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162 | Admission Date :
2015-09-14
Discharge Date :
2015-09-19
Service :
NEONATOLOGY
HISTORY OF PRESENT ILLNESS :
The patient is a 3285 gm infant born at 37 5/7 weeks to a 21 year old G3 P1 now 2 mother with prenatal screens as follows :
O positive , antibody negative , hepatitis B surface antigen negative , RPR nonreactive , GBS negative .
Unremarkable pregnancy except for minor fullness of the left renal pelvis reported during the week prior to delivery .
Past OB history remarkable for postpartum depression .
Mother was admitted in labor .
Baby was delivered by repeat C-section with rupture of membranes at delivery .
Apgars were 8 and 9 .
CMED CSRU staff was called about 30 minutes of age for grunting , flaring and retractions and the baby was admitted to the CMED CSRU .
HOSPITAL COURSE:
1. Respiratory .
The Athol Memorial Hospital hospital course was initially consistent with transient tachypnea of the newborn .
Chest x-ray revealed mild streakiness of the lung fields .
He was initially placed on nasal cannula with subsequent resolution of respiratory distress .
Nasal cannula was weaned off on day of life 3 and he initially was maintaining O2 sat above 94% and breathing comfortably .
He was subsequently placed back on nasal cannula for mild oxygen desaturation and was requiring 25 c/min flow at the time of discharge .
No apneic or brady episodes .
2. Cardiovascular .
The patient 's cardiovascular status has been stable throughout his CMED CSRU stay .
No murmur on exam .
3. FEN .
The patient had been tolerating oral feeding as of day of life 2 and is currently taking Enfamil 20 p.o. ad lib .
He has been weaned off IV fluids and has been maintaining good blood glucose .
His birth weight was 3285 gm .
His weight is 3015 gm on day of life 5 .
4. GI .
The patient 's bilirubin level at 24 hours of life was 4.6.
No phototherapy was started .
5. ID .
The patient was not started on antibiotics , given lack of sepsis risk factors .
His initial CBC showed no left shift .
Blood culture had remained no growth to date .
6. Heme .
The patient 's initial hematocrit was 35.8 .
No transfusion during this admission .
CONDITION ON TRANSFER :
The patient has been doing well on low flow nasal cannula. He has been tolerating p.o. ad lib feeds . | [
{
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{
"text": "37 5/7 weeks",
"start_char": 148,
"end_char": 160,
"id": "T3",
"type": "DURATION",
"val": "p37w5d",
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},... | null | null | null |
348 | ADMISSION DATE :
3-26-93
DISCHARGE DATE :
4-3-93
HISTORY OF PRESENT ILLNESS :
The patient is a 73 year old female who was transferred for cardiac catheterization after ventricular fibrillation arrest in the setting of an acute inferior myocardial infarction and a urinary tract infection .
The patient was admitted on 3-16-93 to Diy Hospital for an E. coli urinary tract infection .
The patient was readmitted on 3-20-93 because of fever , chills and a sudden onset of ventricular fibrillation arrest , successfully cardioverted back to rapid atrial fibrillation and finally to sinus rhythm , where an electrocardiogram then showed ST elevation in inferior leads .
Peak CPK was 2494 with 18% MB 's .
She required intubation for mild to moderate congestive heart failure , treated with diuretics , intravenous nitroglycerin and heparin .
She had post-infarction angina , was transferred here for angiography and possible percutaneous transluminal coronary angioplasty .
HOSPITAL COURSE :
On 3-27-93 , patient underwent cardiac catheterization , coronary and left ventricular angiography without complications .
Review of these angiograms demonstrated a dominant right coronary artery with a focal 50% stenosis in the mid-portion .
The left main coronary artery was clear .
The left anterior descending had moderate plaques with a 50% proximal stenosis of the right anterior oblique caudal view .
The proximal diagonal D1 had a 50% stenosis .
The circumflex had a long 30% stenosis proximally and an 80% stenosis at the origin of the second major marginal artery .
The left ventricular angiogram showed akinesis of the posterobasal walls , severe hypokinesis of the diaphragmatic wall and trace mitral regurgitation .
The patient was maintained on heparin anticoagulation .
An exercise tolerance test with Thallium was to be performed in order to assess myocardial viability in the infarct zone .
The right coronary artery lesion was complex and there was severe stenosis in the obtuse marginal 1 .
The patient had no further angina .
On 4-2-93 , she underwent a Persantine Thallium study .
This showed no diagnostic electrocardiogram changes for ischemia and no angina pectoris .
The thallium images showed a large region of persistently reduced blood flow involving the apex and inferoposterior segments of the left ventricular wall .
This was consistent with scar .
There was no definite perfusion abnormality in the circumflex zone .
In view of these findings , it was elected to discharge her on her present medical program .
The patient is to return to the follow up care of Dr. Ko Kollciem at the Diy Hospital .
CHPO E. JESCOBEA , M.D.
TR :
sq / bmot
DD :
06-13-93
TD :
06/15/93
CC :
Dr. Ko Kollciem , Retchard Healthcare to Dr. Wall | [
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"text": "3-26-93",
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"id": "T0",
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572 | Admission Date :
12/12/1996
Discharge Date :
12/16/1996
HISTORY / REASON FOR HOSPITALIZATION :
The patient is a 42 year old gravida II , para I female with a long history of menorrhagia and pelvic pain .
She also has a history of endometriosis that is symptomatic .
She used Danocrine for approximately nine months and was pain free , but was unable to tolerate the side effects .
She is status post several laparoscopies in the past with which she was diagnosed with endometriosis .
She has recently been on Depo-Provera and has had episodes of break-through bleeding for six weeks at a time .
She desired surgical therapy .
HOSPITAL COURSE :
On 12/12/96 she had an uncomplicated total abdominal hysterectomy and bilateral salpingo-oophorectomy .
Estimated blood loss was 100 cc and she tolerated the procedure well .
On postop day number one she was afebrile and doing well with a PCA for pain control .
On postop day number two she was also afebrile and had not passed any flatus yet .
She was ambulating frequently .
Her hematocrit was 34.2 and stable from her preoperative value .
On postop day number three her abdomen was noted to be distended with a few bowel sounds and she still had not passed gas .
The patient decreased the amount of Demerol she was using and supplemented with Tylenol and continued her frequent ambulation .
On postop day number four she had passed flatus and was feeling much better .
She was discharged to home in good condition on the following medications .
DISCHARGE MEDICATIONS :
Demerol for pain .
Motrin for pain .
Colace stool softener .
DISPOSITION :
The patient should follow-up with Dr. Side in two weeks .
Dictated By :
IEDEARC SIDE , M.D. LB28
Attending :
MITERY D. LOSS , M.D. CB51 II795/2112
Batch :
42100
Index No. ZMFX3O4G1
D :
01/04/97
T :
01/06/97
CC :
1. MITERY D. LOSS , M.D. NT11
[ report _ end ] | [
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"mod": "NA"
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"id": "T8",
"type": "DATE",
"val": "1996-12-16"... | null | null | null |
201 | ADMISSION DATE :
03/11/2002
DISCHARGE DATE :
03/14/2002
DISCHARGE DATE :
03/14/2002
HISTORY OF PRESENT ILLNESS :
This is a 62-year-old hospice chaplain who was referred by Dr. Tomedankell Flowayles and Dr. Es Oarekote for evaluation of his right hip pain .
He states that his pain has been of seven to eight durations , and rated as moderate to severe ( 7/10 ) .
He does limp .
He does not use a cane and he requires a bannister for going up and down stairs .
He has trouble with his shoes and socks .
He uses a walker .
He can walk about a quarter of a mile without stopping .
HOSPITAL COURSE :
The patient was taken to the operating room on March 11 , 2002 , and underwent an uncomplicated right total hip replacement .
The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit and then to the floor in stable condition .
On postoperative check , he was doing well .
He was afebrile and his vital signs were stable .
He was neurovascularly intact .
His hematocrit was 34.7 .
He was started on Coumadin for DVT prophylaxis and Ancef for routine antimicrobial coverage .
He was made partial weight-bearing for his right lower extremity .
He was placed on posterior hip dislocation precautions and was out of bed with physical therapy and occupational therapy .
On postoperative day one , there were no active issues .
He was afebrile .
His vital signs were stable .
He was neurovascularly intact .
On postoperative day two , he was afebrile , vital signs were stable .
His incision was clean , dry and intact with no erythema .
He remained neurovascularly intact .
His hematocrit was 34.8 .
On postoperative day three , lower extremity noninvasive ultrasounds were performed , which showed no evidence of deep venous thrombosis in the lower extremities .
The remainder of his hospitalization was uncomplicated . | [
{
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"type": "DATE",
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"mod": "NA"
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"text": "day two",
"start_char": 1452,
"end_char": 1459,
"id": "T5",
"type": "DATE",
"val": "2002-03-13",
"mod": "NA"
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... | null | null | null |
567 | Admission Date :
2013-09-05
Discharge Date :
2013-09-12
Service :
MEDICINE
History of Present Illness :
HPI : This is a 79 y/o M with h/o of HTN , DM , recent CVA Theresa , chronic respiratory failure on vent , trached , ESRD on HD who was sent from rehab facility for worsening mental status .
Per refferal notes , he went to hemodyalisis today in the morning .
1 L was removed .
At about 2:30 pm , he was found to have worsening mental status .
In that setting he was hypotensive down to the 92/45 , and was given 1 L NS .
Fs was also checked 179 .
At that time , it seems that he had been on T peace since 4 am today .
At 2:30 he was also found with sats in the 90% .
ABG done 7.1 , 89/72 - he was placed on AC 600 / 0.4 and 6 PEEP - sats up to 94% .
Given persistent lethargy , patient was sent to Falkener Amanda .
Of note , after interview with HCP , at around 07-23 , patient started having episodes of dizziness , and had unstable gait .
he was taken to Williams ICU until 08-09 when he was discharged to Waltham/Weston Hospital Rehab .
he had a peg tube and tracheostomy prior to d/c .
He had been chronicallyl vent dependent .
His companion states that they have been trying to wean him down at rehab .
his basline mental staus apparently responds with his head shaking , and also try to write sentences .
In the Amanda : VS T 103 rectal BP90/44 HR : 84 RR 16 Sats : 98 + guiac stool .
He received tylenol , levofloxacin 500 mg IV , Flagyl 500 mg and Vancomycin and I L NS .
ROS : difficult to obtain 2x2 to patient mental status baselin
Brief Hospital Course :
Assessment and Plan :
This is a 79 y/o M with h/o HTN , DM , recent CVA , chronic ventilatory failure , CRI on HD who presents with change in MS and febrile in the Amanda , admitted to CMED .
# Altered mental status : Ct scan with no evidence of new intracraneal bleeding .
Patient febrile in the Amanda .
High WBC .
It was thought that it could have been a combination of hypotension , hypercapnia and infection .
He was initially started on broad spectrum antibiotics .
Despite having a profund limitation communicating given his neurological status , his mental changes seemed to improved initially .
However later on during his course , his mental status deteriorated , being even less responsive .
# ID :
Patient febrile and with a high WBC on admission .
After starting broad spectrum antibiotics - cefepime - vancomycin and flagyl ( for initial concern of aspiration pneumonia ), he responded clinically .
Urine cx from Rehab showed gram negative rods > 100 K enterobacter cloacae .
Urine Cx in house grew Citrobacter Freundi and his sputum grew Acinetobacter Baummani .
Since there was no more evidence of gram positive infections , vancomycin was discontinued and cefepime was kept .
# Fevers : in the Amanda , high WBC , possible pneumonia .
Also possible source sinus infections given findings on intial CT ( see summary in significant studies ). He did not spike any fevers after being transfer to the CMED from the Amanda .
# Resp : Patient was intermitentely switched from AC to Pressure support trials .
However , after Patient did well .
Then trach mask trials were done .
He tolerated this well , although he required PS overnight .
# ESRD on hemodyalisis : Renal service was consulted and HD was continued .
# CV :
Rhythm : NSR , not tachycardic .
Pump : With trace of lower extremity edema .
X ray suggested some pulmonary edema on admission .
Despite this findings , he was supported with 40% FIO2 most of the time .
CAD : On admission Ck low normal , MB not done .
Troponin 0.44.
It was more likely due to CRI .
Second set 12 hours apart , showed no changes .
s/p stroke : continue aspirin , statin , plavix
# Hypotension : per referral form .
Intially concern for sepsis in the setting of fevers and high blood count .
His BP medications were held on admission .
Patient did not require pressors .
His blood pressure remained stable and BP meds were restarted .
# FEN :
Tube feedings were started thorugh peg tube .
On 2013-09-08 , patient pulled out peg tube .
Temporary foley was placed and on 2013-09-11 ,
On 2013-09-12 after deterioration of his mental status and also of his blood pressure , goals of care were discussed with his HCP .
It was decided to direct goals of care towards confort care .
Patient passed away accompanied by his significant other . | [
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{
"text": "overnight",
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"... | null | null | null |
413 | ADMISSION DATE :
5-3-93
DISCHARGE DATE :
5-12-93
HISTORY OF PRESENT ILLNESS :
Mr. Stain was transferred from the Oreiewlefell Merkane I Penaltbridgesgreat University Medical Center for progressive respiratory failure and adult respiratory distress syndrome superimposed on a history of chronic obstructive pulmonary disease , perhaps asthma , and ulcerative colitis .
His only positive result was a sputum culture for Pseudomonas and this came after he had already been on antibiotics .
HOSPITAL COURSE :
The patient was seen in consultation by Dr. Wire who felt that manipulation of the tracheal tube was the best approach to the air leak since it was a new trach and he was requiring such high ventilator support that it was risky to change it .
He also felt that lung biopsy at this time was rather risky .
The patient was therefore completely cultured again and begun on antibiotic coverage which would take care of the Pseudomonas he was known to have .
The steroids were tapered .
He was also begun on anti-Candida regimen for his urinary tract infection with yeast being seen .
Because of the story of hemoptysis , he also underwent an exotic bleeding work up for such things as Wegner 's and Goodpasture 's .
These results were all negative .
He continued to require very high FIO2 .
He was found to have a DVT by ultrasound .
He underwent a trial of TPA followed by heparin .
This produced substantially further hemoptysis and the need for transfusion .
He stabilized from this , but on the fifth while continuing to have extremely ventilator requirement .
In consultation with his family , it was decided that enough support had been done .
At that time , therefore , ventilator support was withdrawn under the comfort measures of morphine .
STAIN J. A , M.D.
TR :
sj / bmot
DD :
6-4-93
TD :
06/05/93
CC : | [
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"id": "T1",
"type": "DATE",
"val": "1993-05-03",
"mod": "NA"
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"te... | null | null | null |
407 | Admission Date :
2017-04-26
Discharge Date :
2017-05-01
Service :
CARD CMED
HISTORY OF PRESENT ILLNESS :
This is a 62 year old gentleman who underwent an exercise treadmill test for screening through the Beth Israel Deaconess Hospital-Needham Clinic .
The test was positive for EKG changes and shortness of breath .
The patient has no history of chest pain; no history of myocardial infarction .
The patient was referred to Cambridge Health Alliance for cardiac catheterization .
Cardiac catheterization showed an ejection fraction of 50% , left ventricular end diastolic pressure of 20 , 90% left anterior descending lesion , 80% left circumflex lesion , 80% mid right coronary artery lesion and 80% distal right coronary artery lesion .
The patient was referred to Dr. Rota for coronary artery bypass grafting .
HOSPITAL COURSE :
The patient was admitted to Saint Vincent Hospital on 2017-04-26 and underwent a coronary artery bypass graft times four with left internal mammary artery to left anterior descending , saphenous vein graft to right coronary artery , saphenous vein graft to PDA and saphenous vein graft to obtuse marginal with Dr. Rota .
Please see the Operative Note for further details .
The patient was transferred to the Intensive Care Unit in stable condition on Neo-Synephrine infusion .
The patient was weaned the next day from mechanical ventilation on his first postoperative night .
Postoperative days one and two , the patient continued to require Neo-Synephrine to maintain systolic blood pressures greater than 100 .
On postoperative day two , the patient 's hematocrit was noted to be 23.1 ; he was transfused one unit of packed red blood cells as well as given a dose of Lasix .
The Neo-Synephrine was weaned off by postoperative day number three .
The patient 's chest tubes were removed on postoperative day three without incident .
The patient was started on low dose Lasix and Lopressor which he tolerated well .
On postoperative day number four , the patient was transferred from the Intensive Care Unit to the regular part of the hospital where he began working with Physical Therapy and on his first session he was able to ambulate 500 feet and climb one flight of stairs while remaining hemodynamically stable without requiring any oxygen .
On postoperative day number five , the patient continued to remain hemodynamically stable .
The patient 's epicardial pacing wires were removed without incident and the patient was cleared for discharge to home . | [
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... | null | null | null |
188 | Admission Date :
2015-10-26
Discharge Date :
2015-10-30
Service :
SURGERY
History of Present Illness :
17 yo male pedestrian who was struck by auto at unknown speed ; +LOC .
He was medflighted to The Hospital for Orthopedics for ongoing trauma care .
Upon arrival GCS 15 , alert and oriented x3 .
Brief Hospital Course :
He was admitted to the trauma service . Orthopedics and Neurosurgery were consulted because of his injuries .
His Neurosurgical issues were nonoperative ; he was loaded with Dilantin ; serial head CT scans were performed and were stable .
He will need to follow up with Dr. Mckinney in 4 weeks for repeat head imaging and continue with Dilantin for one month .
His right tib / fib fracture was repaired by Orthopedics on 10-27 ; postoperatively there were no complications .
Weight bearing status was increased to weight bearing as tolerated .
He was fitted with a hinged Mcdonald brace for his LLE .
He will need to continue on Lovenox injections for at least 4-6 weeks .
He was transfused with 3 u packed cells for a hematocrit of 21 , post transfusion HCT was 26.1 ; there was a questionable transfusion reaction at the end of his first unit of packed cells ; he did subsequently receive the remaining 2 units without any further reaction .
Physical and Occupational therapy were consulted and have recommended home with services . | [
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611 | ADMISSION DATE :
11/3/92
DISCHARGE DATE :
12/6/92
HISTORY OF PRESENT ILLNESS :
The patient is a 68 year old , right handed caucasian female , former R.N. who complained of several days of vertigo , one day of double vision , dysarthria and worsening of vertigo .
She was seen at the outside hospital and put on aspirin for two days .
An magnetic resonance imaging study showed basilar artery disease , questionable aneurysm .
The patient was transferred to the Fairm of Ijordcompmac Hospital .
An angiogram on 11/3 was consistent with thrombosis at the mid basilar artery .
