHARGE MEDICATIONS> LEFT AGAINST MEDICAL ADVICE <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> History of MRSA endocarditis Polysubstance abuse Untreated hepatitis C Asthma <DISCHARGE CONDITION> Afebrile, other vital signs stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> LEFT AGAINST MEDICAL ADVICE
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[REDACTED] year old female with history of polysubstance abuse, recent MRSA endocarditis s/p 4 weeks of daptomycin, who presented with chest and back pain in the setting of incarceration for IV drug possession. She left against medical advice. #. History of recent tricuspid endocarditis: She is status-post a 4-week course of daptomycin, observed at the [REDACTED]. She was admitted for repeat TTE, as she was scheduled for a repeat TTE a few weeks ago and missed her appointment. However, she was admitted on a weekend and refused to wait until [REDACTED] when TTE could be performed. She therefore left against medical advice. #. Back pain and chest pain: She had developed chest pain and back pain in the setting of being handcuffed and riding in the police car. ECG and CXR were unremarkable for acute process. Her chest pain completely resolved. She continued to complain of right-sided lower back pain that she reports had been chronic for a few months and exacerbated by a MVA last week. She denied any recent fevers, weakness, saddle anesthesia, or bowel or bladder incontinence. She was treated with prn Tylenol and Motrin. #. Ongoing polysubstance abuse: She presented in the setting of an arrest for IV drug possession. She would likely benefit from methadone maintenance therapy and it was ensured that she had the contact information for a clinic prior to her leaving against medical advice. #. Paraaortic cystic mass: She had a CT abdomen/pelvis in the ED which showed a 5cm cystic structure in her pelvis similar to prior imaging. It was felt that endometrioma could not be excluded and pelvic ultrasound was recommended. She left against medical advice before pelvic ultrasound was obtained.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) / oxycodone / hydromorphone / Dilantin <ATTENDING> ___ <CHIEF COMPLAINT> Back pain and radiculopathy <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: L3 laminectomy and L3-L4 microdiscectomy <HISTORY OF PRESENT ILLNESS> ___ yo female with low back pain and radiculopathy presents for elective L3 laminectomy and L3/4 microdiscectomy. <PAST MEDICAL HISTORY> silent "bilateral lacunar strokes" found on CT HTN HLD DM lumbar and cervical stenosis (s/p cervical fusion on ___ Hypothyroid h/o orthostatic hypotension <SOCIAL HISTORY> ___ <FAMILY HISTORY> Much of her family deceased at a young age and not much is known about their health. Her father died on an MI. <PHYSICAL EXAM> ON DISCHARGE: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 3-2mm Left 3-2mm Face Symmetric: [x]Yes [ ]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: IPQuadHamATEHLGast ___ [x]Sensation intact to light touch [x]Propioception intact [x]L anterior thigh pain greatly improved Wound: [x]Clean, dry, intact [x]Incision closed with staples. Open to air without drainage. No erythema or swelling. <PERTINENT RESULTS> See OMR for pertinent lab and imaging results. <MEDICATIONS ON ADMISSION> Levothyroxine 88mcg daily Labetalol 600mg qAM Labetalol 400mg qPM Gabapentin 100mg TID Fenofibrate 67mg Daily Lisinopril 20mg daily Atorvastatin 40mg qHS Aspirin 81mg <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN Pain - Moderate Do not exceed 4GM acetaminophen in 24 hours 2. OxyCODONE (Immediate Release) 5 mg PO Q8H: PRN Pain - Severe Do not drive while taking this medication. Hold for sedation. RX *oxycodone 5 mg 1 tablet(s) by mouth q8h PRN Disp #*20 Tablet Refills: *0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Fenofibrate 67 mg PO DAILY 6. Gabapentin 100 mg PO TID 7. Labetalol 600 mg PO QAM 8. Labetalol 400 mg PO QPM 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Lisinopril 20 mg PO DAILY 11.Outpatient Physical Therapy ___ with debilitating left anterior thigh pain found to have L3-L4 disc herniation s/p L3 laminectomy and L3-L4 microdiscectomy. Please evaluate and treat. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> L3-L4 disc herniation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Spine Surgery without Fusion Surgery -Your incision is closed with staples. You will need staple removal. Please keep your incision dry until staple removal. -Do not apply any lotions or creams to the site. -Please avoid swimming for two weeks after staple removal. -Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity -We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. -You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. -No driving while taking any narcotic or sedating medication. -No contact sports until cleared by your neurosurgeon. Medications -Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. - You may resume your home aspirin 81mg 3 days after your surgery. -You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. -It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: -Severe pain, swelling, redness or drainage from the incision site. -Fever greater than 101.5 degrees Fahrenheit -New weakness or changes in sensation in your arms or legs.
Output:
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[REDACTED] yo female with low back pain and radiculopathy presents for elective L3 laminectomy and L3/4 microdiscectomy. #s/p L3 laminectomy and L3/4 microdiscectomy The patient tolerated the procedure well and was extubated in the OR. She was transferred to PACU where she remained hemodynamically and neurologically stable. She was transferred to the floor for ongoing care. She mobilized POD1 with nursing, tolerating a diet, and voiding without difficulty. She complained of urinary symptoms and UA was negative. Her electrolytes were repleted as needed. [REDACTED] evaluated her and recommended home with outpatient physical therapy. She was discharged to home with instructions to hold her home aspirin until 3 days after surgery as well as wound care instructions. #Creatinine bump Patient was noted to have creatinine of 1.5 postoperatively. She was given a 500cc NS bolus and continued her IVF. Repeat labs showed normal creatinine of 1.0.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Cerebral aneurysm <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___: Pipeline Embolization rt ICA aneurysm <HISTORY OF PRESENT ILLNESS> ___ yo with incidental finding of right ICA aneurysm presents for elective pipeline embolization. <PAST MEDICAL HISTORY> Migraines <SOCIAL HISTORY> ___ <FAMILY HISTORY> ___ <PHYSICAL EXAM> ON DISCHARGE ============ Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 5-4mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast ___ Left5 5 5 5 5 5 [x]Sensation intact to light touch Angio Groin Site: R groin [x]Soft, no hematoma [x]Palpable pulses [x]Dsg CD&I <PERTINENT RESULTS> See ___ <MEDICATIONS ON ADMISSION> Spironolactone 100mg PO daily <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN fever or pain 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills: *2 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills: *2 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H PRN Disp #*15 Tablet Refills: *0 6. Spironolactone 100 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Right paraclinoid aneurysm <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Activity - You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. - Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. - You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. - Do not go swimming or submerge yourself in water for five (5) days after your procedure. - You make take a shower. Medications - Resume your normal medications and begin new medications as directed. - You have been instructed by your doctor to take one ___ a day and Plavix. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site - You will have a small bandage over the site. - Remove the bandage in 24 hours by soaking it with water and gently peeling it off. - Keep the site clean with soap and water and dry it carefully. - You may use a band-aid if you wish. What You ___ Experience: - Mild tenderness and bruising at the puncture site (groin). - Soreness in your arms from the intravenous lines. - Mild to moderate headaches that last several days to a few weeks. - Fatigue is very normal - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: - Severe pain, swelling, redness or drainage from the puncture site. - Fever greater than 101.5 degrees Fahrenheit - Constipation - Blood in your stool or urine - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg
Output:
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On [REDACTED], Ms. [REDACTED] presented for elective pipeline embolization of right paraclinoid aneurysm. Her procedure was uncomplicated; see [REDACTED] for full detailed procedure note. Postoperatively, she was monitored in [REDACTED] where she remained neurologically stable. Her groin site was soft without hematoma and distal pulses were palpable. On POD#1, she was ambulating independently, tolerating regular diet and pain was well-controlled. She continued on aspirin and Plavix. She was discharged home in stable condition POD#1.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> NEUROSURGERY <ALLERGIES> simvastatin / atorvastatin <ATTENDING> ___ <CHIEF COMPLAINT> Lumbar stenosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___- L3-5 laminectomy. <HISTORY OF PRESENT ILLNESS> Mr. ___ is a ___ y/o male with Lumbar spinal stenosis who presents for elective surgery. The patient experiences severe left leg pain at what seems to be L4 and maybe L5 distribution. Initially, he has had on and off low back pain for years as well. Numbness and tingling for a year as well. No symptoms on the right leg. The risks and benefits of surgical intervention were discussed and the patient consented to the procedure. <PAST MEDICAL HISTORY> GERD (Gastroesophageal Reflux Disease) Hyperlipidemia Back pain Melanoma - left eye ___, also on back COPD (chronic obstructive pulmonary disease) Squamous cell carcinoma of skin Gout Elevated PSA Hypertension Colonic polyp Coronary artery disease: ___: DES to the LAD; ___: DES to LAD; ___: DES to OM2 Coronary stent Erosive esophagitis Chronic cough ___ esophagus Constipation Lower GI bleed S/P coronary artery stent placement Dysphagia Esophageal dilatation Elevated CPK Lumbar disc disease <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father ___ Son ___ Physical ___: PHYSICAL EXAMINATION ON ADMISSION: SLR is still positive for L5 and L4 distribution pain and pain deep on the left knee as well. PHYSICAL EXAMINATION ON DISCHARGE: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. with steady gait strength and sensation is full incision is closed with staples- well approximated. scant serous drainage <MEDICATIONS ON ADMISSION> Crestor 20mg Norcas 5mg Panloprazole 20mg Ulorig 40mg Amiloride 5mg Atnolol 50mg ASA 81mg MagOx 250mg <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN for fever or pain 2. Amiloride HCl 5 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atenolol 25 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Rosuvastatin Calcium 20 mg PO QPM 8. Senna 17.2 mg PO QHS RX *sennosides [senna] 8.6 mg 2 tab by mouth at bedtime Disp #*30 Capsule Refills: *1 9. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q4PRN Disp #*60 Tablet Refills: *0 10. Bisacodyl 10 mg PO/PR DAILY constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills: *0 11. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 12. Diazepam 2 mg PO Q8H: PRN muscle spasm RX *diazepam 2 mg 1 tab by mouth every eight (8) hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Lumbar Spinal Stenosis. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. with steady gait strength and sensation is full incision is closed with staples- well approximated. scant serous drainage <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Discharge Instructions L3-L5 Laminectomy Surgery · Your dressing is not off please leave your incision open to the air and keep it dry · Your incision is closed with staples. You will need staple removal. Please keep your incision dry until staple removal. · Do not apply any lotions or creams to the site. · Please avoid swimming for two weeks after staple removal. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · No contact sports until cleared by your neurosurgeon. Medications · Please do NOT take any blood thinning medication (Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been cleared to RESTART your aspirin yesterday on ___ · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · New weakness or changes in sensation in your arms or legs.
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The patient was taken to the operating room on the day of admission, [REDACTED] and underwent a L3-L5 Laminectomy. He tolerated the procedure well and was extubated in the operating room. He was then transferred to the floor for further evaluation. On [REDACTED], the patient remained neurologically intact. There was serosanguinous staining on the dressing. The patient remained in the hospital to continue mobilization and increas activity. The patients bowel regemen was increased. On [REDACTED], The patient was neurologically intact. The incicsion was well approximated with staples. There was scant serosanguious drainage from the site. The patient was ambulating with a steady gait. The patient exhibited full strength on exam. The patient was tolerating a regular diet. The patient was voiding without difficulty. He denied post operative bowel movement but had bowel sounds and reported + flatus. The patient was discharged home with stool softeners and was encouraged to continue abbulation at home. The patients pain was well controlled.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> SURGERY <ALLERGIES> Com___ <ATTENDING> ___. <CHIEF COMPLAINT> Trauma: fell off a horse. This patient is a ___ year old female who complains of CLAVICLE AND RIB FX TRANSFER. <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> This patient is a ___ year old female who complains of CLAVICLE AND RIB FX TRANSFER. She was transferred from the referring facility after she fell off a horse and per report landed on her left shoulder. CT scans of her C-spine and T. spine demonstrated a lateral first rib fractures and a clavicle fracture. She was sent here for further evaluation. She denies numbness tingling or weakness. No headache. She is otherwise well recently. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> None Medications: Supplements <SOCIAL HISTORY> ___ <FAMILY HISTORY> none <PHYSICAL EXAM> Temp: 98.6 HR: 71 BP: 130/85 Resp: 18 O(2)Sat: 99 HEENT: Normocephalic, atraumatic, Extraocular muscles intact Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: Low lumbar tenderness to palpation, No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mentation <PERTINENT RESULTS> CT IMPRESSION: 1. Mildly displaced fractures of bilateral first ribs. 2. Comminuted and displaced fracture of the body of the left scapula. 3. Minimally displaced fracture of the left lateral fifth rib. 4. No evidence of vascular injury. 5. No evidence of sternal fracture. 6. Small left hemorrhagic pleural effusion with adjacent atelectasis. LUMBO-SACRAL SPINE (AP & LAT)IMPRESSION: 1. Preserved lumbar lordosis. 2. No compression fracture. 3. Small osseous fragment anterior and superior to vertebral body of L3, likely limbus vertebra. ___ 10: 50PM UREA N-12 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17 ___ 10: 50PM WBC-12.3* RBC-4.39 HGB-13.3 HCT-38.7 MCV-88 MCH-30.3 MCHC-34.3 RDW-13.4 ___ 10: 50PM ___ PTT-26.9 ___ <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 2. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stool. Disp: *60 Capsule(s)* Refills: *0* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Hold for loose stool. Disp: *60 Tablet(s)* Refills: *0* 5. oxycodone 5 mg Tablet Sig: 0.5-2.0 Tablets PO Q3H (every 3 hours) as needed for pain. Disp: *80 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> polytrauma, fall from horse: bilateral 1st rib fxs., L. 5th rib fx, L. scapula frx <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or nurse practitioner if you experience the following: *New chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *Vomiting and cannot keep down fluids or your medications. *Dehydration due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *Blood or dark/black material when you vomit or have a bowel movement. *Burning when you urinate, blood in your urine, or urinary discharge. *Your pain doesn't improve in ___ hours or is not gone within 24 hours. Call or return immediately if your pain becomes severe, changes location or moves to your chest or back. *Shaking chills or fever greater than 101.5F or 38C. *An acute change in your symptoms, or new symptoms that concern you. *Increased pain, swelling, redness, or drainage from any incisions you may have. *Any of the warning signs listed below. . General <DISCHARGE INSTRUCTIONS> *Resume all regular home medications, unless specifically advised not to take a particular medication. Take any new medications only as prescribed. *Give yourself adequate 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. *Do not drive or operate heavy machinery while taking narcotic pain medications.
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This patient is a [REDACTED] year old female who complains of CLAVICLE AND RIB FX TRANSFER. She was transferred from the referring facility after she fell off a horse and per report landed on her left shoulder on [REDACTED]. CT scans of her C-spine and T. spine demonstrated a bilateral first rib fractures and L scapular and L 5th rib fracture. She was sent here for further evaluation. She denies numbness tingling or weakness. No headache. She is otherwise well recently. No surgery was indicated and patient was managed on pain medications. Pain improved over a few days and patient was dicharged home on [REDACTED]. Pt will follow up with her PCP.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> ___ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo female with PMH of cocaine abuse, h/o MI in ___, and asthma who presents with severe ___ that began yesterday at 3AM and woke her from sleep. She describes that pain as sharp and constant. She is having difficulty taking a deep breath secondary to abdominal pain. She reports nausea and vomiting while in the ED. She denies diarrhea, but reports no BM in two days, but + flatus. No chest pain. She initially took nitroglycerin for her abdominal pain without relief of symptoms, though she reports her symptoms are different from her syptoms during previous MI. Patient notes symptoms began a few hours after using cocaine. . Of note, patient reports prior admissions to ___ for abdominal pain. She does not know what this pain was attributed to during these hospitalizations. This episode is more severe than previous admissions for abdominal pain. . In the ED, she was given 8 mg of morphine IV and 1 mg of Dilaudid IV without relief of symptoms. A ___ was negative. A CT torso with contrast failed to reveal an etiliology of her severe abdominal pain. <PAST MEDICAL HISTORY> Asthma MI in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> VS: T 100.7, BP 132/99, HR 99, RR 20, 97% on RA Gen: uncomfortable, tearful, obese female HEENT: EOMI, o/p clear CV: RRR, no m/r/g Pulm: CTA b/l Abd: soft, ___ tenderness to palpation, no guarding, no rebound, bowel sounds present Ext: no peripheral edema Neuro: AxOx3, CNs ___ intact, moving all extremities <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-6.0 Hgb-10.9* Hct-33.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-14.7 Plt ___ Glucose-93 UreaN-7 Creat-0.7 Na-134 K-3.6 Cl-99 HCO3-26 Calcium-8.2* Phos-2.9 Mg-2.0 ___ PTT-24.6 ___ ALT-17 AST-20 LD(LDH)-176 CK(CPK)-211* AlkPhos-79 Amylase-53 TotBili-0.9 Albumin-3.8 ___ 11: 55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CTA Chest, abdomen, and pelvis (___): The lungs are clear without evidence of effusion, airspace disease or pneumothorax. There is no central or axillary lymphadenopathy. Heart size is normal. There is no pericardial effusion. The airways are patent to the subsegmental level. Pulmonary arteries are patent to the subsegmental level. CT ABDOMEN: The liver, spleen, gallbladder, pancreas, adrenals, intra-abdominal loops of large and small bowel are unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. There is no evidence of obstruction, free fluid or free air. CT PELVIS: The rectum, uterus, adnexa are unremarkable. There is no free fluid or free air. Bone windows demonstrate no suspicious lytic or blastic lesions. IMPRESSION: No CT evidence to explain epigastric pain. ___ ultrasound (___): The liver architecture is unremarkable without evidence of intra- or extra-hepatic biliary dilatation. The common bile duct measures 5 mm. The gallbladder demonstrates no evidence of gallstones or gallbladder wall thickening to suggest acute cholecystitis. The main portal vein demonstrates normal hepatopetal flow. IMPRESSION: No cholelithiasis or cholecystitis. CXR AP (___): There is no acute cardiopulmonary abnormality. The lungs are clear, and pleural surfaces are smooth, with no effusion or pneumothorax. Cardiomediastinal silhouette is normal. IMPRESSION: No acute cardiopulmonary abnormality. <MEDICATIONS ON ADMISSION> Albuterol Advair <DISCHARGE MEDICATIONS> 1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed. 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp: *5 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Urinary tract infection Abdominal pain Substance abuse <DISCHARGE CONDITION> Hemodynamically stable. Ambulatory. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted on ___ with abdominal pain. While in the hospital, you were found to have a mild urinary tract infection. A CT scan and ultrasound were performed and did not show any abnormalities. We also ensured that you did not have a heart attack. On discharge, your pain is much improved and you are eatting well. As we discussed, it is very important that you stop using cocaine and other illicit drugs. Your medication regimen has changed. You should continue taking the antibiotic for your urinary tract infection for 3 days. You should continue taking your other medications just as you were prior to the hospitalization. Your should follow with the ___ as listed below. Please return to the emergency department or call your physician for any increase in chest pain, shortness of breath, abdominal pain, inability to keep down fluids, or for any other concerns.