The patient was put on heparin and was stable since .
HOSPITAL COURSE :
The patient was taken to the Intensive Care Unit after her angiogram .
She was aggressively anticoagulated with heparin .
A small intimal tear in the arch of the aorta during the angiogram , was without sequelae .
She was doing well with at least 4+ strength in all of her extremities , when on 11/13 , she had an acute drop in her systolic blood pressure to 70 for unclear reasons and without evidence of acute sepsis .
This was accompanied by substantial decrement in neurologic function .
For a short time , she seemed " locked in " .
She has made slow progress since then and at the time of discharge has 4-strength at the left elbow and 4+ in the left wrist and hand .
Trace movement of the right elbow and 4-strength of the right wrist and hand .
4-to 4+ strength at the left ankle , 4+ strength at the right knee and right ankle .
She is unable to lift either foot off the bed .
The extra ocular movements are full .
Tongue protrudes 4 cm .
She is drowsy at times , but generally alert , responsive , interactive , able to talk in two to three word sentences when she wants to .
She has severe memory deficits , but nevertheless , is able to engage in conversation , answers questions , names things well , does calculations and recognizes family members and states preferences .
She has been working with Speech Therapy , occupational therapy and physical therapy closely and should continue to show improvement .
She is anticoagulated on Coumadin and this has been stable .
She is do not resuscitate in agreement with the wishes of her multiple family members .
Follow up computerized tomography scans and magnetic resonance imaging studies have shown infarction in bilateral basis pontis , mid brain , the superior cerebellar areas , left thalamus , bilateral temporal lobes medially and inferiorly and left posterior communicating artery .
The patient had fevers sporadically during this hospitalization with rising white blood counts .
A chest X-ray documented a progressing left lower lobe infiltrate .
Initially this improved on Clindamycin and Cefotetan , but fevers recurred on this antibiotic regimen .
Sputum grew out Klebsiella pneumoniae , and she was treated with Gentamicin and Ancef for 14 days intravenous ( bug being sensitive to these two drugs ) .
A left pleural effusion developed and this was tapped with ultrasound guidance , and found to be sterile , and without evidence of empyema .
The patient is on Ciprofloxacin .
The day of discharge is day #3 of 7 , after which antibiotics should be totally discontinued .
She has developed bad thrush in this setting , she is not yet able to swallow and so she is on Nystatin swish and spit five times a day .
She also gets Peridex to clean out her mouth .
Once her liver enzymes are completely normal , a seven day course of Fluconazol may be helpful if the thrush is not spontaneously resolving off of antibiotics .
She has been afebrile for greater than 10 days , including several days on oral antibiotics .
The patient 's liver enzymes were noted to be elevated mid way through her hospital course , to about three times normal , especially the SGOT and SGPT .
These have spontaneously reversed , and are nearly normal at the time of discharge .
A right upper quadrant ultrasound documented gallstones , without evidence of common bile duct dilatation or active cholecystitis .
The exact cause of her liver enzyme elevation is unclear , but we are being careful about administering drugs , which might irritate the liver .
The patient had a steady decline in her hematocrit during this hospitalization .
Iron studies are all entirely normal , her anemia is attributed to anemia or chronic disease with hypoproliferation as well as multiple phlebotomies .
The plan is to give her folic acid , but not iron .
The patient 's potassiums have been repeatedly low and require daily checks and repletion .
This is thought due to the extensive course of Gentamicin which she received .
This must be carefully checked despite the standing order for potassium .
The patient has had low sodiums during this hospitalization .
This may due to her central nervous system process or her pulmonary process , with fluids administered as described , she should not have any problems from this .
Her sodiums were never below 130 .
She does well with tube feeds .
Her tube feeds orders are as follow :
full strength Replete with fiber at 70 cc. per hour .
In addition , the patient gets 250 cc. of juice ( not water ) three times a day .
She also gets Lactinex granules three packages in each bottle of tube feeds .
She also gets Metamucil one teaspoon with the first bolus of juice each day .
Please note that evaluation by the swallowing therapist , showed that the patient is aspirating at this time , but there is great hope from the nature of her deficit and the good movements of her tongue that normal swallowing should return soon .
It is for this reason that she is discharged with an nasogastric tube and that no plans for G tube placement are made at this time .
She has a history of of angina without myocardial infarction that has not been worked up .
She did have brief chest pain twice during this admission that did not correlate with electrocardiogram changes .
In the first week of November , her electrocardiogram showed T wave inversions in the lateral leads , correlating with an increase in the LDH , but not CK .
This did not normalize with administration of Isordil and the patient denied chest pain at this time .
As of 4/7 , her electrocardiogram had reverted back to normal and there is no evidence of congestive heart failure or continued electrocardiogram changes , and chest pain is absent .
Her cholesterol was 350 here .
She has been off of her hypercholesterol medicines .
These can be restarted when it is deemed reasonable , in view of her acute disease and recently elevated liver enzymes .
Note that the liver enzymes were normal on admission , at which time she was taking all of the above cholesterol medicines . | [
{
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... | null | null | null |
177 | Admission Date :
2012-11-21
Discharge Date :
2012-11-28
Service :
Transplant
HISTORY OF PRESENT ILLNESS :
This is a 37-year-old female who presents on an elective basis for a living-related kidney transplant .
The patient has a history of end-stage renal failure secondary to type 1 diabetes with a baseline creatinine of around 5 .
She is receiving a kidney from her sister .
The patient has a history of hypertension , coronary artery disease , and insulin-dependent diabetes for 32 years .
She is status post myocardial infarction in April of this year and subsequently underwent coronary artery bypass surgery .
She present electively on the morning of her surgery with no recent changes in her medical problems .
HOSPITAL COURSE :
The patient was admitted to the preoperative holding area and taken electively to the operating room .
She underwent a living-related renal transplant in the right iliac fossa .
The operation was somewhat technically difficult secondary to a short segment of ureter which was anastomosed over a stent to the bladder .
Otherwise , there were difficulties , and estimated blood loss was minimal .
She was taken postoperatively to the recovery room already making a large amount of urine .
Intraoperatively , for immunosuppression she received thymoglobulin and Solu-Medrol .
She was started on Prograf and CellCept in the postoperative period .
She was also maintained on Bactrim postoperatively and did not require ganciclovir , as she and her sister were cytomegalovirus negative .
The patient 's initial postoperative course was relatively uneventful .
Her creatinine , which was 5 initially postoperatively , slowly dropped over the next few days until eventually reaching a low of 1 .
She did receive pamidronate on postoperative day one and received a total of four doses thymoglobulin .
Her steroid doses were slowly tapered over her hospital course , and her Prograf level was adjusted to maintain therapeutic values between 10 and 15 .
She continued to make good urine over the first few days and had her urine losses replaced with intravenous fluids .
On postoperative day three , the patient had an episode of shortness of breath that was evaluated by both the Renal and surgical residents .
It was found that she was in acute pulmonary edema and required transfer to the Surgical Intensive Care Unit .
Her blood pressure at the time of this incident was in the range of 200/120 .
Her electrocardiogram showed no specific ST changes , but there was some loss of her R wave progression laterally .
Serial enzymes were drawn , and Cardiology was consulted .
With blood pressure control via a nitroglycerin drip and fluid restriction , the patient quickly improved and a had a relatively short stay in the Intensive Care Unit .
Throughout this time , her creatinine continued to drop , and there was no apparent deleterious effect on her transplant from this episode .
Her beta blocker was progressively increased , and her nitroglycerin drip was weaned down .
Two days after this event , she underwent an echocardiogram which was significant for slightly depressed left ventricular systolic function with severe posterior wall hypokinesis .
This was a change from her prior echocardiogram and demonstrated evidence of a small myocardial infarction .
Clinically , she did much better and her blood pressure was optimized prior to discharge .
She was transferred out of the Intensive Care Unit on postoperative day five and was stable on the floor for the next two days . | [
{
"text": "the next few days",
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"id": "T6",
"type": "DATE",
"val": "2012-11-22",
... | null | null | null |
163 | Admission Date :
2010-05-17
Discharge Date :
2010-05-29
Service :
HISTORY OF PRESENT ILLNESS :
HISTORY OF PRESENT ILLNESS :
This is an 86-year-old female with a past medical history of diabetes and hypertension who presented to the Emergency Department with a two day history of shortness of breath and easy fatigability .
She also noted increased dyspnea on exertion .
Prior to this patient could walk upstairs but now cannot .
She denies chest pain , orthopnea , paroxysmal nocturnal dyspnea .
However , the patient has noted some abdominal pain , intermittent times a couple of days , none on the day of admission .
Denied nausea , vomiting , diaphoresis , bowel movement changes .
She has noted increased urinary frequency .
Denies fever or chills .
Of note , she has had recent medication changes which included discontinuing Diovan and starting terazosin .
HOSPITAL COURSE :
The patient was admitted to the Cardiac Medicine Service and treated for presumed diastolic and systolic dysfunction .
Echocardiogram was obtained which showed moderately depressed left ventricular systolic function as well as hypokinesis of the lower half of septum and apex .
Also of note was the distal lateral wall hypokinesis .
The wall motion abnormalities were noted to be new .
It was believed that a troponin on admission in addition to the wall motion abnormalities she underwent a non-Q wave myocardial infarction prior to resulted in her current cardiac failure .
Throughout hospital course patient 's troponin trended down to less than 0.3 .
Heart Failure Service was involved .
She was continued with aggressive diuresis .
She was started on _________ with excellent diuresis , however , her renal functioning worsening .
A cardiac catheterization was deferred until the renal issue could be resolved .
However , her creatinine continued to increase .
Diuresis was halted and without improvement in creatinine .
Renal was consulted .
A renal ultrasound was obtained .
It showed a right kidney size of 6.3 cm and a left kidney size of 8.4 cm .
Given her hypertension which was very difficult to control , it was felt that she had renal artery stenosis and thus she underwent MRA of the kidney which showed severe right renal artery stenosis at its origin .
There was also moderate to severe focal stenosis of the left renal artery approximately 1.3 cm from its origin .
Dr. ______________ consulted on the case .
She was transferred to the unit overnight to assess volume which was noted to be optimal .
On 05-25 she underwent catheterization and subsequent stenting of the left renal artery .
Due to dye load required to assess the coronary disease were not visualized .
After the procedure the patient did well .
However , her creatinine has worsened up to 4.2 .
However , her urine output has improved .
She has not required hemodialysis at this time .
She will need close follow up of her renal functioning .
The patient is discharged to an extended discharge facility . | [
{
"text": "2010-05-17",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "2010-05-17",
"mod": "NA"
},
{
"text": "overnight",
"start_char": 2440,
"end_char": 2449,
"id": "T6",
"type": "DURATION",
"val": "PT12H",
"mod": "NA"
},
{
... | null | null | null |
411 | Admission Date :
02/08/1990
Discharge Date :
02/13/1990
HISTORY OF PRESENT ILLNESS :
The patient is a 43-year-old gravida II para II white female referred by Dr. Ca Shuff for evaluation .
She was in her usual state of good health until December when she was seen emergently for treatment of a perforated colon cancer .
That area was resected with no evidence of metastatic disease .
She has had subsequent CEA's and scans which were negative .
A tumor was noted on her vulva which was biopsied and revealed squamous cell carcinoma in situ .
ALLERGIES :
NO KNOWN DRUG ALLERGIES .
MEDICATIONS :
None .
PAST SURGICAL HISTORY :
As above with colostomy .
HOSPITAL COURSE :
The plan was for right radical vulvectomy .
1. Vulvectomy :
The patient on 2/8/90 underwent a right radical vulvectomy with excellent results and negative margins on frozen section .
Her postoperative course was unremarkble .
She was kept on bedrest for two days and then was ambulating and voiding well without trouble on postoperative day number three when the Foley catheter was discontinued .
She has been doing Betadine paint and blow drying the area several times a day and after each bowel movement and urine without incident . | [
{
"text": "several times a day",
"start_char": 1130,
"end_char": 1149,
"id": "T6",
"type": "FREQUENCY",
"val": "RPT6H",
"mod": "APPROX"
},
{
"text": "02/08/1990",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1990-02-08",
"mod": "NA... | null | null | null |
388 | Admission Date :
04/21/1994
Discharge Date :
04/29/1994
HISTORY OF PRESENT ILLNESS :
Patient is an 88 year old female with fatigue and decreased short term memory for the past six months .
The past six weeks , she has also been complaining of hot sensation and tingling sensation in the hands bilaterally .
For the past five weeks , the patient has experienced dragging of the right leg with weakness throughout that side .
Head CT was done which patient reported demonstrated three lesions in the left parietal region of the brain .
Bone scan , CT of the abdomen , chest X-Ray , and mammogram were all negative .
Patient noted the foot dragging to have worsened over the past few weeks but improved since on Decadron the past week before admission .
Patient is now admitted for elective left parietal stereotactic biopsy of the tumor .
PAST MEDICAL / SURGICAL HISTORY :
Significant for a history of hypertension , basal cell carcinoma of the nose six years ago , cataracts , and a hysterectomy .
ALLERGIES :
No known drug allergies .
CURRENT MEDICATIONS :
Hydrochlorothiazide 25 mg q.d. and Decadron 25 mg b.i.d.
HOSPITAL COURSE :
Patient was taken to the Operating Room on April 21 where patient underwent a left parietal stereotactic guided brain biopsy .
Patient tolerated the procedure well without any complications and was taken to the Recovery Room awake and stable then subsequently transferred to the floor .
Patient did well post-operatively , continued to have a right sided deficit , and Physical Therapy and Occupational Therapy visited the patient , worked with the patient , and determined that patient needed rehabilitation with Physical Therapy .
The patient was evaluated by Doing and was subsequently accepted into that program .
Patient is now discharged to Harl Wa Healthcare Network on April 29 , 1994 in stable condition . | [
{
"text": "q.d.",
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"end_char": 1105,
"id": "T7",
"type": "FREQUENCY",
"val": "RP1D",
"mod": "NA"
},
{
"text": "b.i.d.",
"start_char": 1125,
"end_char": 1131,
"id": "T8",
"type": "FREQUENCY",
"val": "RPT12H",
"mod": "NA"
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{
"tex... | null | null | null |
203 | Admission Date :
2015-11-09
Discharge Date :
2015-11-16
Service :
CMED CCU
HISTORY OF PRESENT ILLNESS :
Baby girl Fritsche is the 1670 gram product of a 31 and 06-17 week gestation born to a 34 - year-old G2 P1 now 2 woman .
Fetal screens , O positive , antibody negative , RPR nonreactive , rubella immune , hepatitis surface antigen negative , GBS unknown .
IVF pregnancy complicated by IUGR , 2 vessel cord , normal fetal echo reverse diastolic flow and demise of twin A at 27 weeks .
Twin B with normal fetal survey was transferred to Boston Medical Center at 26 and 2/7 weeks with IUGR of twin A was first noted , presented with preterm labor at 31 weeks .
Betamethasone complete at approximately 26 weeks and 31 weeks .
Mother was on clindamycin since 11-04 .
PPROM with bleeding and transverse lie prompted cesarean section .
Abruption noted .
Apgars were 6 and 9 .
HOSPITAL COURSE :
Respiratory .
Mills was admitted to the newborn intensive care unit with moderate respiratory distress .
Infant placed on CPAP .
X-ray revealed mild respiratory distress syndrome .
She remained on CPAP for a total of 24 hours at which time she transitioned to room air and continues to be stable in room air .
Caffeine citrate was initiated on 11-14 for apnea and bradycardia of prematurity .
She is currently receiving 11 mg po every day .
Cardiovascular .
Has been cardiovascular stable throughout hospital course .
Heart ranges 130 s to 160 s.
Blood pressure most recently 60/37 with a mean of 44 .
Fluid and electrolyte .
Birth weight was 1670 grams 50 th percentile , length 43 cm 50 th percentile .
Head circumference not done .
Infant was initially started on 80 cc per kilo per day of D10W .
Enteral feedings were initiated on day of life #1 .
Infant achieved full enteral feedings by day of life 6 .
She is currently receiving 150 cc per kilo per day of Special Care 20 .
Her discharge weight is 1477 gm .
Her most recent set of electrolytes were on 2015-11-13 with a sodium of 143 , a potassium of 6.3 hemolyzed , a chloride of 113 and a total CO2 of 17 .
She will need advance calorie density for better growth .
GI . Bilirubin peaked on day of life #2 of 9.0 / 0.3 .
Infant is under phototherapy , which was discontinued on 11-13 .
Most recent bilirubin was on 11-14 of 4.8 / 0.3 .
Hematology .
Hematocrit on admission was 53.7 .
She has not required any blood transfusions .
Infectious disease .
A CBC and blood culture obtained on admission .
CBC had a white blood cell count of 9 , 17 polys , 0 bands , platelets of 326 .
She received 48 hours of ampicillin and gentamycin with negative blood cultures and antibiotics were discontinued .
Neurological .
She has been appropriate for gestational age .
Head ultrasound was performed on 2015-11-16 and was normal .
Sensory , hearing screen has not yet been performed , but should be done prior to discharge . | [
{
"text": "24 hours",
"start_char": 1109,
"end_char": 1117,
"id": "T12",
"type": "DURATION",
"val": "PT24H",
"mod": "NA"
},
{
"text": "11-14",
"start_char": 1236,
"end_char": 1241,
"id": "T13",
"type": "DATE",
"val": "2015-11-14",
"mod": "NA"
},
{
... | null | null | null |
571 | ADMISSION DATE :
06-30-93
DISCHARGE DATE :
07-06-93
HISTORY OF PRESENT ILLNESS :
The patient is a 67 year old white male with a recent history of urinary frequency Q2-3H , stranguria , nocturia x 3-4 per night .
He was found on physical exam to have an asymmetric prostate with prominence on the left and a question of a nodule .
Repeat exam one month later showed a firm left-sided lobe .
Transrectal ultrasound showed a hypoechoic left-sided mass in the peripheral zone .
A biopsy showed moderately to poorly differentiated Grade III-IV adenocarcinoma on the left .
The right lobe was within normal limits .
This was done on 05/05/93 at FIH .
He also had a 3-4 year history of impotence .
HOSPITAL COURSE :
The patient was brought to the operating room on 06/30/93 after informed consent was obtained .
A radical retropubic prostatectomy with bilateral lymph node dissection was done .
He was afebrile postoperatively with vital signs stable .
His potassium was 3.7 and his hematocrit 33 .
His postoperative course was remarkable for a low grade temperature to 101.7 .
His blood cultures and chest X-ray were negative .
He had flatus on postoperative day # 3 .
His Jackson-Pratt drained about 35-40 cc per day and was discontinued on postoperative day # 3 .
His hematocrit on 07/03 was 28.1 .
On that day he was slightly diaphoretic with some tachycardia to 100 .
The remaining unit of autologous packed red blood cells was transfused .
A cardiology consult was obtained for this episode of diaphoresis with tachycardia , as well as for an EKG being read as having anterolateral changes .
He had no symptoms of chest pain or myocardial ischemia .
A repeat EKG showed no changes .
He subsequently did well , with a repeat hematocrit of 34.3 after the transfusion .
His creatinine was 1.2 on postoperative day # 5 .
On postoperative day # 6 his low grade temperature resolved .
His vital signs were stable .
He was discharged home on Percocet and Keflex .
He was discharged in good condition .
He will follow up with Dr. Iechalette Cancer in his office .
SIE ROOM , M.D. | [
{
"text": "postoperative day # 3",
"start_char": 1140,
"end_char": 1161,
"id": "T9",
"type": "DATE",
"val": "1993-07-02",
"mod": "NA"
},
{
"text": "postoperative day # 3",
"start_char": 1237,
"end_char": 1258,
"id": "T10",
"type": "DATE",
"val": "1993-07-02",
... | null | null | null |
216 | ADMISSION DATE :
5/14/92
DISCHARGE DATE :
5/19/92
DISCHARGE DATE :
5/19/92
HISTORY OF PRESENT ILLNESS :
The patient is a 71 year old white female with metastatic ovarian carcinoma , who recently underwent an exploratory laparotomy on 5/2 by Dr. Korcblinknud .
She was found to have widely metastatic ovarian carcinoma .
There was sigmoid narrowing near a large left ovarian mass , and distal ileal narrowing by a right ovarian mass .
The patient had an ileostomy performed and had had her first course of chemotherapy and later debulking operation by Dr. Median .
She was well at home until 8:30 p.m. on the day of admission , when she developed acute onset of right foot pain , which was worse with walking .
She complained of increased numbness of the right foot over time , and was seen at Sephsandpot Center , where she was found to have palpable right femoral and popliteal pulses , and no pedal pulses .
The patient was transferred to the Fairm of Ijordcompmac Hospital .
She had previous history of claudication .
HOSPITAL COURSE :
ON 5/14/92 , the patient received an arteriogram which demonstrated an embolus in the right profunda / femoral artery .
There was an occlusion in the proximal calf , of the peroneal and anterior tibial arteries .
There was an occlusion of posterior tibial artery at the ankle .
She was taken urgently to the operating room , where she underwent embolectomy of the profunda superficial femoral vessels .
The estimated blood loss was 200 cc. and she tolerated the procedure well .
Postoperatively , she was again noted to have a cold right lower extremity with diminished pulses and was again taken to the operating room , where she underwent a right popliteal exploration and thrombectomy .
She again tolerated the procedure well and did well postoperatively .
On 5/19 , she had an echocardiogram done which was to be evaluated as an out patient .
By discharge she was walking and taking PO's without problem . | [
{
"text": "5/14/92",
"start_char": 1043,
"end_char": 1050,
"id": "T5",
"type": "DATE",
"val": "1992-05-14",
"mod": "NA"
},
{
"text": "5/14/92",
"start_char": 18,
"end_char": 25,
"id": "T0",
"type": "DATE",
"val": "1992-05-14",
"mod": "NA"
},
{
"tex... | null | null | null |
438 | ADMISSION DATE :
06-22-93
DISCHARGE DATE :
06-27-93
HISTORY OF PRESENT ILLNESS :
Mrs. Cast is a 50 year old white female with a history of chronic obstructive pulmonary disease and evidence of severe lobular emphysema , who has progressive shortness of breath and inability to carry on with activities of daily living without assistance .
She was admitted to the hospital for a pre lung transplant evaluation .
The patient has been steroid dependent for two years and has been intubated in the past only once for a surgical repair of trigeminal neuralgia .
Her previous occupation was an executive secretary , home trainer / nurse , rental aide .
She has no history of asbestos exposure or tuberculosis exposure .
HOSPITAL COURSE :
The patient was seen in consultation by a variety of consultants including Infectious Disease , Cardiology , Endocrine , Psychiatry , ENT , and Neuro-ophthalmology .
She was noted to have mild cataracts , possibly due to chronic steroids , as well as a subtle temporal disc pallor OD , possibly due to previous episode of optic neuritis .
No acute pathology was noted and no treatment was necessary at this time .
Dr. Koteelks indicated that the patient did not have sinus problems currently but thought that the trigeminal pain might be investigated further and that the sphenoid might account for some of the patient 's discomfort .
If so , he considers the possibility that this could be opened .
This is left for further follow up as an outpatient .
Dr. Tikkerth felt that the patient had mild adjustment related anxiety under good control with a history of tobacco abuse in the past .
The patient completed the studies and to be informed of the results as an outpatient .
She knows to return to her local physician for her routine care with her condition unchanged at the time of discharge .
I L. STERPSKOLK , M.D.
TR :
bg / bmot
DD :
09-08-93
TD :
09/09/93
CC : | [
{
"text": "this time",
"start_char": 1135,
"end_char": 1144,
"id": "T4",
"type": "DATE",
"val": "1993-06-27",
"mod": "NA"
},
{
"text": "06-22-93",
"start_char": 18,
"end_char": 26,
"id": "T1",
"type": "DATE",
"val": "1993-06-22",
"mod": "NA"
},
{
"... | null | null | null |
362 | Admission Date :
2017-05-08
Discharge Date :
2017-05-16
Service :
CARDIOTHORACIC
History of Present Illness :
Mr. Williams is an 85 yo gentleman who has a known cardiac history and has had a h/o worsening chest pain and shortness of breath .
He had an echocardiogram which showed an EF 40-45% and severe aortic stenosis .
He underwent cardiac catheterization which showed an 80% LAD lesion , chronically occluded RCA , anneurysmal mid LCX w/50% lesion .
He was refered to Dr. Barber for surgical treatment .
Brief Hospital Course :
Mr. Williams was admitted to Hallmark Health System on 05-08 and taken to the operating room with Dr. Barber for a CABGx2 and AVR w/ 25 mm pericardial valve .
Please see operative note for full details .
He was transfered to the ICU in stable condition .
He was weaned and extubated from mechanical ventillation on POD#1 without difficulty .
He was transfered to the regular part of the hospital on POD#2 , where he began working with physical therapy .
He developed atrial fibrillation on POD#2 with well controlled rate and hemodynamically stable .
He was started on heparin and coumadin for anticoagulation on POD#5 .
On POD#7 he was cleared for discharge to home by physical therapy and on POD#8 he was discharged . | [
{
"text": "POD#2",
"start_char": 1023,
"end_char": 1028,
"id": "T8",
"type": "DATE",
"val": "2017-08-10",
"mod": "NA"
},
{
"text": "POD#5",
"start_char": 1146,
"end_char": 1151,
"id": "T5",
"type": "DATE",
"val": "2017-05-13",
"mod": "NA"
},
{
"tex... | null | null | null |
376 | ADMISSION DATE :
05/08/95
DISCHARGE DATE :
05/14/95
HISTORY OF PRESENT ILLNESS :
The patient is a 72-year-old right-handed gentleman with a history of coronary artery disease status post myocardial infarction in 1984 .
Also with a history of noninsulin dependent diabetes mellitus , now presenting with acute blurry vision on the left side , which is homonymous .
The patient woke up as usual on May 8 , 1995 .
At 8 a.m. the patient was looking at his wife with the background outside a large window .
The patient had sudden onset of blurred vision , where the right side of his wife 's face looked blurred .
The patient did not notice change of vision in the background .
The blurred vision was homonymous , which he had blurred in each eye in the left visual field .
The same blurred vision was also noticed later when the patient was watching television and also when he was reading .
The patient was seen at the Ochtuheihugh Put University Medical Center and then he was referred to the Purckecation Balpoingdelt Pabarnes- Campa Memorial Hospital .
At 8 p.m. the patient seen at the Purckecation Balpoingdelt Pabarnes- Campa Memorial Hospital and was examined and assessed .
The patient was referred to Ph University Of Medical Center for rule out transient ischemic attack and rule out stroke .
The patient denies any nausea , vomiting , ataxia , motor deficits , speech deficits or sensory deficits .
The patient lightly bumped his head on the top three times on the previous night and the patient had frontal headaches and a tight neck .
One hour after he had physical activity on the previously night as well .
ALLERGIES :
The patient denies any drug allergies .
HOSPITAL COURSE :
The patient was admitted with a right occipital cerebral infarction .
The patient was started on intravenous heparin and had the studies as described above for rule out source of embolic strokes including carotid noninvasives , transcranial Dopplers , Holter electrocardiogram and echocardiogram .
The patient also had serial electrocardiogram , which showed no change .
The patient also had serial creatinine kinase with MB fractions studied , which revealed MB fraction too low to be tested .
The patient also experienced a feeling of moving back and forth when lying down with neck extended during the magnetic resonance imaging study and also in bed .
This moving sense , with normal electroencephalogram , was thought to be a mild vestibular dysfunction or from the acute episode of the stroke .
The patient will have these symptoms only when the eyes are closed .
Our opinion was not to intervene or have any further studies for acute period and to continued to observe .
The patient did have a hypotensive episode and the systolic blood pressure was 80 , after the patient received his regular cardiac medications .
The patient had been off his regular medications since during the admission and will be discharged off his medications .
Otherwise , there were no further episodes of blurred vision .
The patient was stable with an unchanged neurological and physical examination and was discharged on aspirin 325 mg po qd , on May 14 , 1995 .
The patient will be randomized on the Wars study early next week by the Stroke Service at Ph University Of Medical Center . | [
{
"text": "8 p.m.",
"start_char": 1062,
"end_char": 1068,
"id": "T7",
"type": "TIME",
"val": "1995-05-08T20:00",
"mod": "NA"
},
{
"text": "three times",
"start_char": 1460,
"end_char": 1471,
"id": "T8",
"type": "FREQUENCY",
"val": "R3",
"mod": "NA"
},
... | null | null | null |
612 | Admission Date :
2014-08-07
Discharge Date :
2014-08-09
Service :
NEUROSURG
HISTORY OF PRESENT ILLNESS :
This is a 56 - year-old man without any significant past medical history who presented to the emergency room after the sudden onset of headache while he was riding a bicycle .
He characterized this headache as the worst headache of his life and had associated nausea and vomiting times one .
He also complained of dizziness at the time of headache onset .
He presented to the Edith Nourse Rogers Memorial VA Hospital emergency room , where an initial head CT scan was read as negative .
However , a lumbar puncture was done , in which tube 1 showed 4800 red blood cells and tube 4 showed 4000 red blood cells .
The patient was sent for an MRI of the head , which raised the question of a right posterior cerebral artery aneurysm .
The CT scan was revealed and , on second analysis , it was thought that it was suspicious for a subarachnoid hemorrhage in the suprasellar cistern .
The patient was then admitted for further evaluation .
HOSPITAL COURSE :
The patient was admitted to the surgical intensive care unit , where a continued cerebral angiogram was done that was essentially normal , without evidence of any obvious aneurysm .
The patient was observed for two days with a repeat CT scan showing no changes from the previous examination .
The headache stabilized after the patient was transferred to the floor .
The patient continued to do well and the decision was made to discharge him . | [
{
"text": "two days",
"start_char": 1270,
"end_char": 1278,
"id": "T3",
"type": "DURATION",
"val": "P2D",
"mod": "NA"
},
{
"text": "2014-08-07",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "2014-08-07",
"mod": "NA"
},
{
"te... | null | null | null |
602 | Admission Date :
2011-06-10
Discharge Date :
2011-06-13
Service :
CMED CSRU
HISTORY OF PRESENT ILLNESS :
This is a 35-year-old gentleman with HIV on HAART with last CD4 count of 268 and undetectable viral load who was referred to the emergency room via his PCP for progressive throat pain and edema .
His throat pain began 2 to 3 days prior to admission , initially treated with ibuprofen , seen in an outside hospital emergency room day prior to admission where he received IV penicillin and was sent home .
In clinic today , the patient desaturated to low 90 s with ambulation and also had complaints of progressive swelling " like my throat is going to close up " with increasing drooling , unable to swallow the HIV medications .
Also noted to have low-grade temperature of 99 to 100 degrees with productive cough and yellow sputum times 1 day with
right ear pain .
No subjective shortness of breath .
The patient describes whole body numbness .
He currently notes improvement in his throat pain after some Decadron and clindamycin .
He was seen by CMED CSRU in the emergency room and the exam was consistent with supraglottitis .
REVIEW OF SYSTEMS :
Review of systems was negative for history of opportunistic infections or prior hospitalizations .
Of note , his CD4 count was less than 200 last winter .
He believes he is up-to-date on all his vaccines .
HOSPITAL COURSE :
This is a 35-year-old gentleman with HIV on HAART , last CD4 count 268 with undetectable viral load who was initially admitted to the CMED CSRU for supraglottitis with significant edema .
PROBLEM LIST :
1. Epiglottitis / supraglottitis .
The patient was observed in the CMED CSRU for 48 hours and noted to have decrease in swelling on serial exams .
He was followed by the CMED CSRU Service and was started on IV Decadron initially in addition to IV Unasyn , which he tolerated well .
His edema was improving and was starting to tolerate p.o.
His airway and symptoms continued to improve and remained stable .
The patient was stable for transfer to the floor , was treated with over 72 hours of IV Unasyn , and then transitioned to oral regimen of Augmentin to be continued as an outpatient .
Eventually , his IV steroids were transitioned to a p.o. steroid taper , which he tolerated well , and was discharged on a steroid taper also with CMED CSRU follow-up as an outpatient .
His oxygenation and symptoms remained stable and again tolerated p.o. without difficulty .
Eventually , as the patient remained hemodynamically stable , his airway remained stable , and he was tolerating PO s, he was transitioned to the floor where he remained otherwise stable and asymptomatic .
His voice improved during the course of his stay and was talking clearly by the time of discharge .
He remained afebrile during the course of his stay after transfer to the floor and per CMED CSRU was to be discharged on a 2-week course of Augmentin with follow-up with Dr. Thibodeau in 2 weeks ' time in addition to a Medrol Dosepak .
1. HIV .
Once , the patient was tolerating p.o. , the patient was restarted on his HAART regimen and remained stable from that perspective . | [
{
"text": "last winter",
"start_char": 1297,
"end_char": 1308,
"id": "T6",
"type": "DATE",
"val": "2010",
"mod": "END"
},
{
"text": "48 hours",
"start_char": 1664,
"end_char": 1672,
"id": "T7",
"type": "DURATION",
"val": "p48h",
"mod": "NA"
},
{
"t... | null | null | null |
366 | Admission Date :
01/11/1996
Discharge Date :
01/19/1996
HISTORY OF PRESENT ILLNESS :
Ms. Less is a 79 year old white female with history of non small cell lung cancer diagnosed in 02/95 .
She underwent a resection for stage I in 10/95 and treated with XRT .
She presented to the hospital with a numb right leg this morning and underwent an emergent embolectomy . | [
{
"text": "01/11/1996",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "1996-01-11",
"mod": "NA"
},
{
"text": "02/95",
"start_char": 181,
"end_char": 186,
"id": "T3",
"type": "DATE",
"val": "1995-02",
"mod": "NA"
},
{
"text": ... | null | null | null |
212 | Admission Date :
2017-06-28
Discharge Date :
2017-07-02
Service :
CMED CCU
HISTORY OF PRESENT ILLNESS :
A 40-year-old female with history of non-ST-elevation myocardial infarction in 2016-09-30 with stent to the LAD and 50% to the mid LAD , had instent restenosis in 2017-04-02 and then underwent brachytherapy to the RCA , who presented to Baldpate Hospital with several weeks of chest pain similar to her anginal equivalent and MI in the past .
It started at rest .
No relief with nitroglycerin x3 .
Radiates to the left arm .
Positive shortness of breath .
Troponins have been less than 0.01.
With history , will go for cardiac catheterization evaluation .
Still getting chest pain intermittently , but relieved by morphine sulfate .
Was on a Heparin and nitroglycerin drip with only intermittent relief .
HOSPITAL COURSE:
1. Chest pain :
The patient ruled out for myocardial infarction .
However , with her history of disease , patient underwent a cardiac catheterization .
The patient was found at cardiac catheterization to have mild diffuse instent restenosis in the mid stent , otherwise hemodynamically normal and the coronary arteries otherwise were without flow-limiting stenoses .
The patient was then continued on her cardiac medications .
It was felt that if we attempted aspirin desensitize her while an inpatient , then she would benefit from the use of aspirin and Plavix .
The patient was sent to the CCU and underwent aspirin desensitization protocol , which she tolerated well .
She had mild worsening of her asthma attacks , which was relieved by Benadryl and occasionally albuterol .
The patient found that if she took the aspirin in the evening with her Benadryl that she takes for sleep , that the asthma exacerbation did not occur .
Aspirin no longer should be considered an allergy for this patient , and she is going to take this as an outpatient .
2. Hyperlipidemia :
The patient 's Lipitor was increased to 80 mg q.d.
3. Back pain :
This is a chronic issue and was controlled with Flexeril and Vicodin . | [
{
"text": "2017-06-28",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "2017-06-28",
"mod": "NA"
},
{
"text": "2016-09-30",
"start_char": 184,
"end_char": 194,
"id": "T3",
"type": "DATE",
"val": "2016-09-30",
"mod": "NA"
},
{
... | null | null | null |
776 | Admission Date :
02/08/1991
Discharge Date :
02/18/1991
HISTORY OF PRESENT ILLNESS :
Mr. Breutzfarstxei is a 30 year old man with recently diagnosed acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia who presented with pneumonia , developed adult respiratory distress syndrome , and died in the hospital after failed efforts of ventilatory support .
Mr. Breutzfarstxei was recently diagnosed with acquired immunodeficiency syndrome when he had Pneumocystis carinii pneumonia on 01/17/91 .
He was admitted to the Retelk County Medical Center at that time and was treated with Bactrim and steroids .
He was actually intubated and underwent bronchoscopy where the diagnosis was made with a positive toluidine blue study .
He initially did well after extubation and completed approximately two weeks of Bactrim and a steroid taper .
At discharge after about two weeks post-extubation , he had an O2 saturation of approximately 95% on room air .
He was seen by Dr. Seen and Dr. Seen as an out-patient .
On 02/06/91 , he was seen in FLFDMC and at that point , his temperature was noted to be 101.4 and he had malaise and diarrhea .
He was evaluated in the Emergency Room .
At that time , his oxygen saturation was only 90% on room air and his chest X-Ray showed no change .
Cultures were taken and he was sent out .