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[REDACTED] year old female with history of asthma, substance abuse, and myocardial infarction presented [REDACTED] with abdominal pain associated with fever. Brief hospital course was as follows: 1. Abdominal pain, mild leukocytosis, and fever: In emergency department, patient complained of sharp right upper quadrant pain that awoke her from her sleep. It was not associated with meals and was different in nature and location from pain experienced with myocardial infarction in [REDACTED]. Of note, pain occurred few hours after using cocaine. While in emergency department, patient had EKG, chest radiograph, CTA of chest, abdomen, and pelvis, and [REDACTED] ultrasound - all were found to be normal with no clear source for the pain. Liver and pancreatic proteins were also checked and found be within normal range. On arrival to floor, patient denied abdominal pain but was mildly tender in [REDACTED] with palpation; [REDACTED] sign was negative. Cardiac enzymes were cycled and found to be normal. She expressed hunger and her diet was quickly advanced. A urinalysis from the emergency department indicated a mild urinary tract infection; patient was given a three day course of Bactrim. On discharge, patient was free of abdominal pain and taking good PO intake. Patient was counseled to the harmful effects of cocaine and other illicit drugs, and expressed understanding. 2. Substance abuse: Cocaine use on the day prior to admission. Patient reports that she does not use cocaine frequently and denies any other drug use. Social work consulted to offer substance abuse counseling.
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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> left hip abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ washout with VAC placement left hip ___ Washout with VAC placement left hip ___ incision and drainag of left hip <HISTORY OF PRESENT ILLNESS> ___ year old female, homeless IV drug user (last use 11AM ___ transferred from ___ with hip abscess. She's been having hip pain for the past two weeks, gradually worsening, having fevers/chills 6 days, finger/toe numbness/tingling last two days. Presented to ___ ED, and CT demonstrated abscess with e/o tracking along facial planes. She was given vanc and transferred here. Patient is upset that she is here. Timing: Gradual Quality: Sharp Severity: Severe Duration: 6 Days Location: L hip Context/Circumstances: IVDA Mod.Factors: Worse with mvmt <PAST MEDICAL HISTORY> denies. Unclear vaccination history <SOCIAL HISTORY> ___ <FAMILY HISTORY> Patient did not provide. <PHYSICAL EXAM> PHYSICAL EXAMINATION: upon admission ___ Temp: 98.5 HR: 63 BP: 108/50 Resp: 18 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Normal first and second heart sounds Abdominal: Nontender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry, tenderness and redness along latreral aspect of L thigh with + pain with mvmt of the LLE Neuro: Speech fluent Psych: Normal mood, Normal mentation Discharge <PHYSICAL EXAM> VS: 98.2/97.6 100 116/68 18 100%RA GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: (+) BS x 4 quadrants, soft, obese, non-tender, non-distended. Wound: pink granulation tissue, filling an approximately 3.5 cm cavity on the left lateral hip, extending deep to the dermis. Wound clean and dry without purulent or foul-smelling draining; dressed with wet-to-dry gauze and tape. EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema. <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-12.6* RBC-3.48* Hgb-9.8* Hct-29.1* MCV-84 MCH-28.1 MCHC-33.6 RDW-15.2 Plt ___ ___ 06: 00AM BLOOD WBC-14.8* RBC-3.59* Hgb-10.1* Hct-30.2* MCV-84 MCH-28.1 MCHC-33.3 RDW-15.3 Plt ___ ___ 03: 45PM BLOOD WBC-14.9* RBC-3.66* Hgb-10.5* Hct-30.4* MCV-83 MCH-28.6 MCHC-34.4 RDW-13.8 Plt ___ ___ 05: 45AM BLOOD Neuts-74* Bands-0 ___ Monos-6 Eos-0 Baso-0 ___ Myelos-0 Promyel-1* NRBC-1* ___ 07: 15AM BLOOD Plt ___ ___ 03: 45PM BLOOD ___ PTT-30.8 ___ ___ 05: 00AM BLOOD Glucose-70 UreaN-11 Creat-0.7 Na-136 K-4.8 Cl-101 HCO3-26 AnGap-14 ___ 06: 20AM BLOOD Glucose-84 UreaN-13 Creat-0.6 Na-134 K-3.9 Cl-101 HCO3-26 AnGap-11 ___ 03: 45PM BLOOD ALT-59* AST-70* AlkPhos-115* TotBili-0.6 ___ 03: 45PM BLOOD Lipase-12 ___ 05: 00AM BLOOD Calcium-8.6 Phos-6.7*# Mg-2.2 ___ 03: 45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05: 49PM BLOOD Lactate-4.0* ___ 06: 20AM BLOOD WBC-5.6 RBC-3.28* Hgb-9.5* Hct-28.2* MCV-86 MCH-28.9 MCHC-33.7 RDW-16.6* Plt ___ ___ 06: 20AM BLOOD Glucose-87 UreaN-29* Creat-0.7 Na-138 K-4.8 Cl-102 HCO3-28 AnGap-13 ___ 06: 20AM BLOOD Calcium-9.3 Phos-6.3* Mg-2.3 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H 2. Ascorbic Acid ___ mg PO BID 3. Calcium Carbonate 1000 mg PO DAILY 4. Cyclobenzaprine 5 mg PO TID: PRN msucle spasm 5. Docusate Sodium 100 mg PO BID 6. Ibuprofen 600 mg PO Q8H *AST Approval Required* 7. Lidocaine Jelly 2% (Urojet) 3 Appl TP PRN VAC change 8. Morphine SR (MS ___ 60 mg PO Q8H RX *morphine 60 mg 1 tablet(s) by mouth every eight (8) hours Disp #*45 Tablet Refills: *0 9. Morphine Sulfate ___ 30 mg PO Q4H: PRN pain 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Nicotine Patch 21 mg TD DAILY 12. Polyethylene Glycol 17 g PO DAILY: PRN Constipation 13. Senna 8.6 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> gluteal abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___ were admitted to the hospital with left hip pain. ___ underwent a cat scan which was concerning for infection. ___ were started on antibiotics. ___ were taken to the operating room cleaning out of the wound. ___ then had a VAC dressing placed over the wound. Your vital signs have been stable. When your wound was small enough, we placed wet gauze in the wound. ___ will need to have this gauze changed at least twice daily to keep your wound clean and free of infection. ___ should do this by taking sterile saline or water, wetting clean gauze that ___ have just removed from a sterile package and inserting the unfolded gauze in the wound. Your nurse ___ tell ___ how to pack this wound. Return to the Emergency room if ___ have drainage from the wound that is foul-smelling, has a new color, for example looks green or creamy, and/or if ___ experience suddenly increased pain, fever, or if your wound or the skin of the leg surrounding the wound becomes red, warm and/or firm. This means that your wound may be infected and ___ will need to seek immediate medical care. ___ should follow up with the ___ clinic in two weeks from your discharge, this appointment has already been made for ___. Please keep your appointment so that we can see how well your wound is healilng. If ___ have to reschedule, ___ may do so by calling ___.
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Ms. [REDACTED] presented to the [REDACTED] ([REDACTED]) on [REDACTED] as a transfer from [REDACTED] with a CT scan demonstrating a gluteal abscess and fascial thickening. She was evaluated by the Acute Care Surgery ([REDACTED]) team and admitted for possible necrotizing fasciitis versus gluteal abscess, broad spectrum antibiotics were started, orthopedic surgery was consulted to determine if bone involvement was possible and she was taken to the operating room (OR) for an incision and drainage with wound exploration. The complete operative report can be found in the [REDACTED] medical record (OMR). On inspection, the wound appeared to be a large gluteal abscess, fluid samples were sent for microbiological culture and analysis and the wound was packed and left open at the end of the case. Her post-operative course in the post-anesthesia care unit (PACU) was uneventful, and she was transferred to the floor for further care and work up. On hospital day 1 (HD 1), Ms. [REDACTED] began working with social work and case management to resolve her housing needs given that she is homeless, and to provide her with addiction resources. The patient then returned to the OR for gauze packing removal and wound VAC placment on [REDACTED]. The complete operative report can again be found in the OMR. She recovered uneventfully in the PACU and was returned to the floor. On HD [REDACTED], she was additionally seen by Psychiatry, Chronic Pain and her pain regimen was adjusted as well as her addiction behaviors and social support evaluated. The patient intermittently refused services, but was ultimately ammenable to discussing out patient addiction and housing resources and options with Social Work and Case Management. On HD 4 she was taken back to the OR for wound VAC replacement under anesthesia. Her wound had evidence of progressive healing and she was transferred to the PACU where she again had an uneventful course. On HD [REDACTED] the patient continued to the work with SW, physical therapy, nutrition and Case Management on supportive measures to provide housing and drug addiction resources, to try to obtain health insurance that would cover placement at a skilled nursing facility or rehabilitation center and VAC supplies. Due to the patient's current homelessness, IV drug use and medical issues, she was not accepted at multiple skilled nursing and rehabilitation facilities. Her insurance coverage has been an issue throughout this stay and she continues to work with Case Management to apply for and recieve adequate insurance for wound care, primary care and potentially a [REDACTED] clinic where she can continue to resolve her heroin addiction. The patient also refused addiction resources intermittently throughout this time and frequently threatened to leave against medical advice (AMA) despite the depth of her wound and the unlikelihood that it would heal without a wound VAC or wet-to-dry dressings. She was counseled daily about the dangers of improper wound care and wound healing, including the risk of infection, sepsis, loss of the lower extremity, and death. The patient agreed to remain hospitalized until the wound was of a sufficient depth to place wet-to-dry dressings; this date was achieved on [REDACTED] when her wound was roughly 3.5-3.75cm deep and had visible pink granulation tissue filling the cavity and surrounding the side walls. The patient remained afebrile, with stable vital signs throughout the hospital course. Her wound VACs were changed at bedside every 3 days starting from [REDACTED] and she was visited daily by a member of the surgical team. She was on a regular diet, except for the midnight of each night prior to the procedures in the OR when she was ordered for a regimen of no oral intake (NPO). Her pain was controlled with a regimen determined by the Chronic Pain team and was strictly followed. She was ambulating, tolerating a regular diet, voiding without assistance and her laboratory values were checked as needed. Her nutritional status was closely monitored initially, she was found to have hypoalbuminemia and several electrolyte abnormalities. These laboratory values can be found in the "Pertinent Results" section of this report. Her electrolytes were repleted and she was given supplemental nutrition with her meals. The final day of her hospital course, [REDACTED], the patient was given detailed instruction about wound care for a her family and friends who will help her change her wet-to-dry dressings. Despite our attempts to place her in a facility, the patient wanted to be discharged home to a relative's home without visiting nurses for wound care. She informed the team, Case Managers and the nursing and Social Work staff that she had adequate support to pack her wounds at her relative's home. She was given detailed instructions about continuing to not use IV drugs, the importance of not smoking tobacco during this time and nutritional needs for wound healing. She was given instructions regarding when to return to the Emergency Department and instructed to obtain a primary care physician and to avail herself of resources provided for drug addiction to avoid relapse while she is recovering and in the future. The patient again declined to remain in the hospital for further wound care until she could be sent home with visiting nurses or sent to a facility where wound care could be done for her. Ms. [REDACTED] was discharged to her relative's home that day with supplies and wound care teaching to only herself. Her other relatives and friends who will help with wound care were unavailable. She was given a two-week prescription for narcotic pain medications and instructed to follow up with a new PCP and addiction specialist for further care.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> tetanus toxoid, adsorbed <ATTENDING> ___ <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP <HISTORY OF PRESENT ILLNESS> ___ w/ diffuse large B-cell lymphoma (diagnosed ___, recurrent in ___ and now in remission again for one year s/p autologous stem cell transplant), and recurrent cholangitis with CBD strictures, possibly due to his history of XRT (s/p multiple ERCPs and stent replacements) who now presents with low grade fevers for several days. Other than fever, the patient has been largely asymptomatic; he denies chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms. The patient and his wife notified his oncologist about the fevers; as this symptom was typical of his prior episodes of biliary stent infections, the patient was told to start Cipro 500 mg PO BID and was referred to the ER for evaluation. In the ER, he was found to have Tbili of 2.4. Labs otherwise were fairly reassuring: AST 42, ALT 70, WBC 6.1. He went for repeat ERCP and is admitted post-procedure for observation. They removed a plastic CBD stent and swept out CBD stones/sludge. The CBD stent was not replaced as stricturing had significantly improved; however, they placed stents in the L and R intrahepatic ducts. ROS GEN: as per HPI CARDIAC: denies chest pain or palpitations PULM: denies new dyspnea or cough GI: denies n/v, denies change in bowel habits GU: denies dysuria or change in appearance of urine Full 14-system review of systems otherwise negative and non-contributory. <PAST MEDICAL HISTORY> Diffuse large B cell lymphoma, ABC subtype ___: presented with 9 cm mesenteric mass ___: 6 cycles R-CHOP, consolidation radiation therapy ___: Recurred in ___ salvage chemotherapy with RICE ___: BEAM and autologous stem cell transplant. ___: Question of mesenteric recurrence on PET; when he refused biopsy, was treated empirically with rituximab and lenalidomide ("R-squared") x2. He later agreed to biopsy and it was found to be benign. Obstructive jaundice and cholangitis s/p multiple ERCPs: ___: severe 3 cm stricture at the distal CBD with proximal dilation of 12 mm in diameter. Sphincterotomy and placement of metal stent. ___: replacement of occluded and migrated stent with a new plastic stent. *Six more interval ERCPs are not summarized here* ___: CHD stricture dilated, ___ X 7cm biliary stent was placed into the right IHD, ___ X 7cm biliary stent into the left IHD. ___: Removal of plastic CBD stent and removal of CBD stones/sludge; CBD stent was not replaced as stricturing had significantly improved. Placement of stents in the L and R intrahepatic ducts Hypertension Obstructive sleep apnea Fanconi syndrome from ifos HBV core positive <SOCIAL HISTORY> ___ <FAMILY HISTORY> No significant family history of malignancy. <PHYSICAL EXAM> VITALS: last 24-hour vitals were reviewed. GEN: NAD HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NABS. Nontender MSK: No visible joint effusions or deformities. DERM: No visible rash. No jaundice. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, no edema <PERTINENT RESULTS> PTT-33.3 ___ WBC-6.1 RBC-2.79* HGB-10.4* HCT-31.7* MCV-114* MCH-37.3* MCHC-32.8 RDW-13.9 RDWSD-58.4* LACTATE-0.9 ALT(SGPT)-70* AST(SGOT)-42* ALK PHOS-858* TOT BILI-2.4* DIR BILI-1.6* INDIR BIL-0.8 GLUCOSE-107* UREA N-15 CREAT-1.2 SODIUM-138 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19 ERCP ___: Limited exam of the esophagus, stomach and duodenum were normal. The scout film revealed a plastic biliary stent and surgical clips in the RUQ. A plastic stent was emerging from the major ampulla; there was evidence of previous sphincterotomy. The stent was successfully removed with a snare. The CBD was sucessfully cannulated with the Hydratome sphincterotome preloaded with a 0.035in guidewire. The guidewire was advanced into the left intrahepatic biliary tree. Contrast injection revealed several filling defects consistent with stones/sludge in the mid CBD. The previously identified CBD stricture had significantly improved compared with previous examination. The CBD was swept several times with sucessful removal of several stones and moderate amounts of sludge material. A second guidewire was advanced into the right intrahepatic biliary tree. A ___ x 5cm Advanix biliary stent was successfully placed into the left IHD and a ___ x 12cm ___ stent into the right IHD. There was excellent spontaneous flow of bile and contrast material at the end of the procedure. The PD was not injected or cannulated. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO TID 2. LaMIVudine 100 mg PO DAILY 3. Pantoprazole 40 mg PO Q12H 4. Mirtazapine 30 mg PO QHS 5. LORazepam 1 mg PO QHS: PRN insomnia 6. melatonin 3 mg oral QHS 7. Phosphorus 250 mg PO DAILY 8. Multivitamins 1 TAB 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 #*7 Tablet Refills: *0 2. Acyclovir 400 mg PO TID 3. LaMIVudine 100 mg PO DAILY 4. LORazepam 1 mg PO QHS: PRN insomnia 5. melatonin 3 mg oral QHS 6. Mirtazapine 30 mg PO QHS 7. Multivitamins 1 TAB PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Phosphorus 250 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cholangitis Protein-calorie malnutrition <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You came in with fevers. We found that you had another mild infection in your bile duct. We performed another procedure to retrieve the stent in your duct and to remove the sludge. You then had 2 new stent placed in the ducts draining your liver. Please continue to take all your antibiotics. It is also important that you maintain adequate nutrition and try to eat as much as you can after you go home.
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[REDACTED] w/ diffuse large B-cell lymphoma (diagnosed [REDACTED], recurrent in [REDACTED] and now in remission again for one year s/p autologous stem cell transplant), and recurrent cholangitis with CBD strictures (s/p multiple ERCPs and stent replacements) who p/w very mild cholangitis and is admitted for observation after ERCP. #Cholangitis-- Clinically mild cholangitis with elevated bilirubin and low grade fever, but otherwise clinically stable. He went for repeat ERCP on [REDACTED] and was admitted post-procedure for observation. They removed a plastic CBD stent and swept out CBD stones/sludge. The CBD stent was not replaced as stricturing had significantly improved; however, they placed stents in the L and R intrahepatic ducts. Post procedure, pt spiked a fever to 102.8. He was continued on Cipro alone and his fever curve improved. He will complete the 5 day course of Cipro after discharge. Blood cultures were NGTD on discharge. # Protein-calorie malnutrition-- Pt was noted to be quite cachectic and reported poor PO intake over the last few weeks to days. He was seen by Nutrition who spoke to him about supplements to increase protein and calorie intake. He was tolerating adequate PO on discharge. #HBV-- Continued lamivudine #Post stem cell transplant-- Continued acyclovir #Insomnia and depression-- Continued remeron 30 mg qHS
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> I hit my head" <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ was ice skating when in trying to avoid young skater, she fell backwards, striking the back of her head. no LOC. C/o HA and nausea. no visual changes, weakness, numbness, seizure. Went to OSH where had CT showing L frontal SAH and pt transferred here for further management. <PAST MEDICAL HISTORY> PMHx: hypothyroid, asthma <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contrib <PHYSICAL EXAM> PHYSICAL EXAM: O: T: BP: / HR: R O2Sats Gen: WD/WN, comfortable, NAD. HEENT: ___ EOMs full no nystagmus Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Neurologically intact on discharge <PERTINENT RESULTS> ___ CT BRAIN TECHNIQUE: Multidetector helical CT scan of the head obtained at ___ ___ was submitted for second review. Axial images in standard and bone algorithms were reformatted as 5 mm thickness slices. COMPARISON: None available. FINDINGS: A few foci of linear, likely subarachnoid hemorrhage are noted near the left vertex (2: 23, 24). There is a small subdural hematoma along the interhemispherical falx at the vertex. No overlying fracture is identified. There is no significant mass effect. No shift of midline structures. The ventricles and sulci are normal in size and configuration. No concerning osseous lesion is seen. A small posterior scalp hematoma is seen. The visualized paranasal sinuses are clear. ___ CT BRAIN: IMPRESSION: Few foci of subarachnoid hemorrhage and a small interhemispheric flax subdural hematoma left of midline at the vertex. No fracture identified. No significant mass effect or shift of midline structures. Findings, including change in wet read regarding likely subdural component of hemorrhage, discussed with ___ by phone at 2: 00 am, ___. FINDINGS: In the left frontal lobe near the vertex, small amount of subarachnoid hemorrhage is identified, not significantly changed in size or distribution from the prior study. Small volume of subdural hematoma is also seen layering along the falx, however, it has redistributed and has changed position compatible with redistribution. Ventricles and sulci are unchanged in size and configuration. There is no shift of normally midline structures. Gray-white matter differentiation is preserved. There is no fracture. Imaged paranasal sinuses and mastoid air cells are well aerated. Posterior scalp hematoma is unchanged. IMPRESSION: Unchanged extent of small volume left-sided subarachnoid and parafalcine subdural, with slight redistribution to the subdural hematoma. <MEDICATIONS ON ADMISSION> synthroid ___ qd <DISCHARGE MEDICATIONS> 1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. Disp: *40 Tablet, Rapid Dissolve(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Subarachnoid hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General Instructions -Take your pain medicine as prescribed. -Exercise should be limited to walking; no lifting, straining, or excessive bending. -Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. -Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING -New onset of tremors or seizures. -Any confusion, lethargy or change in mental status. -Any numbness, tingling, weakness in your extremities. -Pain or headache that is continually increasing, or not relieved by pain medication. -New onset of the loss of function, or decrease of function on one whole side of your body.