On 02/08/91 , the patient called Dr. Seen because of increased shortness of breath and malaise .
He was seen in FLFDMC where he was noted to have jaundice and newly palpable liver edge .
Review of liver function tests revealed a cholestatic picture which was not previously found and it was felt that this was secondary to the Bactrim which had been recently stopped anyway .
His oxygen saturation at that time was only 86% on room air and he was admitted .
HOSPITAL COURSE :
The patient was admitted for work-up of his cholestatic jaundice picture along with work-up for his pulmonary process and treatment of both .
In terms of pulmonary function , it was felt that one possibility was that the patient was a Bactrim failure for PCP although this was unusual .
He was started on Pentamidine , especially in light of the fact that it was felt that his liver function tests were due possibly to Bactrim .
The patient was also covered with Erythromycin and Gentamicin for coverage of community acquired pneumonias and gram negative rods .
He was given supplemental oxygen .
In terms of his liver abnormalities , it was felt that viral hepatitis was in the differential as well as several opportunistic infections of the liver but also was felt that Bactrim could be a cause of these abnormalities .
Titers for CMV and Epstein-Barr virus were sent and a titer for toxoplasma was sent .
Stool was sent for ova and parasites .
Gastrointestinal was consulted .
Initially , the patient did well in terms of his pre-status and required less oxygen .
However , on 02/10/91 , his respiratory rate increased and his oxygen saturation decreased .
Actually in reviewing the records at this point , it appears that Pentamidine was not started initially so on the antibiotics of Erythromycin and Gentamicin , the patient 's respiratory status worsened and his LDH climbed so he began Pentamidine on 02/10/91 .
On 02/11/91 , the patient again appeared more comfortable this time with 50% facemask but then required more oxygen , dropped his O2 saturations , and was intubated on 02/11/91 .
He was transferred to the Intensive Care Unit on 12/12/90 on Gentamicin , Vancomycin , Pentamidine , and Prednisone .
Also of note at that point , hepatitis C virus serologies had come back positive .
However , at this point , his liver function test abnormalities appeared more consistent with a cholestatic picture with his direct bilirubin being 12.1 and total being 14.1 .
The patient 's abdominal CT scan showed no liver disease and no obstruction .
The patient 's liver function tests appeared to improve .
The patient 's penile ulcer was cultured and grew positive herpes simplex virus and the patient was started on Acyclovir .
On 02/13/91 , the patient had a bronchoalveolar lavage performed which showed a toluidine blue with many pneumocysts noted .
No other cultures grew out and the patient 's clinical status deteriorated .
The patient required 100% oxygen to maintain adequate oxygen saturations on the ventilator .
He required elevated ventilatory pressures with PIPS often above 60 .
Fortunately , no evidence of baratroma was ever discerned .
However , the patient 's respiratory status continued to decline and we were unable to maintain oxygen saturations above 80% even using reverse I to E ventilation , paralysis , sedation , and other modes of ventilation .
Patient underwent liver biopsy on 02/16/91 and the results of this were pending when the patient died .
The patient actually developed decreasing counts with white count as low as 1.75 , hematocrit as low as 26 , and platelets as low as 68 noted on 02/15/91 .
These were supported with blood products and Hematology was consulted .
They felt that it was most likely secondary to Bactrim and these actually were getting better when the patient died .
Bone marrow biopsy was not attempted .
Discussions were begun with the family regarding limits of supportive care .
Due to continued worsening pulmonary status and an overall grim prognosis , the family decided , in consultation with the Medical Team , to withdraw ventilatory support .
This was done on the evening of 02/18/91 .
Patient expired after the endotracheal tube was withdrawn at 6:40 p.m. | [
{
"text": "02/06/91",
"start_char": 1021,
"end_char": 1029,
"id": "T4",
"type": "DATE",
"val": "1991-02-06",
"mod": "NA"
},
{
"text": "that time",
"start_char": 1190,
"end_char": 1199,
"id": "T14",
"type": "DATE",
"val": "1991-02-06",
"mod": "NA"
},
{
... | null | null | null |
777 | Admission Date :
2018-05-24
Discharge Date :
2018-05-29
Service :
CARDIOTHORACIC
History of Present Illness :
s/p AVR 05-14 .
Postop course c/b right upper extremity DVT and postop Afib .
Discharged home 05-19 with instructions to f/u in vascular clinic .
Had vascular clinic f/u on day of admission .
At that time had UE duplex which revealed RUE DVT involving IJ , Axillary , subclav , brachial , and basilic veins .
Then referred to ER for Tx
Brief Hospital Course :
Pt admitted 05-24 from ER after positive RUE DVT finding in vascular lab .
During ER evaluation pt was noted to have some degree of dyspnea as well as mental status changes , including loss of short term memory and brief unresponsive period after one dose of IV Benadry and steroids prior to CT scan .
The CT was negative for CVA but positive for Pulmonary embolism .
He was transferred to CSRU for evaluation .
Neurology was consulted and the pt also had MRI which was negative .
The pt was begun on heparin gtt and was noted to have platelet drop > 50% after infusion began , hepain was d/c 'd.
Argatroban was started abd a HIT panel was sent , HIT panel was positive .
Hematology was consulted .
By the following mornig all mental status changes had cleared and the pt was transferred to the floors for continued care .
Over the next several days the patient was maintained on Argatroban when coumadin therapy was initiated .
On HD#6 the pt had a therapeudic INR ( 4.4 ) off Argatroban and wad discharged home .
He was to have f/u INR check with Dr Lewis on 05-31 .
Additionally the pt should f/u with the hematology clinic . | [
{
"text": "the following mornig",
"start_char": 1173,
"end_char": 1193,
"id": "T8",
"type": "DATE",
"val": "2018-05-25",
"mod": "START"
},
{
"text": "05-14",
"start_char": 119,
"end_char": 124,
"id": "T3",
"type": "DATE",
"val": "2018-05-14",
"mod": "NA"
... | null | null | null |
213 | Admission Date :
2016-07-18
Discharge Date :
2016-07-21
Service :
MEDICINE
History of Present Illness :
46 - yo-man w/ active cocaine use presents w/ LE edema .
10 days ago , he developed b/l LE edema that has gotten progressively worse until now .
Three days ago , he developed dyspnea on exertion when climbing stairs , assoc w/ 2-pillow orthopnea and PND .
He denies any recent chest pain , palpitations , headache , confusion , weakness , numbness , abd pain , or hematuria .
No recent viral syndromes or URI s.
He does admit to cocaine use last night .
Today , his wife convinced him to present to the Deanna for evaluation .
In the Deanna , his BP was 230/170 .
BNP was elevated at 7500 .
CXR revealed evidence of cardiomegaly and pulm edema .
He was treated w/ ASA 325 mg , lasix 10 mg IV , and hydralazine 10 mg IV x 2 .
He responded well to lasix w/ good UOP , but diastolic BP remained elevated at 170 , prompting initiation of nitroprusside gtt .
He is now admitted to the CCU for further care .
Brief Hospital Course :
46 - yo-man w/ cocaine abuse presents w/ LE edema and DOE likely from diastolic heart failure in the setting of cocaine use complicated by hypertensive urgency .
Hypertensive urgency :
BP 230/170 on presentation , most likely from chronic HTN exacerbated by cocaine use .
No signs of end-organ damage at present except for elevated creatinine , which is more likely a chronic problem .
The patient was started on labetalol and Lisinopril .
His blood pressure was taken down from 230 systolic to approx 160 systolic / 100 diastolic on discharge .
His lower extremity edema improved with diuresis .
An echo performed on admission showed an LF EF of 25% .
It is hoped with good blood pressure control and use of an ACE-I with follow up in addition to cocaine abstaining will improved his cardiac function .
Renal Failure : creatinine on admission was 1.6 Likely acute hypertensive nephropathy plus probalbe long-standing hypertensive disease .
discharged on ACE-I .
Substance Use : Social work saw patient and counceled him regarding substance abuse .
Discharged with Margaret Hallock , cardiology follow up as well as scheduled appointment with a new PCP @ Newton Health Center . | [
{
"text": "10 days ago",
"start_char": 162,
"end_char": 173,
"id": "T2",
"type": "DATE",
"val": "2016-07-08",
"mod": "NA"
},
{
"text": "2016-07-18",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2016-07-18",
"mod": "NA"
},
{
... | null | null | null |
367 | Admission Date :
2013-10-21
Discharge Date :
2013-10-31
Service :
CARDIOTHORACIC
History of Present Illness :
This is an 85 year old female with prior history of non-hodgkins lymphoma , s/p Cytoxan in 2003 a with recurrence in 2009 .
Follow up examinations have found a suspicious left lower lobe finding .
Cardiac workup prior to left lower lobe resection led to cardiac catheterization which found severe three vessel disease with 04-05+ mitral regurgitation .
She now present for surgical intervention .
Brief Hospital Course :
Mrs. Mandelbaum was admitted and underwent three vessel coronary artery bypass grafting by Dr. Larry Mckinney .
Of note , intraoperative transesophageal echocardiogram evaluation showed only mild mitral regurgitation , so no repair/replacement was indicated .
Following the operation , she was brought to the CSRU .
On postoperative day one , she was noted to be largely unresponsive with left hemiparesis .
Restlessness with body tremors were also noted .
A stat MRI was notable for multiple abnormal foci consistent with systemic emboli .
These were found in the right cerebellar , occipital and anterior parietal lobes .
The neurology service was consulted and attributed these findings to cholesterol emboli .
Due to seizure activity , Dilantin was started .
Anticoagulation was not recommended .
Over the next several days , her neurological status slowly improved .
She was eventually extubated without incident .
She went on to experience paroxysmal atrial fibrillation which was initially treated with intravenous Amiodarone .
She concomitantly had loose stools which were C. diff negative .
Her clinical status stablized and she transferred to the step down unit on postoperative day six .
She remained mostly in a normal sinus rhythm and transitioned to oral Amiodarone which will need to continue for three months postop .
She tolerated beta blockade which was slowly advanced as tolerated .
She worked daily with physical and occupational therapy .
Her neurological status continued to improve .
Acyclovir was eventually increased from her maintenance dose for a herpes zoster breakout on her right upper back .
In addition , she was empirically started on Flagyl for persistent diarrhea ( despite negative C. diff cultures ) , however she developed an additional rash on her buttocks after the first dose of flagyl , so the flagyl was discontinued .
She developed a urinary tract infection for which she was started on Bactrim .
A foley catheter was inserted given her mutiple episodes of incontinence that were adding to skin irritation .
On insertion she was found to be retaining 1400 cc of urine , so the foley catheter was left in .
She continued to make clinical improvements and was cleared for discharge to rehab on postoperative day 10 . | [
{
"text": "the next several days",
"start_char": 1338,
"end_char": 1359,
"id": "T6",
"type": "DURATION",
"val": "p3d",
"mod": "APPROX"
},
{
"text": "postoperative day six",
"start_char": 1707,
"end_char": 1728,
"id": "T7",
"type": "DATE",
"val": "2013-10-27",
... | null | null | null |
373 | ADMISSION DATE :
06/29/92
DISCHARGE DATE :
07/27/92
HISTORY OF PRESENT ILLNESS :
Mr. Villesatelkscurb is a fifty year old black gentleman with a long history of hepatitis C , believed to be contracted during transfusions in a previous trauma .
The patient had recently prior to this admission , had a rise in his alpha feta protein and a biopsy of his liver had shown hepatocellular carcinoma .
The patient was admitted for liver transplant workup and to await liver transplant .
PAST MEDICAL and
SURGICAL HISTORY :
Significant for motor vehicle accident in 1966 , requiring exploratory laparotomy and splenectomy , tonsillectomy as a child , pneumonia in the past , hepatitis C and recent diagnosis of hepatocellular carcinoma .
ADVERSE DRUG REACTIONS :
no known drug allergies .
MEDICATIONS ON ADMISSION :
On admission medications included Lasix and iron .
HOSPITAL COURSE :
Preoperatively , the patient underwent chemo-embolization for his hepatocellular carcinoma .
The remainder of his preoperative course was benign .
On July 15 , 1992 , a liver became available , and the patient underwent hepatectomy and orthotopic liver transplant .
His operation was complicated by severe coagulopathy requiring fifty-nine units of packed red blood cells , 64 units of FFP and 34 units of platelets .
Postoperatively , the patient continued to have a coagulopathy requiring re-exploration on postoperatively day 2 , with findings only of hematoma and no active bleeding .
Initially , the patient did well in the Intensive Care Unit , mentally alert , and oriented , however , he continued to be coagulopathic and was requiring large amounts of blood and FFP transfusions , with a resultant pulmonary edema .
He developed renal failure felt to be ATN secondary to ischemia of his kidneys .
The patient remained intubated in the Intensive Care Unit for twelve days prior to his death .
He had daily transfusions of FFP and blood , and continued coagulopathy .
He also developed thrombocytopenia , requiring persistent platelet transfusions on a daily basis .
His immunosuppression was OKT3 and Solu Medrol , and he underwent hemodialysis and ultra filtration to remove fluid .
While in the ICU he developed seizures , requiring large amounts of intravenous Valium to break his seizures , and he was maintained on Tegretol and Dilantin .
However , he became progressively more mentally obtunded .
During the seizure , he bit his tongue , resulting in a large bleed from his tongue , which was sutured by the ENT Service , however , his continued coagulopathy resulted in bleeding from his nasopharynx , which could never be identified , and also upper gastrointestinal bleeding .
Endoscopy never revealed specific sources of bleeding , although he appeared to have a diffuse duodenitis .
He was started on Pitressin to try to control the gastrointestinal bleeding , but he continued to have severe bleeding , and became progressively hypotensive , with eventual bradycardia and cardiac arrest .
He was pronounced dead at 3:49 PM on July 27 , 1992 . | [
{
"text": "July 15 , 1992",
"start_char": 1028,
"end_char": 1042,
"id": "T4",
"type": "DATE",
"val": "1992-07-15",
"mod": "NA"
},
{
"text": "postoperatively day 2",
"start_char": 1387,
"end_char": 1408,
"id": "T5",
"type": "DATE",
"val": "1992-07-17",
"mod... | null | null | null |
167 | Admission Date :
2019-06-25
Discharge Date :
2019-07-01
Service :
CARDIOTHORACIC
History of Present Illness :
69yoM with OA having workup for knee replacements found to be in Afib , had stress test that was positive followed by cardiac catheterization which revealed severe 3VD .
Then referred for CABG
Brief Hospital Course :
69 yo M with known Atrial fibrillation and coronary artery disease admitted preop for transition fro Coumadin to Heparin .
Brought to the OR on 06-26 for CABG , please see OR report for details .
In summary pt had off pump CABGx4 with LIMA-LAD , SVG OM-Y graft - Diag , SVG-PDA .
Pt tolerated surgery well and was transferred to CT CMED ICU .
He did well in immediate post-op period was extubated and on POD1 he was transferred to the step down floor .
On POD2 his chest tubes and epicardial pacing wires were removed and his Coumadin was restarted .
Over the next several days his activity was advanced on POD5 it was decided he was stable and ready to be discharged home with visiting nurses . | [
{
"text": "2019-06-25",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2019-06-25",
"mod": "NA"
},
{
"text": "2019-07-01",
"start_char": 46,
"end_char": 56,
"id": "T3",
"type": "DATE",
"val": "2019-07-01",
"mod": "NA"
},
{
"t... | null | null | null |
173 | Admission Date :
2009-05-01
Discharge Date :
Date of Birth :
Service :
Surgery
HISTORY OF PRESENT ILLNESS :
The patient is a 39 year-old gentleman admitted on 2009-05-01 to the Jewish Memorial Hospital referred from South Cove Community Health Center .
He is a 39 year-old gentleman with hyperlipidemia and smoking who presented with acute onset of chest pain since five in the morning with radiation to the left arm and nausea .
Symptoms resolved spontaneously .
He was taken to the Cath Lab at the Pinewood , Norfolk that evening where a stent procedure to the RCA was complicated by guidewire entrapment inside of a stent requiring CT surgery to do a thoracotomy with bypass and excision of the wire .
The case was complicated by an episode of coffee ground emesis and a bleed from femoral access site prior to CT surgery .
Gastroenterology was consulted and they recommended Protonix and felt it was due to peptic ulcer disease .
HOSPITAL COURSE :
The patient was diagnosed as having an acute myocardial infarction .
The patient was taken emergently to the operating room on 2009-05-02 for his CABG , right coronary endarterectomy , removal of RCA stents and retrieval of the aortic guidewire .
Postoperatively he did well and was transferred to the Cardiac Surgery Intensive Care Unit where he was on pressor support of Neo-Synephrine and he was extubated .
The patient slowly weaned off Neo-Synephrine as tolerated .
He was transferred to the floor on 2009-05-04 .
His chest tube had been discontinued .
Upon arrival to the floor the patient 's wires were discontinued on 2009-05-05 and his Foley catheter was discontinued .
The patient was seen by Physical Therapy .
His electrolytes were repleted and the patient was discharged home on 2009-05-06 after tolerating a level V .
MEDICATIONS : His prescriptions shall include
1. Lopressor 25 milligrams po bid .
2. Lipitor 20 milligrams po q HS .
3. Niferex 150 milligrams caplet one cap per day .
4. Protonix 40 milligrams po q day .
5. Colace 100 milligrams po bid .
6. Percocet one to two tablets q four H prn for pain .
He will get 60 of those .
7. Plavix 75 milligrams po q day times three months .
8. Aspirin 325 milligrams po q day .
9. Lasix 20 milligrams po times 30 days .
10. KCL 20 milliequivalents po q d times three days . | [
{
"text": "2009-05-02",
"start_char": 1080,
"end_char": 1090,
"id": "T4",
"type": "DATE",
"val": "2009-05-02",
"mod": "NA"
},
{
"text": "2009-05-04",
"start_char": 1459,
"end_char": 1469,
"id": "T5",
"type": "DATE",
"val": "2009-05-04",
"mod": "NA"
},
... | null | null | null |
72 | Admission Date :
06/26/2004
Discharge Date :
07/08/2004
HISTORY OF PRESENT ILLNESS :
The patient is a 38-year-old gentleman , Spanish-speaking , from the Taheimpromong , with no significant past medical history , who presents with shortness of breath x 2 months as well as a dry cough x 1 month .
The patient was in his usual state of health until two months prior to admission when he began to notice shortness of breath on climbing flights of stairs .
He stated that this became worse over the last month until he was noted to be short of breath at rest .
He also states that he has had a dry and nonproductive cough for one month .
He denied any fevers , chills , or night sweats .
No nausea , vomiting , or diarrhea .
He did note some weight loss over the past several months , though the amount was unknown .
He denied any contact with TB positive patients .
He describes a negative PPD one year prior to admission when he was in prison for one week .
He did travel to the Taheimpromong , last in 01/2004 for three weeks .
He did note multiple female sexual partners , although described using condoms except with his wife .
He denies any IV drug use , did describe cocaine use last two months ago .
He did drink alcohol three drinks per day , no withdrawal symptoms .
In emergency room , he was noted to be afebrile with stable vital signs , was treated with IV fluids , azithromycin , and cefuroxime .
HOSPITAL COURSE BY SYSTEM :
1. Pulmonary / Infectious Disease :
The patient 's differential diagnosis included initially a question of an atypical pneumonia or PCP .
His PPD has been negative one year prior to admission , PPD was rechecked during this admission and was negative .
He was ruled out for tuberculosis with an induced sputum x 3 , which showed no AFB .
Chest CT showed bibasilar diffuse infiltrates , PCP was negative .
Thus initially he had been started on prednisone and Bactrim , this was discontinued .
He was continued on azithromycin and cefuroxime until bronchoscopy results were known , negative .
Thus they were discontinued .
He initially had refused HIV testing , however , was finally consented , HIV was noted to be negative .
Pulmonary consult was invited , initially the patient refused bronchoscopy , however , did agree to it during his hospital stay .
The results were negative for Micro , most likely diagnosis as per review of pathology is organizing pneumonia with possible diagnosis of BOOP and chronic inhalational injury was a possibility .
The patient required supplemental oxygen to keep his oxygen saturation greater than 93% .
Ambulatory saturation was 82% on room air .
He was treated with supportive medical therapy for his cough .
He was to follow up with pulmonary as an outpatient .
2. Cardiovascular :
Echocardiogram was checked to rule out CHF , showed LVH and trace TR , ejection fraction of 60% without any pulmonary hypertension .
3. Heme
/ID :
Hepatitis serologies were negative .
4. FEN :
The patient was kept on a house diet .
His electrolytes were repeated p.r.n.
5. Prophylaxis :
Lovenox .
6. Code status :
Full .
7. Disposition :
The patient was discharged to home in satisfactory condition with home oxygen .
Multiple conversations were had with the patient as well as an interpreter stating the importance of not smoking and keeping flames away from his oxygen tank .
He was sent home with LDAMC services to help with his medications as well as oxygen education .
He was told to call a doctor or come to the emergency room should he have any further troubles , breathing , chest pain , or fevers .
He was to follow up with Dr. Malta at Firmert Hospital on 07/23/04 at 3:00 p.m. , as well as Dr. Shawn Leick at the Stonho Health Care pulmonary division as directed . | [
{
"text": "01/2004",
"start_char": 1003,
"end_char": 1010,
"id": "T4",
"type": "DATE",
"val": "2004-01",
"mod": "NA"
},
{
"text": "three weeks",
"start_char": 1015,
"end_char": 1026,
"id": "T5",
"type": "DURATION",
"val": "P3W",
"mod": "NA"
},
{
"t... | null | null | null |
8 | Admission Date:
2011-02-08
Discharge Date :
2011-02-14
Service :
CMED
HISTORY OF THE PRESENT ILLNESS :
Briefly , this is a 57-year-old gentleman with a history of COPD , status post intubation six years ago but not on home 02 with recent FEV1 27% of predicted value , and FEV1/FVC ratio 56% of hypercholesterolemia , who was admitted for COPD exacerbation and worsening of upper respiratory tract infection symptoms for a week prior to admission .
He was afebrile with stable vital signs on presentation to
HOSPITAL COURSE :
He was started on p.o. steroids and to CMED for management of COPD exacerbation but he appeared in more respiratory distress overnight and was started on IV Solu-Medrol and more frequent nebulizers for COPD .
He was also started on antibiotics for possible bronchitis or community-acquired pneumonia .
Given his tenuous respiratory status , he was transferred to the FICU with closer observation .
He did not require intubation and improved with q. two hour nebulizers and chest PT .
He was again transferred to the CMED Service for further management of his COPD exacerbation .
He was continued on p.o. prednisone and frequent nebulizers for COPD .
He was evaluated by the physical therapist in the hospital and was found to desaturate to 84% with ambulating on room air .
Therefore , home 02 was recommended on discharge . | [
{
"text": "2011-02-08",
"start_char": 17,
"end_char": 27,
"id": "T1",
"type": "DATE",
"val": "2011-02-08",
"mod": "NA"
},
{
"text": "six years ago",
"start_char": 194,
"end_char": 207,
"id": "T0",
"type": "DATE",
"val": "2005-02-08",
"mod": "APPROX"
},
... | null | null | null |
417 | Admission Date :
2017-09-13
Discharge Date :
2017-09-15
Service :
NSU
HISTORY OF PRESENT ILLNESS :
The patient is a 45 - year-old female here for a diagnostic cerebral angiogram with coiling .
HOSPITAL COURSE :
On admission , the patient 's vital signs were stable .
Her blood pressure was 102/82 .
Her heart rate was 71 .
Her SPO2 was 98 percent on room air .
MEDICATIONS ON ADMISSION :
1. Plavix 75 mg times 6 doses .
2. Xanax q.d.
3. Prozac 20 mg q.d.
4. Cyclobenzaprine 10 mg q.d.
5. Aspirin 325 mg times 3 doses .
6. Vitamin E .
PAST SURGICAL HISTORY :
Tubal ligation , 1986 .
Cystectomy , 1992 and 1998 .
Breast lesion excision , 1989 .
ALLERGIES :
TETRACYCLINE .
SOCIAL HISTORY :
The patient uses alcohol socially ; was a smoker , used tobacco , she quit 4 years ago ; denies using recreational drug .
HOSPITAL COURSE :
On 2017-09-13 , the patient was brought to the operating room and underwent a coiling with stent placement of the left carotid ophthalmic aneurysm .
The patient underwent coiling and stent placement without complications .
She was discharged to the PACU in stable condition .
Postoperative check , the patient 's vital signs were stable .
Her temperature was 96.3 degrees , blood pressure was 128/63 .
Her pulse was 61 , respirations 12 , and her O2 saturation was 98 percent on room air .
Her labs showed a white blood count of 7.7 , hematocrit of 33.3 , and platelets were 305 .
Her coags , her PT was 14.5 , PTT was 143.4 , and her INR was 1.3 .
Her electrolytes were all within normal limits .
On physical exam , the patient was awake , alert , and oriented times 3 .
She had a symmetric smile .
Her extraocular movements were full .
Her pupils were 3 to 2 bilaterally , briskly reactive .
The visual fields were intact .
Her strength was 05-31 throughout except for right was not tested due to the angiocele in her groin .
Angiocele was intact without hematoma , and she exhibited strong pedal pulses on the right side .
The assessment at that time was she was neurologically stable .
The plan was q. 1-hour neuro checks .
She was started on a heparin drip at 800 per hour .
Her PTT goes 50 to 60 at that time .
She was cleared to take sips of clear fluids and was to remain flat for 4 hours .
On postoperative day 1 , the patient was alert and oriented times 3 .
She exhibited no drift .
Her IPs were full at 5/5 .
She had no hematoma in her groin site .
Visual fields were full , her pupils were round and reactive bilaterally .
Her vital signs were stable with a temperature of 97.8 degrees , blood pressure was 104 to 121 over 50s .
Pulse was 60 to 70 .
Respirations were 15 , and she was saturating at 96 percent on room air .
Her PTT at that time was 67.8 .
She was started on aspirin 325 mg q.d. and Plavix 75 mg q.d.
On 2017-09-14 , she was transferred to the regular floor at Far 5 .
Postoperative day 2 , the patient was stable without events , all vital signs were stable .
She was moving all extremities and exhibiting good strength .
Her visual fields were intact .
Her extraocular movements were full .
Angio site was clean , dry , and intact without bleeding or drainage .
She was to be discharged today and encouraged to ambulate on her own .
Discharge condition for this patient was good .
She was ambulating on her own and tolerating a p.o. diet .
She was discharged to home in stable condition . | [
{
"text": "2017-09-13",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "2017-09-13",
"mod": "NA"
},
{
"text": "that time",
"start_char": 1972,
"end_char": 1981,
"id": "T17",
"type": "DATE",
"val": "2017-09-13",
"mod": "NA"
},
{
... | null | null | null |
577 | Admission Date :
2009-06-23
Discharge Date :
2009-07-12
Service :
CMI ; then to Medcine ; then transferred to CCU
HISTORY OF PRESENT ILLNESS :
The patient is an 83-year-old male with a history of diabetes mellitus , steroid-treated polymyalgia rheumatica , hypertension , benign prostatic hypertrophy , and high cholesterol who presented for a lower extremity peripheral angiography for bilateral foot ulcers , and he was found to an evaluated blood urea nitrogen , and creatinine , and potassium .
The patient notes he developed worsening foot pain and ulcers four months ago .
Due to his worsening blood glucose , he was started on insulin .
His foot ulcers continued to develop , and the patient complained of pain in his feet ; primarily at night .
The patient was referred to for Vascular consultation because of the ulcerations and pain and scheduled for a lower extremity angiography on the day of admission , but due to his renal failure the procedure was cancelled .
The patient showed peaked T waves on electrocardiogram , and he was transferred to Medicine .
The patient denied any oliguria , hematuria , dysuria , foamy urine , flank pain , abdominal pain , or urinary hesitancy .
He has complained of fatigue , anorexia , and a 10-pound weight loss in the last four months .
He gets short of breath with one flight of stairs .
He denies any fevers , chills , recent infections , chest pain , orthopnea , nausea , vomiting , diarrhea , hematemesis , melena , or hematochezia .
The patient also notes he has had hoarseness for the last two to three weeks .
HOSPITAL COURSE :
The patient is an 83 - year-old male with a history of diabetes , steroid-treated polymyalgia rheumatica , hypertension , benign prostatic hypertrophy , and high cholesterol without presented to the hospital for lower extremity angiograph ; however , that was deferred due to new onset renal failure .
1. RENAL FAILURE :
The patient was initially thought to be prerenal , and his renal status improved after hydration and increased oral intake .
He did have a magnetic resonance angiography of his kidneys which showed mild right-sided renal artery stenosis .
His renal function fluctuated throughout his hospital stay , and when he was in the Medical Intensive Care Unit he did have decreased urine output in the setting of cardiogenic shock .
2. CARDIOVASCULAR :
The patient with severe peripheral vascular disease .
During his hospital stay , he developed some nonsustained ventricular tachycardia .
He also became hypotensive on 07-02 in the setting of infection .
The patient had a central line placed and went into sustained ventricular tachycardia that was treated with lidocaine .
After being treated with lidocaine , the patient became apneic requiring intubation and transfer to the Coronary Care Unit .
His nonsustained ventricular tachycardia was treated with a lidocaine drip .
It was found that he had elevated troponins and likely an ischemic event on the 07-02 .
A repeat echocardiogram showed a decreased ejection fraction from prior .
He had a cardiac catheterization which revealed 3-vessel disease .
Cardiothoracic Surgery was consulted , and due to the patient 's acute illness , they wanted to re-evaluate after the patient was extubated .
The patient continued to have intermittent episodes of ventricular tachycardia .
He was continued on lidocaine and eventually changed over to amiodarone .
He was noted to be cardiogenic shock requiring pressors .
Of note , he likely suffered a second ischemic event during his Coronary Care Unit stay .
The patient did have a Swan-Ganz catheter in place and had a low cardiac output .
The patient 's family eventually decided to withdraw care , and the patient was extubated and passed away on 2009-07-12 .
2. INFECTIOUS DISEASE :
The patient was initially treated with levofloxacin for a left lower lobe infiltrate and a urinary tract infection .
He then developed positive blood cultures with Staphylococcus aureus sensitive to levofloxacin , and that was continued .
When the patient became hypotensive and required intubation and pressors , his antibiotics were broadened , and he was put on stress-dose steroids .
He was found to have bilateral Staphylococcus pneumonia .
3. PULMONARY :
The patient required intubation in the setting of hypotension and ventricular tachycardia .
He was actually extubated on 07-09 , but then reintubated one hour later due to hypoxia .
He was also found to have a bilateral Staphylococcus pneumonia . | [
{
"text": "the last four months",
"start_char": 1266,
"end_char": 1286,
"id": "T4",
"type": "DURATION",
"val": "P4M",
"mod": "NA"
},
{
"text": "the last two to three weeks",
"start_char": 1539,
"end_char": 1566,
"id": "T5",
"type": "DURATION",
"val": "P17D",
... | null | null | null |
576 | ADMISSION DATE :
5-28-93
DISCHARGE DATE :
6-4-93
HISTORY OF PRESENT ILLNESS :
The patient is a 58 year old right hand dominant white male with a long history of hypertension , changed his medications from Aldomet to Clonidine six weeks ago .
The patient has a history of adult onset diabetes mellitus , ankylosing spondylitis , status post myocardial infarction in '96 ( ? ) now with acute onset of left face and arm greater than leg hemiplegia and primary hemisensory loss on the left .
Briefly , he was talking to a friend at 5:30 p.m. the day prior to admission , when he had to grab his locker and sit down .
His voice became slurred and he had a mild central dull headache .
He was unable to move the left side of his body and felt numb on that side .
He was taken to Wayskemedcalltown Talmi and transferred to Heaonboburg Linpack Grant Medical Center with a computerized tomography scan showing a 1x2 thalamic capsular hemorrhage without superficial mass effect .
His blood pressure was 220/110 there .
He denies any visual symptoms or cortical-type symptoms .
He is a heavy smoker and drinks 2-3 shots per day at times .
MEDICATIONS ON ADMISSION :
Vasotec 40 mg q.day , Soma 1 tablet q.day , Demerolprn , Clonidine .
ALLERGIES :
The patient has no known drug allergies .
HOSPITAL COURSE :
The patient was admitted to the floor for observation .
The neurological examination on discharge was no movement in the hand on the left or arm .
Slight abductive and adductive movement on the left only in the upper extremity .
On the lower extremity , could wiggle toes , flexor and plantar , 3+/5 , quadriceps 4/5 on the left .
2. hypertension .
The patient was managed with Vasotec , Nifedipine and Clonidine with blood pressure under good control at the time of discharge , average 125 systolic , 70 diastolic , heart rate of 72 .
Also managed with Valium 5 mg PO t.i.d.
Muscle spasms were managed with Flexeril 10 PO t.i.d.
3. diabetes mellitus .
The patient was started on 2.5 of Micronase with resulting sugars as low as 63 , decreased to 1.25 mg q.day .
The patient is discharged in fair condition with medical approval to the Pasi . | [
{
"text": "2-3 shots per day",
"start_char": 1105,
"end_char": 1122,
"id": "T5",
"type": "FREQUENCY",
"val": "RP8H",
"mod": "APPROX"
},
{
"text": "q.day",
"start_char": 1175,
"end_char": 1180,
"id": "T6",
"type": "FREQUENCY",
"val": "RP1D",
"mod": "NA"
}... | null | null | null |
172 | Admission Date :
2018-04-23
Discharge Date :
2018-05-01
Service :
MEDICINE
History of Present Illness :
95 yo male with PMH large right thyroid cystic mass eroding into trachea , who presented to St. Anne 's Hospital 2018-04-22 with hemoptysis and respiratory distress , now diagnosed with anaplastic thyroid carcinoma .
.
Pt reports that he noticed a right neck mass last October .
The mass grew larger , to the size of a baseball .
It appears that FNA was performed but was non-diagnostic ( probably because anaplastic tumors tend to be necrotic ) .
The mass appears to be cystic in nature and has been aspirated at least 3 times , which decrease in size each time .
Now size is 6.5cm*6.5cm .
Plan for surgery in Oct was deferred 04-05 syncope and pacer placement for SSS; again deferred 2 weeks ago 04-05 URI; was planned for surgery this Thurday .
.
Pt was o/w in his USOH until 2-3 weeks ago when he developed a URI with symptoms of dry cough; no fever , chills , sore throat , myalgias .
Pt was treated with 3 days of an antibiotics , followed by a 10 day course of levaquin ( completed 2 days PTA ) .
Per pt and son , no James pna .
2 days prior to admission , pt developed hemoptysis; states he coughed up 4 tsp of blood .
1 day PTA , pt developed stridorous breathing and respiratory distress .
Pt was initially seen at Lahey North , where he was given steroids , with improvement in respiratory status .
Pt was transferred to New England Baptist Hospital , where his surgeon is located .
There he was admitted to the CMED .
Thyroid cyst was aspirated with removal of 300cc of fluid .
Pt was given racemic epinephrine and Decadron 10mg IV x1. CT neck showed tracheal mass per nursing s/o ( pt brought CT ) .
.
Pt now breathing more comfortably .
He has not had fever and night sweats but reports weakness and weight loss for several months recently .
Brief Hospital Course :
Pt was transferred here for further mgmt of airway and large thyroid mass by our IP team .
IP found endotracheal obstructing tumor and extrinsic compression of the high trachea by thyroid mass .
After rigid bronchoscopy with removal of the intratracheal tumor component on 2018-04-24 , stat pathology showed anaplastic tumor .
He was tranferred to the CMED .
Subsequently extubated and his respiratory Sx are now improved .
Pt was seen by Rad Onc , who recommended transfer to the East Campus for XRT .
On the morning of possible radiation , patient and family met with interventional pulmonary team who explained that the most recent CT showed further invasion of the tumor into the trachea .
After a long discussion , patient and family asked to be made CMO .
Patient was started on morphine drip and palliative care team was consulted with recommendations to ensure comfort .
Mr . Davison died approximately 24 hours after decision to be CMO , on 2018-05-01 .
Discharge Disposition :
Expired
Discharge Diagnosis :
NC
Discharge Condition :
NC
Discharge Instructions :
NC
Followup Instructions :
NC
John Iris MD 70-363
Completed by :
Patricia Rojas MD 73-701 2018-05-06 @ 1434
Signed electronically by :
DR. John J. Booker on :
WED 2018-05-30 5:50 PM
( End of Report ) | [
{
"text": "3 days",
"start_char": 1015,
"end_char": 1021,
"id": "T10",
"type": "DURATION",
"val": "P3D",
"mod": "NA"
},
{
"text": "a 10 day course",
"start_char": 1054,
"end_char": 1069,
"id": "T12",
"type": "DURATION",
"val": "P10D",
"mod": "NA"
},
{
... | null | null | null |
98 | Admission Date :
2015-09-16
Discharge Date :
2015-09-21
Service :
CARDIOTHOR
HISTORY OF PRESENT ILLNESS :
The patient is a 52 year old Czech speaking gentleman with a history of severe mitral regurgitation .
For the past several years , the patient has continued to have significant exercise intolerance which has limited his ability to work .