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Pt was admitted to the neurosurgical service after sustaining TBI / SAH after falling while ice skating. Her repeat imaging was stable and she remained well. She ambulated without issue and was cleared for home by [REDACTED]. She agree'd with this plan.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> NEUROSURGERY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Left arterio-venous malformation. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Left craniotomy for arterio-venous malformation on ___. cerebral angiogram/diagnostic ___ <HISTORY OF PRESENT ILLNESS> ___ is a ___ right-handed white female who recently had a diagnosis of a left frontal AVM. She states that she had been drinking and went to stand up too quickly and felt funny in her head, fell over and hit and had been hospitalized after that as they were working of a possible syncopal or head injury. During the workup, she had an MRI that demonstrated a left frontal AVM. She denies any focal symptoms such as unilateral weakness, numbness or seizure-like episodes. She reports the following: right-sided ptosis, constant pressure in her head, hand and feet numbness. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Demonstrates hypertension. Her past medical history is also significant for possible cervical cancer. PAST SURGICAL HISTORY: Includes two lumbar operations, appendectomy, cholecystectomy, wrist surgery, C-section and ___ eye surgery. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: She has no family history of AVMs. <PHYSICAL EXAM> PHYSICAL EXAMINATION ON ADMISSION: GENERAL: She is awake, alert and oriented x 3. NEUROLOGIC: Cranial nerves II through XII are intact, although she does have some right-sided ptosis, ___ strength in bilateral upper and lower extremities. No sensory deficits. Normoreflexic throughout. PHYSICAL EXAMINATION ON DISCHARGE: alert and oriented to person/place/time left upper extremity ___ right lower/upper extremity tremulous 4+ strength-> give away weakness. poor effort left nasal labial fold flattening sutures left head-> incision clean/dry intact pupils 5->2 mm reactive toungue midline <PERTINENT RESULTS> Radiology Report MR HEAD W/ CONTRAST Study Date of ___ 6: 59 AM FINDINGS: Again seen is a tangle of vessels in the left frontal lobe corresponding to the known arteriovenous malformation. Cortical venous drainage is again demonstrated. Images of the remainder of the brain appear normal. . IMPRESSION: Left frontal. Arteriovenous malformation unchanged since prior studies. Radiology Report CAROTID/CEREBRAL ARTERIOGRAM BILAT Study Date of ___ 10: 54 AM CONCLUSIONS: 1. No evidence of residual arteriovenous malformation status post resection. 2. No evidence of thromboembolic complication. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 5: 31 ___ IMPRESSION: Status post left frontal AVM resection, with small to moderate pneumocephalus and residual blood products at the surgical bed and overlying the left frontal lobe, expected post surgical changes. ___ ___ ___ Department of Pathology Patient Name: ___ ___ MRN: ___ ___ ___ Birth Date: ___ Age: ___ Y <SEX> F Surgical Pathology voice: ___ Surgical Pathology Facsimile: ___ Cytology voice: ___ Date of Procedure: ___ ___ #: ___ Date Specimen(s) Received: Patient Location: ___ ___ ___ Date Reported: ___ Ordering Provider: ___ ___, ___ Responsible Provider: ___ ___, ___ SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: Brain, left frontal AVM, excision: Findings consistent with arterio-venous malformation. CLINICAL HISTORY: Clinical Diagnosis and Data: Arteriovenous malformation, left frontal. GROSS DESCRIPTION: The specimen is received fresh in a container labeled with the patient's name ___, medical record number and additionally "left AVM". It consists of a piece of tan-red soft tissue that measures 1.3 x 1.1 x 0.5 cm. The specimen is entirely submitted in cassette 1A. <MEDICATIONS ON ADMISSION> Lansoprazole 15mg PO daily; Acetaminophen 500mg 2 tablets PO q4-6H prn for pain; Unisom 25mg PO QHS prn insomnia; Multivitamin 1 tablet PO daily; Vitamin B complex PO daily <DISCHARGE MEDICATIONS> 1. MEDrol (Pak) (methylPREDNISolone) 4 mg oral daily Duration: 1 Week medrol Dosepak please take as directed 2. Acetaminophen 325-650 mg PO Q6H: PRN fever or pain 3. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H: PRN headache do not exceed a total of 4 grams tylenol in 24 hours 4. Bisacodyl 10 mg PO/PR DAILY: PRN constipation 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 6. DiphenhydrAMINE 25 mg PO HS: PRN insomnia 7. Docusate Sodium 100 mg PO BID 8. Famotidine 20 mg PO Q12H 9. Glucagon 1 mg IM Q15MIN: PRN hypoglycemia protocol 10. Glucose Gel 15 g PO PRN hypoglycemia protocol 11. Heparin 5000 UNIT SC TID 12. HydrALAzine ___ mg IV Q6H: PRN for SBP > 140 13. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain hold for rr < 12 RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 14. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 15. LeVETiracetam 750 mg PO BID 16. Ondansetron 4 mg IV Q8H: PRN nausea 17. Senna 17.2 mg PO QHS 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Arterio-Venous Malformation on the Left <DISCHARGE CONDITION> alert and oriented to person/place/time left upper extremity ___ right lower/upper extremity tremulous 4+ strength-> give away weakness. poor effort left nasal labial fold sutures pupils 5->2 mm reactive toungue midline <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Discharge Instructions Dr. ___ ___ your neurosurgeons office and speak to the Nurse Practitioner if you experience: - Any neurological issues, such as change in vision, speech or movement - Swelling, drainage, or redness of your incision - Any problems with medications, such as nausea vomiting or lethargy - Fever greater than 101.5 degrees Fahrenheit - Headaches not relieved with prescribed medications Activity: - Start to resume all activities as you tolerate but start slowly and increase at your own pace. - Do not operate any motorized vehicle for at least 10 days after your surgery your Nurse Practitioner can give you more detail at the time of your suture removal. Incision Care: - Keep your wound clean and dry. - Do not use shampoo until your sutures are removed. - When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. - Do not rub, scrub, scratch, or pick at any scabs on the incision line. - You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical - Jaw pain on the same side as your surgery; this goes away after about a month - You may experience constipation. Constipation can be prevented by: o Drinking plenty of fluids o Increasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements o Exercising o Using over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea - Fatigue which will slowly resolve over time - Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve - Muffled hearing in the ear near the incision area - Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional - You may experience depression. Symptoms of depression can include o Feeling down or sad o Irritability, frustration, and confusion o Distractibility o Lower Self-Esteem/Relationship Challenges o Insomnia o Loneliness - If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist - You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation o More information can be found at ___
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The patient was taken to the operating room on the day of admission, [REDACTED] and underwent a left craniotomy and resection of arterio-venous malformation. The procedure went well. Post-operatively he underwent a diagnostic angiogram which was negative for AVM. She was admitted to the ICU post-operatively for close observation. She experienced bilateral upper extremity tremor with movement. She received 0.5mg of Ativan. Her tremors were improved after receiving the Ativan but still present. On [REDACTED], the patient remained stable on examination. It was determined she would be transferred to the floor. On [REDACTED], the patient was seen by physical therapy to assist in dispo planning. She remained neurologically stable on examination with intermittent right upper extremity and bilateral lower extremity tremors. On [REDACTED] Patient remained neurologically stable. [REDACTED] reassessed the patient and recommended rehab. Patient to be screened for rehab. On [REDACTED], The patient was neurologically stable. She was tolerating a regular diet. There was a rehabilitation bed available and the patient was discharged to rehab in the afternoon with proper discharge instructions.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> PSYCHIATRY <ALLERGIES> Penicillins / Codeine <ATTENDING> ___ <CHIEF COMPLAINT> "Depressed" <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y.o. male with h/o HIV dx'd in ___ and h/o depression with multiple inpatient psychiatric hospitalizations, self-presented to ED for evaluation of worsening depression with associated loss of interest in all activities, weight loss of 15 pounds in ~ 2 weeks, poor sleep, low energy, terrible concentration, ongoing ruminations with themes of hopelessness and worries that people see how sick he has become and resultant social isolation and withdrawal. No frank abnormal perceptions. No c/o physical pain (e.g., no headaches, no body pain). Although he has recently been employed as a ___ at ___, he has not been going to work recently. He has also not been taking his medications (including ART) regularly, stating sometimes he just does not feel up to it and other times he does not care if he lives or dies. He has had more active thoughts of suicide, including thoughts of OD and thoughts of walking into traffic, although he identified concern for his only friend as the reason he would not do this. He does not want to put his friend through the emotional pain that people experience after someone close to them commits suicide. Regarding acute worries and stressors, patient acknowledged worry about his HIV status. He has also recently passed the one year anniversary of his mother's death. Patient does have h/o cocaine abuse in the past and recently used cocaine in an effort to try to lift his mood. <PAST MEDICAL HISTORY> 1. HIV (per clinic notes) Diagnosed with HIV in ___, risk factor being MSM. On diagnosis, his initial CD4 count was 300 and his viral load was >100,000. By record, his known CD4 nadir was 60 from his initial years in care in ___. He started HAART in ___ with Epivir, Sustiva, and d4T. He was on that regimen for about 60 days and had ?lactic acidosis so his Epivir was switched Videx at that time. He discontinued all medications in ___ and moved to ___. He had been off medications until ___ when he started the regimen of Truvada and Kaletra which he has been on since that time. (Of note, his viral load was 3,160,000 on ___, when he started haart.) Good response to that regimen with viral load becoming undetectable by ___. 2. Rheumatic fever as a child. 3. h/o non-cardiac chest pain (negative cath in ___ 4. major depressive disorder (hospitalized at ___ in ___ 5. chronic renal insufficiency (baseline 1.4-1.6) 6. chronic elevation in CPK. 7. h/o genital herpes <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VITALS IN ED: Afebrile, 98.5 HR 54 and BP 96/61 (stable over readings in ED), 16, 100% RA MSE: Thin but muscled black male with smoothly bald head, faint mustache, appears mildly agitated with clenching fists, but otherwise still in bed. Minimal to no eye contact, frequently closing eyes. No tremors, no diaphoresis, no evidence of intoxication on gross observation. Speech sparse, very quiet (barely audible at times), + latency of response, no dysarthria. Mood is "depressed, very depressed" with a blunted affect, a few tears. Thoughts slowed, themes of hopelessness. Denied frank abnormal perceptions, feels people think ill of him but no frank paranoia. + thoughts of wanting to die, thoughts of suicide with plans, intent limited only by connection to a friend. No thoughts of harming others reported. Insight into need for help fair and decision to seek help supports efforts at good judgment. CSE: Patient is oriented to self, ___, day of week as ___, month as ___ and year as ___, but gave date as 19--surprised to hear it is 23. Able to do MOYF slowly, much more difficulty with MOYB, stumbling through, skipping two, needing to stop and reorient self to task. STM ___ registered, ___ recalled, additional 2 with category clue (1) and list (1). Naming intact, repetition intact. Trouble with proverb interpretation- grass is greener, "you need to get to the other side where it is better." <PERTINENT RESULTS> ___ 12: 40PM URINE HOURS-RANDOM ___ 12: 40PM URINE HOURS-RANDOM ___ 12: 40PM URINE GR HOLD-HOLD ___ 12: 40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG ___ 12: 40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12: 40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-7.0 LEUK-NEG ___ 10: 25AM GLUCOSE-146* UREA N-14 CREAT-1.6* SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-30 ANION GAP-9 ___ 10: 25AM estGFR-Using this ___ 10: 25AM ALT(SGPT)-45* AST(SGOT)-39 CK(CPK)-311* ALK PHOS-59 TOT BILI-0.8 ___ 10: 25AM CK-MB-4 cTropnT-<0.01 ___ 10: 25AM CALCIUM-9.3 PHOSPHATE-2.2* MAGNESIUM-2.3 ___ 10: 25AM VIT B12-574 FOLATE-5.5 ___ 10: 25AM TSH-0.89 ___ 10: 25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10: 25AM WBC-3.3* RBC-4.46* HGB-14.4 HCT-40.4 MCV-91 MCH-32.3* MCHC-35.6* RDW-13.1 ___ 10: 25AM NEUTS-43.2* BANDS-0 LYMPHS-49.7* MONOS-3.8 EOS-2.9 BASOS-0.3 ___ 10: 25AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-OCCASIONAL BITE-OCCASIONAL ___ 10: 25AM PLT SMR-NORMAL PLT COUNT-226 <MEDICATIONS ON ADMISSION> ALBUTEROL WELLBUTRIN SR 150 mg PO bid TRUVADA 1 Tablet(s) by mouth daily KALETRA 2 Tablet(s) by mouth twice a day ATIVAN 0.5 mg PO bid prn anxiety CIALIS 20 mg PO every 36 hours as needed TESTOSTERONE 50 mg/5 gram (1 %) Gel in Packet - One packet Daily TRAZODONE 50 mg PO at bedtime as needed ZOLPIDEM 5 mg by mouth qhs prn <DISCHARGE MEDICATIONS> 1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> AXIS I: Major Depressive Disorder, recurrent, severe AXIS II: Deferred AXIS III: HIV +, Chronic renal insufficiency, history of rheumatic fever <DISCHARGE CONDITION> stable, improved MSE: Appearance/behavior: NAD, groomed, appears stated age, cooperative with interview, good eye contact, no abnormal movements. Speech: regular rate, volume, and prosody Affect: Euthymic Mood: OK Thought Process: linear Thought Content: -SI/HI. the patient denies homicidal ideation, no auditory or visual hallucinations, no evidence of delusions, no paranoid ideation, no preoccupations Insight/Judgment: fair/fair COGNITION: Orientation: A& O x 3 <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> -If you are having thoughts of wanting to hurt yourself or others, please call ___ or come to the Emergency Department immediately. -Please continue to take your medications as indicated. -Please follow up with your outpatient treaters as detailed below.
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On first day of hospitalization, briefly reviewed with pt some of the circumstances leading up to his current hospitalization including his worsening depression with associated loss of interest in all activities, anhedonia, (+) neuroveg sxs, weight loss of 15 pounds in ~ 2 weeks, poor sleep, low energy, terrible concentration, ongoing ruminations with themes of hopelessness and worries that people see how depressed he has been, leading to social isolation and withdrawal. Pt reported that was not taking his psychiatric medications, specifically his wellbutrin x 2 months as he felt this medicatin stopped working for him, although it was initially very helpful. However, pt reports that he continued to take all of his HIV medications. Early in hospitalization, pt reported that sometimes he did not care if he lives or died. Pt identified concern for friends and his job as the reason he would not try to kill imself. He would not want to put his friends through the emotional pain that people experience after someone close to them commits suicide. Throughout hospitalization, pt denied HI. Denied manic sxs. Pt apologized to primary team for sometimes appearing irritated or harsh. Pt reported that he appreciated the care and attention the primary team provided for him while on the unit. Pt continued to endorse depressed mood, however, but died suicidality. Early on in hospitalization, pt agreed to have ECT that could be completed on outpt basis. Pt tolerated initial 2 ECT's as inpatient very well, and quickly begain to report improved mood and a desire for early discharge, to complete ECT as outpt. Pt also expressed interest to return to work on part time basis while completing ECT. Pt wanted to follow up with his old therapist, and utilize in PCP for medication. He agree to eventually accept referral for psychiatrist to eventually take over [REDACTED] [REDACTED]: Pt PCP came to [REDACTED] unit to provide medical clearance for ECT. PCP agreed with the primary teams treatment plan for ECT, and provided medical clearance. Pt was also cleared by anesthesialogy for ECT. There were no medical complications during this hospital course. Psychopharm: Pt c/o of difficulty sleeping and ?AH. Pt started on low dose seroquel at night with good effect. Pt did not tolerate trial on day time seroquel as this made him sleep and nauseaous. That was no concern for new onset psychosis.
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> MEDICINE <ALLERGIES> Penicillins / clindamycin <ATTENDING> ___. <CHIEF COMPLAINT> Uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> Uterine Artery Embolization <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ with PMH of uterine fibroids with menorrhagia that recently became palpable and uncomfortable, and she was also concerned about its potential future growth. She had an endometrial biopsy in ___ that showed simple proliferative endometrium. She has a regular menstrual period. Besides that she has no other complaints. ___ embolized L uterine artery, but it did require a significant amount of embospheres which increased amount of contrast she received to 330mg. They did not embolize the ovarian artery given the risk for induced menopause. She tolerated the procedure well, however, as pre-op antibiotics, she received clindamycin at which point she started having coughing and an itchy throat. This was immediately stopped and antibiotics were changed to cipro. During the procedure moderate hydroureteronephrosis noted L > R due to fibroid mass effect. No significant pain at end of procedure (dilaudid PCA reduced to ___ dose by doubling lockout time, 0.24 mg q 12 min as needed for pain) She received 30mg Toradol and 4mg Zofran. She was transferred from the PACU to the floor. <PAST MEDICAL HISTORY> +PPD with negative CXR Uterine fibroids menorrhagia <SOCIAL HISTORY> ___ <FAMILY HISTORY> None <PHYSICAL EXAM> ADMISSION PHYSICAL: Vitals: 98.2, 116/80, 67, 18, 100RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild suprapubic tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, foley draining clear yellow urine Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Puncture site with occlusive dressing c/d/i Neuro: Currently with straight left precautions, bilateral upper extremities ___ DISCHARGE PHYSICAL: Vitals: 98.3, 97-116/68-75, 61-73, 18, 100RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, no tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Puncture site with occlusive dressing c/d/i Neuro: moves all extremities spontaneously, bilateral upper extremities ___ <PERTINENT RESULTS> ADMISSION LABS: ___ 09: 35AM BLOOD WBC-4.2 RBC-4.96 Hgb-14.8 Hct-46.4 MCV-94 MCH-29.8 MCHC-31.8 RDW-12.6 Plt ___ ___ 09: 35AM BLOOD ___ DISCHARGE LABS: ___ 06: 15AM BLOOD WBC-7.1# RBC-4.39 Hgb-13.2 Hct-41.5 MCV-95 MCH-30.0 MCHC-31.7 RDW-12.6 Plt ___ ___ 06: 15AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-135 K-3.5 Cl-103 HCO3-25 AnGap-11 ___ 06: 15AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.0 ___ 10: 15AM URINE UCG-NEGATIVE <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Uterine artery embolization <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, ___ were admitted to the hospital in order to observe ___ overnight after your procedure. The interventional radiologist used a chemical to cut off the blood supply to the fibroid in your uterus that was causing pain and bleeding. We made sure that ___ were able to eat, walk around and have your pain controlled prior to sending ___ home. Here are more detailed instructions from your doctors: -Small amount of vaginal bleeding is normal for up to 2 weeks after the procedure -The pain should improve gradually every day -Call Dr. ___ office (___) for increasing pain, fever/chills, or heavy vaginal bleeding; after hours call the hospital operator and have them page Dr. ___ follow up appointment with ___ will be scheduled in 1 month the ___ office will call ___ to book it Please continue to take your medications as prescribed and keep all of your follow-up appointments. It was a pleasure taking care of ___. Sincerely, The ___ Medicine Team TRANSITIONAL ISSUES: #Should have electrolytes checked with special attention to creatinine given that contrast-induced nephropathy would be more apparent in a few days after discharge. #Will be called with an appointment from ___ to follow up in about 1 month