He reports severe dyspnea on exertion .
The patient had a recent admission earlier in the month and he was discharged on 2015-09-10 , after undergoing cardiac catheterization .
This was significant for demonstrating no flow-limited disease in the coronaries but several fistulae
from the left anterior descending to the PA .
Several of these were coil embolized during this admission .
He tolerated this well , was sent home , and now returns for his mitral valve repair .
HOSPITAL COURSE :
On the day of admission , the patient went to the Operating Room and underwent a minimally invasive
mitral valve repair .
He tolerated this procedure well .
The patient was brought to the cardiothoracic Intensive Care Unit in stable condition on minimal pressor support .
He was successfully weaned off this support .
The patient was fully weaned from ventilatory support secondary to a persistent acidemia .
This was treated with sodium bicarbonate and a Swan-Ganz was placed to provide close hemodynamic monitoring .
The patient was found to have stable hemodynamics with appropriate mixed venous saturations in the 70% range .
The patient was corrected to a normal pH of 7.41 by the first postoperative night and remained stable .
He was then weaned off of ventilatory support and was successfully extubated .
The patient did have a slight bit of confusion early in post-extubation course which cleared .
This was also compounded by a language barrier since the patient cannot speak English .
In addition , the patient 's early postoperative course had a tremendous urine output .
It was equally up to 700 cc. an hour and a renal consultation was obtained .
He underwent a head CT scan to rule out intracranial pathology leading to diabetes insipidus .
This was negative .
The patient 's serum and urine electrolytes indicated that this diuresis was appropriate .
The patient 's urine output has decreased and his BUN and creatinine remained normal .
The patient 's Foley was discontinued .
He had developed some hematuria which has resolved .
The patient has remained stable and is now ready for discharge to home with follow-up in approximately four weeks . | [
{
"text": "the first postoperative night",
"start_char": 1518,
"end_char": 1547,
"id": "T8",
"type": "DATE",
"val": "2015-09-16",
"mod": "END"
},
{
"text": "post-extubation course",
"start_char": 1705,
"end_char": 1727,
"id": "T9",
"type": "DATE",
"val": "2015... | null | null | null |
166 | Admission Date :
07/04/1999
Discharge Date :
07/09/1999
Discharge Date :
07/09/1999
HISTORY OF THE PRESENT ILLNESS :
This is a 49 year-old male with a history of a low anterior resection in May of 1998 and a recurrence of metastasis with asleeve of section of left colon diverting ileostomy for recurrent metastasis later in May of 1999 who presents with anterior midepigastric abdominal pain .
The patient states that the pain began at 10:30 on the day of admission with increase during the day of admission with positive nausea and vomiting , no diarrhea , decreased output from the ostomy , and the pain was radiating to the back .
HOSPITAL COURSE :
Assessment was continued with laboratory studies which showed the patient to have a white blood cell count of 9 , hematocrit 39 , and platelets 470 .
The patient had a normal amylase and lipase , and a normal basic metabolic panel .
The patient had KUB that showed multiple dilated loops of small bowel and was admitted for a partial small bowel obstruction .
An nasogastric tube was placed and had an H2 blocker started , and was admitted for bowel rest and decompression .
The patient tolerated the nasogastric tube well .
The nasogastric tube was removed on hsp day # 3 .
The pain improved quickly and the patient was started on a clear liquid diet which was advanced as tolerated .
On 7/9/99 , the patient was tolerating a house diet .
The patient had some minimal back pain that occurred after food but with negative urinalysis and negative fever spikes over the entire course of this stay .
The patient will be discharged home on Zantac , Simethicone , and preoperative medications with follow-up with Dr. Ur in two weeks .
Dictated By :
NISTE BLOCKER , M.D. AQ36
Attending :
STIE FYFE , M.D. BW3 BL436/5666
Batch :
85114
Index No.
FNQXCX58 EM
D :
07/09/99
T :
07/09/99 HP8 | [
{
"text": "hsp day # 3",
"start_char": 1215,
"end_char": 1226,
"id": "T7",
"type": "DATE",
"val": "1999-07-07",
"mod": "NA"
},
{
"text": "7/9/99",
"start_char": 1343,
"end_char": 1349,
"id": "T3",
"type": "DATE",
"val": "1999-07-09",
"mod": "NA"
},
{
... | null | null | null |
28 | Admission Date :
2012-04-30
Discharge Date :
2012-05-14
Service :
O-CMED CCU
HISTORY OF PRESENT ILLNESS :
The patient is a 55 - year-old male with recently diagnosed abdominal carcinomatosis .
The patient presented with abdominal pain and bloating and was found to have a large omental mass .
Biopsy revealed adenocarcinoma .
Histochemical stains are consistent with hepatobiliary origin .
Endoscopies were negative except for an extrinsic mass present on the stomach .
The patient presents with increased abdominal pain and poor oral intake as well as generalized weakness .
On presentation , the patient denied chest pain , shortness of breath , and cough .
HOSPITAL COURSE :
The patient was admitted to the O-CMED
Service .
He was placed on a patient-controlled analgesia for pain control .
He was administered intravenous fluids and oral diet as tolerated .
On the night of 05-01 , the patient complained of increased vomiting .
He also complained of increased shortness of breath and " difficulty catching his breath ."
On room air , the patient 's oxygen saturation was 80% .
His saturation increased to 87% on a nonrebreather .
A chest x-ray disclosed a left pleural effusion .
The patient was bolused with intravenous heparin due to concern for pulmonary embolism .
The patient expressed a desire to be full code , so he was transferred to the Intensive Care Unit .
The patient became more comfortable being seated upright with nebulizer treatments .
An angiogram was done which disclosed possible subsegmental pulmonary emboli of the upper lobes as well as infiltrates consistent with aspiration pneumonia .
The patient was placed on Flagyl and Levaquin for treatment of pneumonia .
He was continued on heparin for treatment of the pulmonary emboli .
While in the Intensive Care Unit , the patient was noted to have increasing abdominal distention .
On 05-03 the patient underwent an abdominal ultrasound with paracentesis , and 5 liters of fluid were removed .
On 05-04 , the patient was transferred back to the O-CMED CSRU
Service .
Due to persistent gastric secretions , an nasogastric tube was placed for decompression .
The patient was noted to have a functional ileus .
Octreotide was initiated in an attempt to decrease the gastric secretions .
On 05-13 , the patient 's respiratory status declined further .
He was noted not have an increasing left-sided pleural effusion .
A thoracentesis was done with removal of 1.5 liters of fluid .
A paracentesis was repeated with removal of 2.5 liters of fluid .
On the night of 05-13 , the patient continued to decline .
The family decided to pursue comfort measures .
Morphine was administered to insure patient 's comfort .
The patient expired at 6 p.m. on 05-14 . | [
{
"text": "2012-04-30",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2012-04-30",
"mod": "NA"
},
{
"text": "05-03",
"start_char": 1863,
"end_char": 1868,
"id": "T3",
"type": "DATE",
"val": "2012-05-03",
"mod": "NA"
},
{
"te... | null | null | null |
471 | ADMISSION DATE :
06-06-93
DISCHARGE DATE :
06-07-93
HISTORY OF PRESENT ILLNESS :
The patient is a 68 year old male status post three and a half cycles of adjuvant EAP chemotherapy .
He had a good response to preoperative therapy and negative nodes , and is admitted for the final portion of his postoperative cycles .
His chemotherapy the week before was decreased because the white blood count dropped to 2.8 .
In the interim , the white blood count rose again to 4.2 with a hematocrit of 30.5 , platelet count of 196 thousand .
HOSPITAL COURSE :
The patient was treated with Adriamycin 25 mg , Cis-platinum 40 mg , preceded by Mannitol 12.5 grams intravenous bolus , and Zofran 11 mg on two occasions given as an antiemetic .
The chemotherapy was well tolerated . | [
{
"text": "06-06-93",
"start_char": 18,
"end_char": 26,
"id": "T0",
"type": "DATE",
"val": "1993-06-06",
"mod": "NA"
},
{
"text": "the week before",
"start_char": 336,
"end_char": 351,
"id": "T2",
"type": "DURATION",
"val": "",
"mod": "NA"
},
{
"te... | null | null | null |
511 | Admission Date :
Report Status :
Discharge Date :
01/23/2003
HISTORY OF PRESENT ILLNESS :
The patient is a 50-year-old female with history of low back pain radiating to both legs .
She had increasing symptoms overtime , not controlled by conservative management .
She therefore elected to undergo surgical treatment .
HOSPITAL COURSE :
She was taken to the operating room on 01/16/2003 for decompression at L2 , L5 and laminectomy with posterior instrumented fusion at L3 to L5 .
She tolerated the surgery well .
She was transferred to recovery room in stable condition .
She received blood transfusions intraoperatively and postoperatively in addition to autologous blood .
Her hematocrit was stable postoperatively .
Her neurologic exam was stable postoperatively with 5/5 bilaterally , tibial , EHL , FHL , gastroc soleus , and intact quadriceps .
She has intact sensation L3 to S1 and bilateral lower extremities .
She was fitted for Verholl Aet over leg brace and mobilized out of the bed in the brace with physical therapy .
Her wounds were stable without any erythema or drainage .
She reported nausea on pain medications .
Her pain medications were changed around until an acceptable regime was accomplished .
She is stable for discharge to rehab . | [
{
"text": "01/16/2003",
"start_char": 376,
"end_char": 386,
"id": "T1",
"type": "DATE",
"val": "2003-01-16",
"mod": "NA"
},
{
"text": "01/23/2003",
"start_char": 51,
"end_char": 61,
"id": "T0",
"type": "DATE",
"val": "2003-01-23",
"mod": "NA"
}
] | null | null | null |
707 | Admission Date :
2012-09-26
Discharge Date :
2012-10-01
Service :
NEONATOLOGY
HISTORY OF PRESENT ILLNESS :
This is a 5235 - gram full-term male infant of a diabetic mother born by repeat cesarean section to a 29-year-old gravida 1 , para 2 , woman .
Prenatal screens benign .
Group B strep status negative .
Pregnancy complicated by insulin-dependent gestational diabetes .
Apgar scores were 8 at 1 minute and 9 at 5 minutes .
The infant admitted to the Neonatal Intensive Care Unit for a dextrose stick of 20 in the delivery room .
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEM :
RESPIRATORY :
The infant has remained on room air throughout his hospitalization with oxygen saturations of greater than 95 percent .
Respiratory rates have been 40 s to 60 s.
The infant has had two spontaneous desaturations which quickly self-resolved on day of life one .
No other issues .
No apnea or bradycardia .
CARDIOVASCULAR :
The infant has remained hemodynamically stable with heart rates in the 120 s to 140 s and mean blood pressures of 57 to 60 .
FLUIDS , ELECTROLYTES AND NUTRITION :
The infant was admitted to the Neonatal Intensive Care Unit for treatment of hypoglycemia .
The infant was started on enteral feedings of Enfamil 20 calories per ounce by mouth ad lib and maintained glucoses in the middle to high 40 s taking by mouth feedings every two to three hours by mouth ad lib .
On day of life one , the infant had a dextrose stick of 34 .
At that time , an intravenous of D-10-W was started at 80 cc / kilogram per day .
On day of life two , the infant began to wean off intravenous fluids , and this was completed by day of life four .
Calories were increased to Similac 24 calories per ounce .
Before discharge to the Newborn Nursery , the infant was taking Similac 22 calories per ounce by mouth ad lib and maintaining dextrose sticks in the 60 s.
Weight on discharge was 5200 grams .
GASTROINTESTINAL :
No issues .
HEMATOLOGY :
No issues .
NEUROLOGY :
Normal neurologic examination .
SCREENS :
A hearing screen was performed with automated auditory brain stem responses and the infant passed on both ears .
PSYCHOSOCIAL :
The parents are involved . | [
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"val": "R",
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{
"text": "every two to three hours",
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"val": "RPT2.5H",
"mod": "APP... | null | null | null |
458 | Admission Date :
01/17/1993
Discharge Date :
01/21/1993
HISTORY OF PRESENT ILLNESS :
The patient is a 42 year old gentleman who suffered lower back pain during an accident at work in 1990 .
This gradually increased until June 1992 where he had recurrent severe right sided sciatica .
In September 1992 CT myelogram showed a lateral L-1 S-1 disc bulge and small L-4-4 bulge .
He has had no change in pain in the last few months .
HOSPITAL COURSE :
He was admitted , taken to the operating room where he underwent L5-S1 right hemilaminectomy and discectomy .
He tolerated the procedure well , was taken to the floor in stable condition .
Over the next three days he increased his activity gradually , was able to do stairs with Physical Therapy and had pain which could be controlled with oral analgesics . | [
{
"text": "01/17/1993",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "1993-01-17",
"mod": "NA"
},
{
"text": "1990",
"start_char": 184,
"end_char": 188,
"id": "T0",
"type": "DATE",
"val": "1990",
"mod": "NA"
},
{
"text": "Jun... | null | null | null |
316 | ADMISSION DATE :
03/07/2002
DISCHARGE DATE :
03/13/2002
HISTORY OF PRESENT ILLNESS :
The patient is a 79-year-old man status postradical cystoprostatectomy with ileal loop for locally invasive prostate cancer .
This operation was performed 2/11/02 by Dr. Doje Para .
The postoperative course was complicated by atrial fibrillation with transfer to the Cardiac Step-Down Unit .
This transfer occurred around postoperative day 8 for anticoagulation and amiodarone load .
The anticoagulation was stopped due to concern for postoperative bleeding .
The patient complained of fevers .
The patient presented to the emergency room on 3/7/02 , complaining of fevers since Monday 3/2/02 .
He developed erythema around the wound on Wednesday and was seen by Dr. Para , who started Keflex and obtained a CT scan which demonstrated a fluid collection at the site of erythema .
The fevers continued as high as 102.5 degrees F with chills on the morning of admission .
He was draining pus from the wound site with subsequent relief of discomfort at the site .
HOSPITAL COURSE :
The patient was admitted to Urology .
After the wound was further opened , he was started on ampicillin , Gentamicin , and Flagyl antibiotics and he was placed on a bid dressing change and packing .
On hospital day 2 , the patient had no complaints .
He was afebrile with stable vital signs and good urine output .
The wound erythema was improving and the wound was packed twice a day .
Wound cultures remained negative at that time .
We continued his ampicillin , Gentamicin , and Flagyl .
By hospital day 4 , he remained afebrile throughout his hospital course .
The wound cultures demonstrated gram-positive cocci in clusters and gram-negative rods .
Blood cultures remained negative .
The patient was continued on antibiotics and we obtained a CT scan to check for an enterocutaneous fistula .
We discontinued his Flagyl on that day .
We contacted the patient 's primary care physician , Dr. Aslinke ______ , regarding his cardiac medication management .
We agreed that he should resume his atenolol .
He was started on 2.5 mg PO qd .
He was continued on his dressing changes .
We changed the dressings tid instead of bid for continued drainage .
The CT scan that was obtained on 3/10/02 demonstrated no connection between bowel and the wound .
The drainage had been decreasing and the patient continued to be afebrile .
On the following day , 3/11/02 , a fistulogram was obtained which was negative for a fistula from the bowel to the wound .
The patient was continued on ampicillin and Gentamicin .
Her remained afebrile with stable vital signs .
He was comfortable and erythema continued to decrease with improvemeent in the appearance of the wound .
In consultation with Infectious Disease , it was agreed to discharge the patient on Augmentin for coverage .
We obtained sensitivities of his wound bacteria .
His intravenous antibiotics were discontinued .
He remaineda febrile with daily improvement in the appearance of his wound .
On hospital day 7 , the patient remained afebrile with stable vital signs .
His wound demonstrated no erythema with moderate dark drainage .
The patient will be discharged with WH and continued dressing changes bid . | [
{
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"type": "DATE",
"val": "2002-03-08",
"mod": "NA"
},
{
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"id": "T7",
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"val": "RP12H",
"mod": "NA"
... | null | null | null |
302 | Admission Date :
2010-02-05
Discharge Date :
2010-02-06
Service :
TRAUMA
HISTORY OF PRESENT ILLNESS :
The patient is a 23 year old female , status post fall from standing position after slipping on ice .
She had no loss of consciousness .
She recalled the entire event .
She was found by family and friends to be somewhat confused and was therefore taken to Newton-Wellesley Hospital thereafter .
Workup at the outside hospital included a CT scan of the head revealing a possible parietal subdural bleed on the right side .
The patient 's GCS was 15 .
She was hemodynamically stable .
She was thereafter transferred to Beverly Hospital for further evaluation and management . | [
{
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"end_char": 28,
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"type": "DATE",
"val": "2010-02-05",
"mod": "NA"
},
{
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"start_char": 46,
"end_char": 56,
"id": "T2",
"type": "DATE",
"val": "2010-02-06",
"mod": "NA"
}
] | null | null | null |
666 | ADMISSION DATE :
09/15/2000
DISCHARGE DATE :
The patient was admitted to the hospital on July 12th for a chole with a principle diagnosis of recurrent biliary colic .
HISTORY OF PRESENT ILLNESS :
The patient is a 42 year old with recurrent biliary colic .
She has had ultrasound proven gallstones for ten years , seen on an earlier obstetric ultrasound .
The patient has had no symptoms until approximately two years ago when she began having classic biliary colic pain with right upper quadrant epigastric pain radiating to midback with nausea , but without vomiting .
Onset was an hour to 1 hour after meals , worse with greasy meals , lasting five minutes to two hours .
Episodes have been increasing in frequency over the last few months .
She has had no fevers , chills , respiratory symptoms , diarrhea , bright red blood per rectum or melena .
She has not found any relieve with any over the counter medications .
She has no family history of gallbladder or pancreatic disease .
She has had no significant weight loss .
No anorexia .
An ultrasound on 1/25/00 showed six gallstones without cholecystitis .
She has no history of liver disease , hepatitis .
The patient is from 45 Sidewonly Blvd , Fresa Loharanleah , Maryland .
Has lived in 896 Lokatspur Pkwy , Ingrich Vepobuffh , Indiana for 25 years and works as a teaching assistant in a second grade in Satlnonew Rollglend Pabridrham .
HOSPITAL COURSE :
The patient was admitted for the lap coli with an intraoperative cholangiogram by Dr. Sterp under general anesthesia .
A separate operative note has been dictated .
Operative course and recovery were without complication .
The patient was admitted to floor .
The patient was afebrile , vital signs were stable .
She is taking po 's .
She is ambulatory .
The patient will be discharged to home in stable condition with a follow up appointment with Dr. Sterp . | [
{
"text": "1/25/00",
"start_char": 1059,
"end_char": 1066,
"id": "T2",
"type": "DATE",
"val": "2000-01-25",
"mod": "NA"
},
{
"text": "25 years",
"start_char": 1300,
"end_char": 1308,
"id": "T8",
"type": "DURATION",
"val": "P25Y",
"mod": "NA"
},
{
"... | null | null | null |
116 | Admission Date :
11/30/1993
Discharge Date :
12/07/1993
HISTORY OF PRESENT ILLNESS :
The patient is a 40 year old woman with end stage renal disease , on hemodialysis since 12/91 .
This was secondary to polycystic kidneydisease , which was noted since age 12 .
She is status post cadaveric renal allograft in 03/93 , and she subsequently underwent an early postoperative transplant nephrectomy secondary to rupture .
He has been having difficult access problems and now has a left upper arm PTFE .
She had been placed on emergency transplant for this difficult access problem .
Otherwise , she has been healthy and her last hemodialysis was the day prior to transplant .
HOSPITAL COURSE :
She was taken to the Operating Room on 11/30/93 where Dr. Tiveloydherdes performed a cadaveric renal allograft to the left iliac fossa which she tolerated well .
Postoperative course was unremarkable .
She was started on her immunosuppressive agents as per protocol .
Her creatinine fell to the normal range early .
Over several days she continued to make good amounts or urine .
She was gradually advanced to a regular diet .
Her prednisone was tapered to a stable dose . | [
{
"text": "several days",
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"end_char": 1023,
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"type": "DURATION",
"val": "P6D",
"mod": "APPROX"
},
{
"text": "several days",
"start_char": 1011,
"end_char": 1023,
"id": "T8",
"type": "DURATION",
"val": "P5D",
"mod": "APPROX"
... | null | null | null |
472 | Admission Date :
2017-06-16
Discharge Date :
2017-07-27
Service :
MEDICINE
History of Present Illness :
Patient is a 58 year old male with a recent admission for abdominal pain s/p negative exploratory laparotomy for suspected intussuception now returns on day of discharge with fever and tachycardia .
Patient has a history for terrible vasculopathy s/p recent right BKA with dry gangrene of the distal stump .
Patient 's last admission was significant for a negative ex-lap .
Post-operatively , his course was complicated by respiratory distress necessitating an urgent return to the ICU and was intubated .
After multuple failed attempts at extubation , the patient was trached .
Patient then did well on a trach mask and was transferred to rehab on the day of admission but now returns with tachycardia to the 120 's , and fever to 102 degrees F .
Brief Hospital Course :
The patient was re-admitted to the surgical service and taken to the CMED .
A chest x-ray on admission showed effusions consistent with CHF along with overlying pnumonia .
Urine cultures were significant for Klebsiella UTI and sputum cultures were significant for MRSA .
He was placed on vancomycin , levofloxacin and fluconazole .
He underwent PICC line placement on 06-18 .
A trach collar was placed on 06-19 .
GI was consulted for colonoscopy .
Patient was transferred to the floor on 06-20 .
He was seen by respiratory therapy and suctioned continually throughout his hospital course .
His respiratory status improved .
He tolerated his trach collar , and tube feeds at goal .
The fluconazole was discontinued .
On 06-21 the patient was seen by physical therapy .
A nutrition consult was obtained on 06-22 .
He underwent a failed bedside swallow study .
Based on a chest x-ray that showed a small hydro-pneumothorax on the left lower lobe of the lung , a thoracic surgery consult was obtained , though no specific interventions were warranted at the time .
On 06-23 the patient 's tube feed were changed from Respalor to Deliver 2.0 to give increased calories .
On 06-25 , urine cultures grew out VRE , and a C diff was negative .
He experienced low grade fevers .
He was pan-cultured on 06-26 for continued fevers .
On 06-27 , his nutrition regimen was changed to Deliver 2.0 at 70 cc / hr with 15 g ProMod .
On 06-28 , the patient experienced PVC 's .
An EKG showed ST segment depression along the lateral pre-cordial leads .
Serial enzymes showed mild elevation of troponins .
A cardiology consult was obtained .
The cardiology service simply recommended increasing the beta-blockade and maximizing the patient 's electrolyte status .
On 06-29 , the patient was transferred to the medical service .
Pt 's vancomycin was stopped after 14 days of treatment .
HIV test was found to be negative .
MRI head was obtained to further w/u patient 's apparent cognitive decline .
MRI showed prominent sulci and enlarged ventricles abnormal for the patient 's age .
Due to concerns for dementia , neurology consult was obtained .
Neurology felt that the patient 's cognitive symptoms were consistent w/ metabolic encephalopathy due to his multiple medical problems .
They felt that his mental status would improve as his health improved .
Underlying dementia was possible but difficult to assess with an overlying delerium .
The patient continued to pull out his doboff tube .
Pt had EGD performed to evaluate his poor nutritional status .
He was found to have a large gastric ulcer and high dose PPI was started .
The gastric biopsy and the serology were both negative for H. pylori .
PEG placement was unsuccessful by GI due to the patient 's anantomy .
07-05 the patient had a J tube placed in interventional radiology for nutritional support .
He was re-started on tube feeds .
07-06 patient failed a repeat swallow evaluation due to discoordinated swallow .
07-07 the patient was taken for colonoscopy and found to have a normal colon to cecum .
07-12 the patient was found to be C diff positive and was started on 14 day course of Flagyl .
On 07-18 , as his mental status improved , he did well at the bed side swall evaluation .
On 07-19 , he underwent video swallow evaluation and was able to tolerate ground consistent food and thin liquids .
His meds should be crushed and mixed with puree thick liquid .
He has gained 30 lb since the tubefeed was initiated ( 70 lb to 100 lb ) during this admission .
He will still need to be on tubefeed to support his nutrition until he is cleared by a nutritionist .
In terms of his mental status , he continued to improve steadily over the last few weeks of his hospital stay .
He was more alert and engaged with activity .
He did much better with PT and OT at the end after his mental status improved .
As noted above , his mental status change was likely toxic-metabolic from acute infection .
He started to develop more pain around the right stump since 07-17 .
He was seen by the vascular surgery who felt that he is too medically sick and malnourished to have surgery at this time .
He will follow up with Dr. Javier as outpatient .
Initially , his pain was controlled with titrating up the Oxycontin .
However , it was titrated too quickly from 10 mg bid to 30 mg bid .
He then developed urinary retention requiring foley placement .
After he passed the video swallowing , he was tolerating ground consistent solids .
On 07-24 , he had an emesis x 1 , and had aspiration pneumonia ( + interstital markings on the left on CXR , fever , leukocytosis ) .
His Flagyl course was extended , and Vanc / Levo were added .
His sputum showed many GPC which later grew Staph aureus .
Given his recent MRSA pneumonia , he will be treated with 2 week course of Vanc / Levo / Flagyl .
He was seen by the pain service who recommended to discontinue Oxycontin , and start Neurontin , MSIR , and lidocaine patch in addition to the standing Tylenol .
On 07-25 , his J-tube was noted to be obstructed but was able to be flushed by IR on 07-26 .
Tubefeed was resumed without any difficulty since .
Since oxycontin was discontinued , the foley was removed on 07-27 and was able to void without any difficulty . | [
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"type": "DATE",
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"mod": "NA"
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{
"tex... | null | null | null |
512 | Admission Date :
2019-02-28
Discharge Date :
2019-03-26
Service :
CARDIOTHORACIC
History of Present Illness :
Mr. Pizano is a 75 y/o man who has a PMHx significant for Enterococcus mitral valve endocarditis which has been treated since 09-19 .
He has had 2 6 week courses of antibiotics with recurrent bacteremia .
He had a TEE on 2019-01-22 which revealed thickened mitral leaflets with small vegetations on both anterior and posterior leaflets with moderate to severe mitral regurgitation .
He has preserved LV systolic function with mild TR and AR and LAE without abscess .
He had a repeat TEE on 02-19 which revealed 4 + MR .
Thomasine was tranferred from MWMC ( where he was admitted on 02-15 with fevers and positive blood cultures ) to IDMC for further treatment and possibly MVR .
Brief Hospital Course :
As mentioned in the HPI , Mr. Mcculley was transferred from MWMC to Nantucket Cottage Hospital for ongoing care ( ? MVR ).
And Infectious disease consult was immediately made .
IV Daptomycin was continued via PICC line which was inserted on 02-20 at MWMC .
Mr Stutts had an extensive preop evaluation including cardiology , infectious diseases , orthopedics , psychiatry and ethics services .
He ultimately was brought to the operating room on 03-19 .
At that time he had a Mitral Valve replacement , aortoomy , and left atrial appendage resection .
His bypass time was 103 minutes / crossclamp 89 mins .
Please see OR report for full details .
He tolerated the surgery well and was transferred from the OR to the CSRU on Epinephrinne and Propofol infusions .
He did well in immediate postoperative period .
Following surgery his anesthesia was reversed , he was weaned from ventilator and successfully extubated .
His iv medications were also weaned to off .
On POD1 His PA line and chest tubes were removed , he was also started on Beta blockers and diuretics .
On POD2 the patient remained hemodynamically stable and was transferred from the ICU to F2 for continued postop care .
Over the next several days with the assisstance of the nursing staff and physical therapy the patients activity level was advanced , he was transitioned to all oral medications with the exception of his antibiotics .
On POD7 it was decided that the pt was stable and ready for discharge to rehabilitation .
It should be noted that the patient did have episodes of postoperative atrial fibrillation , he was seen by the
Electrophysiology service , started on Procainamide and Coumadin . | [
{
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"type": "DATE",
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"mod": "NA"
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{
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248 | Admission Date :
2016-04-05
Discharge Date :
2016-04-11
Service :
Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS :
This is a 67 - year-old male with a history of high cholesterol who was in his usual state of health until 2016-04-03 .
He was raking leaves on 04-02 and then developed episodes of mid chest pain and burning which radiated to the left arm .
That night he reportedly stopped breathing and was unresponsive .
His wife gave him mouth-to-mouth resuscitation and he regained consciousness .
He presented to an outside hospital with an acute inferior myocardial infarction and was treated with thrombolytic therapy .
His troponin was 20 and he had EKG changes .
He underwent catheterization on 2016-04-05 which revealed a left ventricular ejection fraction of 50% , no mitral regurgitation , insufficiency or hypokinesis .
Left main coronary artery was narrowed 50-60% , left anterior descending coronary artery 70% proximally , right coronary artery dominant diseased up to 90% proximally in the midportion , 70% distally .
The left circumflex coronary artery was 50% proximally , 90% obtuse marginal #3 .
HOSPITAL COURSE :
The patient was admitted to the hospital and on 2016-04-06 the patient underwent coronary artery bypass grafting x 4 with left internal mammary artery to the left anterior descending coronary artery , saphenous vein graft to the diagonal , saphenous vein graft to obtuse marginal , saphenous vein graft to right coronary artery , posterior descending coronary artery .
The patient appeared to have tolerated the procedure and was transferred to the cardiac intensive care unit for postoperative management .
He was started on beta blockers .
The patient had pacing wires and chest tubes in place , both of which over the course of his stay were removed successfully .
The patient did well postoperatively and was transported to the regular cardiac surgery floor where he tolerated a regular diet , ambulated well , did well with his activities of daily living .
He was seen by physical therapy and cleared .
They requested that he follow up in three to five weeks for endurance training , however then physical therapy followed him a number of times afterward and decided that he was in good condition and did not need further physical therapy .
On 2016-04-11 the patient was in good condition and he is being discharged on a regular heart-healthy diet .
He may observe regular activity although he should avoid strenuous activity and should not drive while on pain medications .
He should follow up with Dr. Dushaj in four weeks .
He should follow up with his cardiologist in two to three weeks and he should follow up with his primary care physician in one to two weeks . | [
{
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{
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{
"tex... | null | null | null |
711 | ADMISSION DATE :
10-03-94
DISCHARGE DATE :
10-06-94
HISTORY OF PRESENT ILLNESS :
This 85 year old man was admitted because of the new onset of focal left-sided seizure and unresponsiveness .
He had a past history of ischemic cardiomyopathy with an ejection fraction of 10 , mild aortic stenosis and a right middle cerebral artery territory stroke in 07/94 .
He was at Orlak on the day of admission and was found unresponsive with left tonic-clonic movements , greater in the arms than in the legs .
He was transferred to Fairm of Ijordcompmac Hospital , where seizures were stopped with 2 mg of Ativan .
He was loaded with IV Dilantin .
He remained unresponsive with poor airway protection .
HOSPITAL COURSE :
By the patient and his family 's prior wishes , the patient was extubated .
An electroencephalogram revealed generalized slowing without ictal events .
He had no carotid bruits .
He had stertorous breathing , positional tremors of the left upper extremity , a spastic left hemiparesis in flexion .
He withdrew both legs to painful stimuli .
The right upper extremity was flaccid and paresthetic .
Again , comfort measures only were undertaken as per the patient 's previous wishes and the family 's current insistence .
At 1:15 PM on 10/06/94 , the patient was found unresponsive with no heart sounds , carotid pulse , respiratory excursions , or pupillary reactions .
His family was notified .
Consent for autopsy was denied . | [
{
"text": "1:15 PM on 10/06/94",
"start_char": 1249,
"end_char": 1268,
"id": "T4",
"type": "TIME",
"val": "1994-10-06t13:15",
"mod": "NA"
},
{
"text": "10-03-94",
"start_char": 18,
"end_char": 26,
"id": "T1",
"type": "DATE",
"val": "1994-10-03",
"mod": "NA... | null | null | null |
301 | ADMISSION DATE :
03/30/97
DISCHARGE DATE :
04/01/97
HISTORY OF PRESENT ILLNESS AND REASON FOR HOSPITALIZATION :
The patient was a 108-year-old nursing home resident , who was admitted with a two-day history of increased respiratory secretions and a 24-hour history of elevated fever .
Despite Augmentin , the patient 's delirium worsened in the 24 hours prior to admission , and her temperature was up to 102 .
She was refusing to take p.o.'s .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted for treatment of a presumed aspiration pneumonia and for rehydration .
She was started on Clindamycin and Ofloxacin at renal dose to cover the aspiration pneumonia and positive urine culture , which subsequently came back .
She had some wheezing , which responded well to Albuterol nebulizers .
She was generally doing well with resolution of her temperature until 4/1/97 at 9:20 P.M. , when she was noted to be unresponsive with fixed dilated pupils .
She was certified dead at 9:20 P.M.
MI CUCHSLI , M.D.
TR :
vgo
DD :
05/11/97
TD :
05/15/97 8:26
Acc :
MI CUCHSLI , M.D.
cc :
Nursing Director Pcaer,ter Medical Center Sco , Ohio | [
{
"text": "03/30/97",
"start_char": 18,
"end_char": 26,
"id": "T0",
"type": "DATE",
"val": "1997-03-30",
"mod": "NA"
},
{
"text": "a two-day",
"start_char": 190,
"end_char": 199,
"id": "T2",
"type": "DURATION",
"val": "p2d",
"mod": "NA"
},
{
"text"... | null | null | null |
473 | ADMISSION DATE :
12/25/96
DISCHARGE DATE :
12/29/96
HISTORY OF PRESENT ILLNESS :
Ms. Lenkpruskihkooglekih is a 63-year-old lady with a history of frequent premature ventricular contractions and infrequent short runs of non-sustained ventricular tachycardia ( one four-beat run ) in 1991 , for which several antiarrhythmic agents including Propranolol , Quinidine , Procainamide , Tenormin , Norpace , Corgard , and Flecainide were used , but were stopped because of intolerance .
At that time , she had clear coronary arteries on coronary angiography and an ejection fraction greater than 50% .
She did well off antiarrhythmic agents until October of this year when she was noted to have atrial fibrillation with a rapid ventricular rate after several days of decreased exercise tolerance .
She was started on Coumadin and had a failed attempt at DC electrical cardioversion on 11/16/96 .
She has been on Coumadin since and has continued to have occasional palpitations and mild shortness of breath .
HOSPITAL COURSE AND TREATMENT :
The patient was started on Propafenone 300 mg three times a day and underwent an attempt at electrical cardioversion after seven doses of this .
This failed , despite one shock at 300 joules and two shocks at 360 joules .
The Propafenone was stopped , and the patient was changed to Amiodarone 400 mg t.i.d. , which was continued for two days .
The patient was discharged to home on Amiodarone 200 mg daily on 12/29/96 .
An electrocardiogram showed no evidence of QT prolongation prior to discharge , and pulmonary function tests will be performed before the patient goes home today .
The patient will follow up with Dr. Ther Ludzjesc at Shiekeu Hospital Medical Centers in Connecticut .
In addition , she will return to this hospital in early February for repeat attempt at electrical cardioversion on Amiodarone .
She will continue her Coumadin until then and arrangements for her readmission can be made through Dr. Iceca Rhaltkaaispehbreun 's office here .
MEDICATIONS :
Other than the addition of Amiodarone 200 mg daily , will be the same as her admission medications .
STA BODEJOVE , M.D. | [
{
"text": "three times a day",
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{... | null | null | null |
16 | Admission Date :
02/21/1991
Discharge Date :
02/26/1991
HISTORY OF PRESENT ILLNESS :
The patient was a 63 year old female with long-standing history of polycythemia vera , managed medically , who on a routine follow-up examination complained of left side pain and had an ultrasound that demonstrated a complex left renal mass .
A computerized tomography scan demonstrated a contrast enhancing complex left renal mass .
Metastatic work-up was negative .
The patient presented for nephrectomy .
HOSPITAL COURSE :
The patient was taken to the operating room by Dr. Suot N. Dragtente on 02-21-91 , where a left radical nephrectomy was performed .
At operation , there was no gross adenopathy or renal vein involvement , and it was felt that the tumor was completely excised .
The patient thereafter had a benign convalescence , and was discharged on the 5th postoperative day .
The oncology fellows from Venbonlea Health followed her course and recommended holding off on her Hydrea while she is hospitalized , and they will follow her as an outpatient and restart her Hydrea when her hematocrit is over 40% . | [
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"text": "02/21/1991",
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{
"text": "02/26/1991",
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"id": "T1",
"type": "DATE",
"val": "1991-02-26",
"mod": "NA"
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{
"t... | null | null | null |
107 | ADMISSION DATE :
02/01/2000
DISCHARGE DATE :
02/08/2000
HISTORY OF PRESENT ILLNESS :
This patient is an seventy eight year old female with history of peripheral vascular disease who is status post above knee to fem pop bypass graft with 6 millimeter PTFE .
This operation was performed for two months of increased rest pain .
Her pain resolved after surgery and she has been doing well since , although at baseline now she is minimally ambulatory from bed to commode .