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Ms. [REDACTED] is [REDACTED] with PMH of fibroids who presents s/p uterine artery embolization for relief of symptomatic uterine fibroid. #Uterine artery embolization post-procedure: Patient was stable s/p procedure and admission from PACU. She received excess amounts of contrast that required more aggressive hydration with 3L of NS post-procedure. Her leg was kept straight for 6 hours post-procedure and all pulse checks were +2. She received two doses of toradol 30mg IV and used her dilaudid PCA extremely sparingly. Her foley was discontinued and she was able to void without difficulty. She was given a dose of ibuprofen x1 in the morning and her dilaudid PCA discontinued. She was encouraged to use percocet because of the potential for contrast induced nephropathy. Ibuprofen was not recommended and she was not sent home with a prescription. At discharge, she was able to tolerate a regular diet and was able to ambulate independently. TRANSITIONAL ISSUES: #Should have a Cr and lytes drawn by PCP next week in order to monitor kidney function #Will follow-up with [REDACTED] in a few weeks
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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> post tace monitoring <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ chemo embolization FINDINGS: 1. Superior mesenteric arteriogram demonstrates right hepatic artery arising from the SMA. 2. Celiac arteriogram demonstrates a patent splenic artery and common hepatic artery, the left and middle hepatic arteries arise from proper hepatic artery. There is no contribution to the targeted segment 7 tumor from the middle or left hepatic arteries. 3. Right hepatic arteriogram demonstrates tumor blush in the segment 7 tumor. 4. Catheterization and identification of 2 third order right hepatic arterial branches supplying the segment VII tumor. 5. Post-embolization showing staining of the tumor in segment 7. <HISTORY OF PRESENT ILLNESS> Mr. ___ is an ___ yo MW with ___ prostate CA s/p radiation, T2DM, htn, hld, h/o CVA with left residual sensory loss, chronic foot drop from helicopter accident, cirrhosis of unknown origin (likely ___) with HCC s/p roux-en-y hepaticojejunostomy ___ now s/p TACE # 1 ___ with post TACE observation. Mr. ___ has known ___ s/p roux-en-y hepaticojejunostomy with TACE #1 procedure today. He tolerated procedure well, groin intact without hematoma. No fever, nausea, abdominal pain or any complaints of symptoms. Mr. ___ has had a CVA ___ years ago with afib on Coumadin. He stopped his Coumadin 1 week prior to procedure and had been bridged with lovenox 70 BID until ___ evening. Per family, plan to restart ___ morning with lovenox bridge. Review of systems: (+) chronic left foot drop (-) Denies nausea, vomiting, abd pain, numbness/tingling, chest pain, SOA, diarrhea, constipation, hematochezia, melena, dysuria, hematuria, rash 10 pt ROS otherwise neg <PAST MEDICAL HISTORY> 1. Cirrhosis. 2. ___ status post Roux-en-Y hepaticojejunostomy. 3. Non-insulin-dependent diabetes. 4. Hypertension. 5. Hyperlipidemia. 6. CVA with residual left facial sensory deficit. 7. Atrial fibrillation. 8. Prostate cancer status post radiation treatment in the 1990s followed by Dr. ___ at ___ Urology in ___, has a PSA that has been rising slightly, but no further treatment has been required, most recently 17. 9. Perforated diverticulum status post colectomy after GI bleed. 10. Compression fracture of L3 through L5 and T7 through T8. 11. Gout. 12. Left foot drop after helicopter crash in ___. 13. Chronic UTIs due to difficulty emptying his bladder treated with antibiotics approximately every three months and has declined straight cath or catheter placement. 14. Non occlusive portal vein thrombosis PAST SURGICAL HISTORY: 1. Partial colectomy as above. 2. Roux-en-Y hepaticojejunostomy as above in ___. 3. Left total knee replacement. 4. Skeletal injury requiring surgery after helicopter crash in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father lived until ___, ___ until ___. No cancer, Strokes, heart attacks in family or liver disease. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: Vitals: T: 97.9 BP 134 / 66 HR 55 RR 18 O2 sat 94 RA Gen: NAD, resting Eyes: EOMI, no scleral icterus HENT: NCAT, trachea midline, poor hearing CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ ___ BLE Lungs: CTA B, no w/r/r/c GI: +BS, soft, NTTP, ND GU: No foley MSK: ___ strength bilaterally, intact ROM Neuro: Moving all extremities, no focal deficits, A+Ox3, left foot ___ dorsiflexion Skin: No rash or ecchymosis Psych: Congruent affect, good judgment Discharge <PHYSICAL EXAM> 98.2 PO 128 / 66 R Lying 59 20 96 Ra Gen: NAD, laying in bed, pleasant. Eyes: EOMI, no scleral icterus HENT: NCAT, trachea midline, poor hearing CV: RRR, no murmur Lungs: CTAB, breathing comfortable GI: +BS, soft, NTTP, ND Neuro: Moving all extremities, no focal deficits, A+Ox3, left foot ___ dorsiflexion Skin: No rash or ecchymosis Psych: Congruent affect, good judgment <PERTINENT RESULTS> Admission Labs: ___ 07: 30AM BLOOD WBC-6.0 RBC-4.20* Hgb-9.6* Hct-33.2* MCV-79* MCH-22.9* MCHC-28.9* RDW-21.5* RDWSD-58.2* Plt ___ ___ 07: 30AM BLOOD ___ ___ 07: 30AM BLOOD UreaN-22* Creat-1.3* Na-143 K-4.3 Cl-109* HCO3-18* AnGap-20 ___ 07: 30AM BLOOD ALT-30 AST-41* AlkPhos-176* TotBili-0.4 ___ 07: 30AM BLOOD AFP-118.5* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Warfarin 2.5 mg PO 2X/WEEK (MO,WE,TH) 5. Warfarin 5 mg PO 4X/WEEK (___) 6. Enoxaparin Sodium 70 mg SC BID Start: Future Date - ___, First Dose: First Routine Administration Time <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain - Mild 2. Levofloxacin 500 mg PO Q24H 3. MetroNIDAZOLE 500 mg PO/NG BID 4. Atenolol 25 mg PO DAILY 5. Enoxaparin Sodium 70 mg SC BID Start: Today - ___, First Dose: Next Routine Administration Time 6. Losartan Potassium 25 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Warfarin 2.5 mg PO 2X/WEEK (MO,WE,TH) 9. Warfarin 5 mg PO 4X/WEEK (___) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 1. Post TACE 2. HCC/Cirrhosis ___ NASH 3. Chronic atrial fibrillation on anticoagulation 4. Essential hypertension, controlled 5. h/o CVA 5. T2DM not on medications <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> Mr ___, It was a pleasure taking care of you in the hospital. You were admitted for a procedure (TACE) and monitoring post procedure. You had no complications from the procedure. Please follow the instructions below and follow up as noted below. 1. Restart Lovenox 70 mg SC twice daily on ___ Afternoon ___, continue until told that Coumadin level is therapeutic 2. Restart Coumadin the evening of ___ at previous doses. 3. Continue Levaquin 500 mg every day and flagyl 500 mg twice a day for 2 weeks, until complete
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Mr. [REDACTED] is an [REDACTED] yo MW with PMH prostate CA s/p radiation, T2DM, htn, hld, h/o CVA with left residual sensory loss, chronic foot drop from helicopter accident, cirrhosis of unknown origin (likely [REDACTED]) with [REDACTED] s/p roux-en-y hepaticojejunostomy [REDACTED] now s/p TACE # 1 [REDACTED] with post TACE observation. # HCC/Post TACE #1- unknown cirrhosis likely due to [REDACTED] with 3.9 x 3.3 cm OPTN5B hepatocellular carcinoma along the posterior aspect of the liver and evidence of portal vein tumor thrombus (non-occlusive). S/p roux-en-y hepaticojejunostomy [REDACTED]. He tolerated the procedure well and post procedure imaging was stable. He was able to tolerated a diet and had no pain at all. He was afebrile and did well. Plan for Levofloxacin 500mg once a day for 2 weeks (Family has Rx), Metronidazole 500 mg twice a day for 2 weeks (family has Rx). He will follow up with radiology in 1 week as an outpatient. # Essential hypertension, controlled - Continued home atenolol and losartan. # chronic atrial fibrillation - controlled, on Coumadin, held for procedure. CHAD2DS2-VASc score 6, CHADS2 5 which places at high risk of stroke. h/o CVA in past but not in last 3 months. Discussed with [REDACTED] and plan to restart Lovenox 70 SQ BID on [REDACTED] and restart Coumadin until back at goal. Patient reports that his PCP monitors his INR. # T2DM - diet controlled, not on medications. FSBG 200s post TACe but then down trended. # h/o CVA - residual left sided sensory loss per notes but pt denies deficit and none on exam # chronic left foot drop - due to h/o helicopter accident Follow-up: 1 week: [REDACTED] 03:30p XSP [REDACTED] CLINIC [REDACTED] BUILDING, [REDACTED] FLOOR RADIOLOGY 1 month: [REDACTED] 08:15a XMR [REDACTED] BUILDING, BASEMENT [REDACTED] [REDACTED] 08:45a [REDACTED] (LIVER TUMOR LMOB 8) [REDACTED] BUILDING ([REDACTED]), [REDACTED] FLOOR LIVER TUMOR MULTIDISC (SB) # Code status: Full # Contact [REDACTED] [REDACTED] , wife [REDACTED]
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Summarize or extract clinical findings from the following EHR note:
<SEX> F <SERVICE> ORTHOPAEDICS <ALLERGIES> Dicloxacillin <ATTENDING> ___. <CHIEF COMPLAINT> R thigh pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ on coumadin for AF pw 36 hours of R thigh pain and swelling after bumping leg on a table corner <PAST MEDICAL HISTORY> AFIB (on Coumadin), TIA in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> AFVSS NAD, A&Ox3 RLE: thigh firm but compressible, pt able to lift, flex and extend thigh, skin c/d/i; SILT s/s/sp/dp/t; ___ <PERTINENT RESULTS> ___ 03: 49AM BLOOD ___ PTT-52.5* ___ ___ 02: 10PM BLOOD ___ PTT-40.7* ___ ___ 07: 15AM BLOOD ___ ___ 03: 49AM BLOOD WBC-6.9 RBC-4.34 Hgb-13.5 Hct-40.9 MCV-94 MCH-31.2 MCHC-33.1 RDW-13.5 Plt ___ ___ 03: 49AM BLOOD Glucose-113* UreaN-17 Creat-0.7 Na-141 K-4.1 Cl-103 HCO3-31 AnGap-11 <MEDICATIONS ON ADMISSION> Digoxin 0.125 mg PO DAILY Diltiazem Extended-Release 120 mg PO DAILY Coumadin <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN pain 2. Digoxin 0.125 mg PO DAILY 3. Diltiazem Extended-Release 120 mg PO DAILY 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills: *0 Coumadin to start ___ <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> L thigh hematoma <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> - Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chest pain, shortness of breath or any other concerns. Please continue to wear your thigh high ___ stocking until follow up. ******WEIGHT-BEARING******* weight bearing as tolerated left lower extremity ******MEDICATIONS*********** - Resume your pre-hospital medications. - You will not resume taking your coumadin until ___ ___. On ___ you will start taking your regularly scheduled coumadin doses. You will need your INR checked on ___ and to see your PCP, ___ week. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink ___ glasses of water daily and take a stool softener (colace) to prevent this side effect. - Medication refills cannot be written after 12 noon on ___.
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The patient was admitted to the orthopaedic surgery service on [REDACTED] with R thigh hematoma. Pt was admitted for monitoring for question of compartment syndrome and for reversal of INR of 4.7. Pt's coumadin was held and Vit K was administered. Upon discharge pt's INR was 1.8. Pt's PCP, [REDACTED] was contacted and was ok with the plan to hold pt's coumadin until this [REDACTED]. Pt's pain decreased during her stay and she felt she was able to move it more. She was placed in a thigh high [REDACTED] stocking and worked with [REDACTED] on crutches. She was instructed to f/u with her PCP next week and with Orthopaedic Surgery in [REDACTED] days. Neuro: Patients pain was controlled with oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Hematology: The patient was hemodynamically stable and INR was reversed and coumadin held as explained above. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. At the time of discharge on HD#2, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The incision was clean, dry, and intact without evidence of erythema or drainage; the extremity was NVI distally throughout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge.
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Summarize or extract clinical findings from the following EHR note:
<SEX> M <SERVICE> MEDICINE <ALLERGIES> All allergies / adverse drug reactions previously recorded have been deleted <ATTENDING> ___. <CHIEF COMPLAINT> Back and leg pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ male with history of sickle cell anemia who is here for evaluation of diffuse back and leg pain. Patient states that the night prior to admission he noticed pain in his back and legs consistent with prior pain crises. The pain is diffuse across his mid-back and over his knees and calves. He denies any fevers, chills, cough, shortness of breath, abdominal pain, malaise, jaundice, nausea, vomiting, diarrhea. He does state he has been taking his medications and vaccines as directed. Per prior discharge summary, pt has history of being confrontational regarding IV narcotic pain medications and leaving AMA from several hospitals. He used to get his ___ care with Dr. ___ at ___, however his care there was terminated several months ago after missing several appointments and due to medication noncompliance. He was on hydroxyurea while getting his care at ___ however he reports he had crises despite the medication and requested to stop taking it. In the ED, initial VS were 99.2, 79, 125/65, 18, 100% RA Labs significant for mild leukocytosis of 11.8 with normal diff, anemia essentially at baseline (___) and INR 1.2. LDH, retic count, and haptoglobin wnl. Imaging with normal CXR. Received 3mg Dilaudid IV. On arrival to the floor, patient reports he is in ___ pain. He denies sick contacts and recent travel. ROS: 10 point ROS negative except as otherwise noted above in HPI <PAST MEDICAL HISTORY> - Sickle cell anemia s/p vaso-occlusive crises - Beta thalassemia - Osteomyelitis s/p multiple surgical procedures of right and left lower extremities - IV heroin abuse - MSSA bacteremia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother with sickle cell trait Borther x1 and sister x1 with no sickle cell disease (all different fathers) <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM: VS: T 98.5 BP 120/68 HR 64 SPO2 100% on RA GENERAL: Extensively tattooed young man in NAD. AOx3, answering questions appropriately. HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, patent nares, MMM, good dentition, nontender supple neck CARDIAC: RRR, ___ systolic murmur best heard at ___. LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well without pain, no cyanosis, clubbing or edema. Knees without inflammation or effusion. Spine nontender to palpation. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: 12-hr VS - Tmax 98.3 BP 110s/40s HR ___ SPO2 100% on RA GENERAL: Extensively tattooed young man in NAD. AOx3, answering questions appropriately. HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, patent nares, MMM, good dentition, nontender supple neck CARDIAC: ___ SEM at ___, no g/r LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, EXTREMITIES: moving all extremities well without pain, no cyanosis, clubbing or edema. Knees without inflammation or effusion. Mid spine and shoulders nontender to palpation. PULSES: 2+ Radial pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes <PERTINENT RESULTS> ADMISSION LABS: ___ 08: 38AM BLOOD WBC-11.8* RBC-4.44* Hgb-9.4* Hct-29.8* MCV-67* MCH-21.1* MCHC-31.4 RDW-17.4* Plt ___ ___ 08: 38AM BLOOD Neuts-53.3 ___ Monos-5.5 Eos-3.5 Baso-0.4 ___ 08: 38AM BLOOD ___ PTT-20.3* ___ ___ 08: 38AM BLOOD Ret Aut-3.1 ___ 08: 38AM BLOOD Glucose-129* UreaN-12 Creat-0.8 Na-138 K-3.5 Cl-102 HCO3-25 AnGap-15 ___ 08: 38AM BLOOD ALT-14 AST-20 LD(LDH)-212 AlkPhos-86 TotBili-0.3 ___ 08: 38AM BLOOD Lipase-20 ___ 08: 38AM BLOOD cTropnT-<0.01 ___ 08: 38AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.2 Mg-2.0 ___ 08: 43AM BLOOD ___ pO2-117* pCO2-31* pH-7.48* calTCO2-24 Base XS-1 ___ 08: 43AM BLOOD Lactate-1.4 ___ 08: 43AM BLOOD O2 Sat-96 DISCHARGE LABS: ___ 10: 30AM BLOOD WBC-8.2 RBC-4.64 Hgb-10.1* Hct-30.8* MCV-66* MCH-21.7* MCHC-32.7 RDW-17.2* Plt ___ ___ 10: 30AM BLOOD Glucose-123* UreaN-11 Creat-0.8 Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 IMAGING: CXR ___ IMPRESSION: Stable mild cardiomegaly. No convincing signs of pneumonia or overt CHF. MICROBIOLOGY: Blood culture ___ - No Growth <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraMADOL (Ultram) 50 mg PO TID: PRN pain 2. Methadone 10 mg PO DAILY 3. OxyCODONE SR (OxyconTIN) 30 mg PO Frequency is Unknown <DISCHARGE MEDICATIONS> 1. OxycoDONE (Immediate Release) 30 mg PO Q4H: PRN pain RX *oxycodone 30 mg 1 tablet(s) by mouth q4hrs Disp #*72 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> # Primary: Sickle Cell Disease <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 pleasure taking care of you at the ___ ___. You were admitted with complaints of an acute pain crisis related to your sickle cell disease. We are discharging you with enough pain medication to get you through to your next hematologist appointment. It is VERY important you make that appointment.
Output:
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[REDACTED] with sickle cell disease and beta thalassemia who presents with back and bilateral leg pain. #Pain/sickle cell disease: Presented with diffuse back and bilateral leg pain without specific findings on physical exam. No laboratory evidence of a vaso-occlusive pain episode, but patient did report this was similar to previous sickle crises he has had in the past. No respiratory findings to suggest acute chest syndrome. Possible inciting factors for this episode could be infection (mild leukocytosis at admission) vs psychosocial stress. No exam findings to suggest focal joint inflammation, and infectious workup was negative. We were able to reach his former outpatient hematologist, Dr. [REDACTED], at [REDACTED], who informed us that the patient's care with her was terminated due to his IV heroin use and noncompliance with his medications, which did not match with patient's report of missed appointments. Dr. [REDACTED] reported the patient was recently hospitalized at [REDACTED] for similar complaints of pain, which patient had denied during this admission. The patient was also noted by RNs to be leaving the floor to smoke during this admission. Given his apparent drug-seeking behavior and purposeful deceit, he was discharged with enough oxycodone to last until his scheduled appointment with a new hematologist at [REDACTED], which we were able to confirm. For additional details, please see note documented in OMR by Attending physician (hospitalist), Dr. [REDACTED] on [REDACTED] titled 'Sickle Cell Disease Collateral." #Leukocytosis: WBC count at admission was elevated 11.8, thought to be possibly infectious vs leukemoid reaction from pain/stress. WBC quickly normalized on hospital day #2. His CXR did not show evidence of pneumonia and his blood culture did not grow any bacteria. He denied any dysuria. No rashes to suggest cellulitis were noted. TRANSITIONAL ISSUES: - Requires new hematologist and regular followup. Our team had extensive discussion with the patient regarding medication compliance and importance of consistent followup in managing his sickle cell disease. - He requested a new PCP, with [REDACTED] new PCP appointment established at [REDACTED]. However, pt did report he may choose to seek a PCP closer to home - in terms of follow-up with a new hematologist, he has already been referred to [REDACTED] by Dr. [REDACTED] (at [REDACTED] and has a follow-up appointment arranged already. He has been instructed to keep that appointment.
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