For the past couple of months the patient has had a non-healing right dorsal foot ulcer which has been increasing in size and started as a pin hole and she does not recollect any trauma , as similar small ulcers developed on the left foot as well around the same time , but that has subsequently healed .
The ulcer was managed conservatively at Har Hospital by Dr. Holes with Silvadene b.i.d. lower extremity non-invasive study obtained at that time showed poor distal right extremity perfusion .
The patient was referred back to Dr. Pop for the possibility of a revascularization procedure .
She is status post angiography today .
She has just finished a ten day course of Ciprofloxacin .
She denies any fevers or chills .
She does have rest pain in the right foot and ankle .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted and taken to the operating room on the following day and she underwent a right fem to below knee popliteal bypass graft using a six millimeter ring PTFE .
She had a strong popliteal doppler pulse intraoperatively and good PVR on the right postoperatively .
The patient did well in the postoperative period .
She was afebrile , her vital signs were stable .
She was making adequate urine output anywhere between 20 to 50 ccs an hour .
Her hematocrit was 26.8 and she was transfused 1 unit of packed red blood cells .
Her diet was advanced from clears to a diet as tolerated .
On postoperative day two the patient was noted to have some swelling in her left lower extremity and this was felt to be a hematoma secondary to her PVR cuff .
There is mild amount of surrounding erythema and the patient was started on Ancef at that time .
The patient was seen by physical therapy .
The area of erythema on her left leg enlarged slightly and the patient was placed on Vancomycin for several days after which time her erythema again began to decrease .
Her right foot remained warm .
She had wounds which were clean , dry and intact and the patient was stable from a respiratory standpoint using her respirator at night .
The patient required an additional blood transfusion during her hospital stay as her hematocrit had decreased to 27 on postoperative day three .
The patient while in bed had her legs elevated .
The patient was tolerating a general diet , she was voiding on her own and the patient was discharged to home as her daughter is a nurse .
She was discharged with PO Keflex that she was to take for the next ten days .
The patient is to follow up with Dr. Pop in one week and the patient was afebrile with stable vital signs at the time of discharge .
LAYMIE ASLINKE , M.D. | [
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311 | ADMISSION DATE :
04/07/97
DISCHARGE DATE :
04/08/97
HISTORY OF PRESENT ILLNESS :
Mr. Vessels is a 49-year-old man status post orthotopic heart transplantation in 1991 at Dautenorwe Stuart Erec Hillpa Of Hospital who is admitted with dyspnea and severe heart failure .
Mr. Vessels 's postoperative course has been marked by CMV infection , hypertension , poorly controlled lipids , peripheral vascular disease , and chronic renal insufficiency with a creatinine of 1.8 or so .
Recently he had documented coronary angiography based on a catheterization performed in January 1996 with moderate to diffuse atherosclerosis .
A repeat angiogram performed a year later showed marked progression of coronary allograft disease .
A biopsy at that time revealed grade 1B rejection with endothelialitis and eosinophils .
He was treated with pulsed IV steroids and Imuran , was augmented with mycophenolate Mofetil .
Chest x-ray showed cariogenic pulmonary edema and he was faring poorly .
Prior to admission he was seen approximately 1 week in the office with mild congestive heart failure .
An echocardiogram then revealed an ejection fraction of 40% and an endomyocardial biopsy revealed no ejection .
HOSPITAL COURSE AND TREATMENT :
The patient was admitted to the hospital via the emergency room where a bedside echocardiogram was performed .
The echocardiogram revealed no pericardial effusion , an ejection fraction of 30% and worsening systolic dysfunction .
Hydrocortisone was given 1 g in an attempt to reverse what was thought to be aggressive coronary allograft vasculopathy .
The patient diuresed and responded to Lasix 100 mg administered in the emergency room and was admitted to a monitored bed .
At 2:30 AM the following morning the patient was found in cardiac arrest .
Despite intravenous fluids , intravenous epinephrine , and multiple attempts at defibrillation , the patient was unable to be resuscitated .
Upon arrival of the covering access physician the patient was being ventilated mechanically and CPR was being performed .
The rhythm revealed sinus tachycardia with no palpable or measurable blood pressure .
There were also runs of ventricular tachycardia which generated into ventricular fibrillation that was refractory to multiple cardioversions .
A pericardiocentesis was attempted with no yield of pericardial fluid .
A transvenous pacing wire was attempted and a pacing rhythm was obtained but with no palpable blood pressure .
In total , the patient was defibrillated 10 times , given 5 courses of intravenous epinephrine , one course of intravenous Atropine and intravenous calcium x 1 in addition to an amp of bicarbonate .
The resuscitation efforts were discontinued at 4:15 AM and were begun at 3:38 AM .
The patient was pronounced dead .
Patient 's mother was informed by Dr. Vessels .
An autopsy permission was granted . | [
{
"text": "1 week",
"start_char": 1028,
"end_char": 1034,
"id": "T4",
"type": "DATE",
"val": "1997-03-31",
"mod": "APPROX"
},
{
"text": "1991",
"start_char": 163,
"end_char": 167,
"id": "T2",
"type": "DATE",
"val": "1991",
"mod": "NA"
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{
"text": ... | null | null | null |
463 | Admission Date :
03/03/1999
Discharge Date :
03/08/1999
HISTORY OF PRESENT ILLNESS :
Mr. Prehekote is an 88-year-old Portuguese speaking only male who was diagnosed with adenocarcinoma of the prostate in 1998 .
He received transurethral resection of the prostate one year ago because of persistent urinary retention .
After that , he was on Lupron and Nilandron hormone therapy .
The patient was admitted on February 23 , 1999 to Eifro Medical Center because of failure to thrive and decreased hematocrit .
He was noted to have elevated BUN and creatinine .
BUN was 34 and creatinine was 2.6 , up from his baseline of 1.0 .
Prostate specific antigen increased from 77.9 to 88 , and the patient also had urinary incontinence and body weight loss .
Further evaluation of his renal failure showed that the patient has bilateral hydronephrosis , most likely obstructive uropathy due to prostate CA in the pelvic area .
Because of the increasing creatinine to 8.0 on February 28 , 1999 , a left nephrostomy tube was placed .
However after the procedure , the patient 's hematocrit dropped to 24 and he was transfused two units of packed red blood cells .
His hematocrit increased to about 30 , but he continued to have hematuria and his renal function only improved very slowly .
He also received Kayexalate for hyperkalemia .
Due to the persistent blood in the urine , he was transferred from Eifro Medical Center to the Retelk County Medical Center for angiographic studies to rule out any vascular injuries .
The patient was transferred to Genearocktemp Ry Health on March 3 , 1999 .
REVIEW OF SYSTEMS :
The patient had constipation with dysuria , but no fever or chills .
No cough .
No chest pain .
No palpitations , history of epigastric pain and body weight loss .
No headache .
No bone pain .
HOSPITAL COURSE :
After admission , urology , nephrology as well as interventional radiology was consulted about the management of this patient .
The specialist concluded that because the patient 's hematuria seemed to be stable and hematocrit to maintain at about 29-30 , there is no urgent need to do an arteriogram which may cause further damage to the patient 's kidney .
Urology consultation thinks that cystoscopy would not add any benefit to the management and only would consider a right nephrostomy if renal function failed to improve .
After admission , the patient was treated conservatively to correct his electrolyte and metabolic acidosis .
He was given blood transfusion , two units when his hematocrit dropped to 29.4 .
After transfusion , the patient 's hematocrit rose to 37.7 on the day of discharge .
The patient was also given sodium bicarbonate to correct his metabolic acidosis .
He continued to pass about 1500-2000 cc of urine a day and his renal function improved slowly with creatinine decreased to 4.2 on the day of discharge .
During this admission , the patient also developed atrial fibrillation with ventricular rate of about 70-80 .
CPK was tracked , but was totally normal .
No beta blockers were given .
A long discussion amongst the specialist , nephrology , urology , interventional radiology , primary oncology as well with the family lead to the conclusion that conservative management may give the patient more comfort than crisis treatment in this well advanced prostate CA .
Dr. Lucreamull discussed the patient 's clinical status and overall situation with the patient 's family and the family decided that Mr. Prehekote could return home with hospice .
The patient 's primary care physician , Dr. Tomedankell Flowayles will manage the hospice issues .
The patient was discharged to home for hospice on March 8 , 1999 . | [
{
"text": "March 3 , 1999",
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"end_char": 1585,
"id": "T7",
"type": "DATE",
"val": "1999-03-03",
"mod": "NA"
},
{
"text": "03/03/1999",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1999-03-03",
"mod": "NA"
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... | null | null | null |
271 | Admission Date :
10/30/2006
Discharge Date :
11/03/2006
Service :
RNM
HPI :
62 yo m w / IgA nephropathy , developmental delay , began HD 7/31 .
Was seen in dialysis on day of admission and was seen to have " raccoon eyes " and HD staff was worried about sending home .
Head CT w / o bleed .
Trauma series normal .
Pt denies abuse or loc associated w / fall , but has noticed several recent falls .
Recent neuro w / u including EEG , carotid u / s , head ct ( old stroke ) , dobutamine-MIBI ( fixed defect and small inferolateral reversible ) were all negative .
Notable
HOSPITAL COURSE :
1. Falls A PT consult was obtained to assist with ambulation .
A social work consult was also obtained and deemed that the patient has appropriate support at home and is safe at home .
The patient was placed on telemetry and had no telemetry events while an inpatient .
He was also seen by the Electrophysiology service , his pacemaker was interrogated and working fine , with no signs of recent ventricular arrhythmia .
The patient his undergoing a TTE prior to discharge to rule out a thrombus .
His TTE showed EF 45-50% , moderate cLVH , abnormal diastolic function , moderate MR , moderate TR and severe LAE .
THere was a question of ionfiltrative cardiomyopathy , and the patient underwent abdominal fat pad biopsy to assess for amyloidosis .
He also currently has an SPEP / UPEP/Beta 2 microglobulin / ACE test that are currently pending .
These should be followed up as an outaptient .
He had carotid ultrasound studies 3 months ago that were normal without evidence for stenosis .
2. Renal - cont MWF HD ; electrolytes have been stable .
Perhaps his recent falls are related to orthostatic hypotension after dialysis .
3. CV -The pt has a small area of reversible ischemia on recent MIBI , and has troponins persistently elevated in the setting of his renal disease .
His troponins remained lower than his baseline levels and there was no suspicion of ACS causing syncope .
He continued on his zocor , cozaar and labetalol .
We will now hold his coumadin given his recent falls and bleeding risk .
His aspirin was restarted prior to discharge .
4. Endo - TSH was 4.7 and normal .
5. Heme :
The patient has a macrocytosis .
His B12 level was 418 and normal .
He does have a history of B12 deficiency in the past , and evidence for peripheral neuropathy BLE which may also be contributing to his recent falls . ? EtOH
6. Psych :
watch for EtOH WD .
THe patient had no signs of alcohol withdrawal .
His serum toxicology screen was negative .
7. Pulm :
COPD and R pleural effusion , off oxygen and stable .
8. GU :
R complex renal cyst , bladder diverticula .
THe patient will need a follow up ultrasound to further evaluate these incidental findings seen on imaging upon admission .
9. ID :
The patient 's urinalysis was normal .
He had no fecal leukocytes .
A c.difficile test is negative on prelim read , however very low suspicion given no recent antibiotic use . | [
{
"text": "7/31",
"start_char": 138,
"end_char": 142,
"id": "T2",
"type": "DATE",
"val": "2006-07-31",
"mod": "NA"
},
{
"text": "3 months",
"start_char": 1526,
"end_char": 1534,
"id": "T4",
"type": "DURATION",
"val": "p3m",
"mod": "NA"
},
{
"text":... | null | null | null |
517 | Admission Date :
2016-03-22
Discharge Date :
2016-04-04
Service :
MEDICINE
History of Present Illness :
75 yo F with CAD s/p MI x4 ( s/p LAD stent. '09 and RCA stent x 2 in. '00 and. '04 ) , CHF with EF 55% , PAF , Inducible Vtach s/p AICD placement , sick sinus syndrome s/p pacer and COPD with restrictive lung disease .
Per daughter , pt was in her USOH until two days prior to admission when she was noted to have a superficial ulcerations on her foot with erythema .
Pt was taken to Bridgewater Chelsea Soldier 's Home Hospital and started on unasyn IV .
Pt awoke later that night and felt unsteady on her feet and sustained a mechanical fall .
Per daughter , pt did not note chest pain , tachycardia , had a good PO intake and no noted seizure activity .
Pt was in severe " back pain " as per daughter which was treated with dilaudid .
CT of the neck revealed a possible C1 fracture and the X-ray at the OSH revealed intratrochanteric fracture of the right femur .
Pt was subsequently transferred to Hallmark Health System for orthopaedic evaluation .
In Monica at Hallmark Health System , pt was seen by the Trauma service where a CT of the neck revealed no fracture ( however , the c-collar was maintained secondary to pain ) .
The orthopaedic service recommended emergent repair of the intratrochanteric fracture secondary to instability .
The Monica stay was complicated by runs of afib to 133 requiring IV lopressor .
ROS :
Pt is very SOB at baseline , not on home ox , no CP at rest , no LE edema , no PND , stable orthopnea ( 2 pillows ) .
Pt ambulates 10 feet with significant fatigue as per daughter .
( ? dec in exercise tolerance ) .
CMED CCU change include discontinuation of coumadin secondary to inc risk of upper GI bleed .
Digoxin , Norvasc and Imdur was also discontinued .
HPI :
75 yo F with CAD s/p stenting , VT , SSS s/p pacer , COPD , presented to OSH 2016-03-21 with foot ulceration .
Started on unasyn , in hospital suffered mech. fall with hip fx .
Transferred to Hallmark Health System 03-22 .
Medically eval not high risk surgery , preop beta blocker given .
ORIF with repair of neck fracture 2016-03-23 .
Expected prolonged extubation course given COPD history , as with colon CA resection surgery .
In PM extubated , transferred to floor 2016-03-23 .
Late 03-23 found with afib and RVR , given beta blocker with min. response , started dilt. drip .
Received 2 mg dilaudid for pain o/n .
This AM with respiratory failure , continued tachycardia on dilt. gtt .
Transferred to unit and urgently intubated ( labs below. )
Of note , a NGT by Xray was not in correct position ? lungs -> possibly used for medication administration this AM .
Brief Hospital Course :
A/P :
75 y F s/p MI x4 , numerous cath , PAF , Inducible VTach s/p AICD and pacer with severe COPD / restrictive lung disease s/p fall with intertrochanteric fracture .
As per CMED CCU , pt requires emergent repair of intertrochanteric fracture to preserve neurovascular function .
Pt is a moderate risk for a needed emergent non-cardiac procedure .
Pt is medically cleared for procedure. , likely has some mile rate related ischemia .
1. Cards :
--- Pre-op B-blocker with goal HR < 70
--- No real utility in MIBI / cath prior to procedure gien previous caths with no significant lesions to be intervened on .
--- V-Tach : pt has AICD in place , however b-blocker should contorl Vtach for now .
--- B-blocker IV , Dilt PRN for PAF
--- Hold coumadin for afib given hx of upper GIB and surgery in AM
--- Continue ASA , plavix
--- ROMI , check AM ECG
2. COPD / Restrictive lung disease :
--- Nebs / MDI PRN
--- no need for steroids now
--- expect prolonged wean given previous history of prolonged wean s/p colonic resection
--- incentive spirometry for atelectasis
3. Hip fracture :
--- pain control with diluadid , tylenol
--- lovenox tonight x1 , hold AM dose per CMED CCU
--- Pt to OR in early AM
4. Anemia :
--- iron studies
--- TSH
---no need for transfusion currently , keep Hct > 30
5. Hypokalemia :
--- 60IV K now
--- continue PO K
--- check lytes in PM
6. Cellulitis :
--- continue unasyn
--- hold off on X-rays for now
7. DM :
--- RISS - tight glucose control pre-op
8. PPx :
--- Protonix , Lovenox , R boot as per CMED CCU
9. Diet :
NPO
10. Code :
Full --> DNR / DNI
CMED course :
ORIF with repair of neck fracture 2016-03-23 .
Had expected prolonged post-op extubation in PACU given COPD history , as with colon CA resection surgery .
In PM extubated , transferred to floor 2016-03-23 .
Late 03-23 found with afib and RVR , given beta blocker with min. response , started dilt. drip .
Received 2 mg dilaudid for pain o/n .
On 03-24 AM p/w with respiratory failure , continued tachycardia on dilt. gtt.
Transferred to unit and urgently intubated .
Of note , there was a question of misplaced NGT .
When NGT tube was pulled out , it was noted to have respiratory-like secretions .
Concern for aspiration of mediations to lungs .
However , evaluation of CXR revealed NGT coiled in esophagus .
Pt 's respiratory distress is most likely on setting of aspiration pneumonia vs. pneumonitis in the setting of depressed mental status secondary to post-operative narcotics .
Pt was pan-cultured and switched from unasyn ( started at OSH for foot ulcer ) to zosyn .
Vanco was added for possible nosocomial infection .
CTA was performed which was negative for PE , but revealed bilateral patchy ground glass opacities c/w aspiration vs. pneumonia vs. edema .
Pt was weaned down on ventilator , minimal secretions noted .
On 03-27 , pt was noted to have depressed mental status off all sedating medications ; mental status improved over the course of the day .
Pt was diuresed .
Atrial fibrillation was rate-controlled on dilt drip .
Dilt drip was discontinued and metoprolol titrated up .
Cardiac enzymes were cycled in setting of rapid AF and were flat .
Initially , pt was noted to be dry with low FeNa and given IVF .
Then , noted to be volume overloaded and diuresed with lasix .
Pt had depressed mental status on transfer to CMED in setting of narcotics .
She was then started on propofol while intubated .
Head CT was negative for acute bleed , mass effect , or stroke .
Mental status improved during times when propofol was held .
On 03-27 , pt was noted to have significantly depressed M.S. off propol improved off sedation .
All sedating medications including prn narcotics were held and mental status cleared somewhat .
s/p hip fx repair : started on lovenox for anti-coagulation .
Given standing NSAID , tylenol for pain control .
opiates used very sparingly in setting of MS change
On transfer to floor team from CMED active issues and plan included :
Resp failure / COPD :
Initially got steroids upon intubation .
Off for days now .
Extubated on 03-31 .
Still tachypneic and hypoxic on room air .
Lung sounds fairly clear .
? COPD vs atelectasis as cause of hypoxia .
On Blake , Nancy pe less likely
- atrovent standing .
prn albuterol only given A fib with RVR
- inhaled steroids
- obtaining pcp set of Reginald
Fever :
In the ICU .
Had received unasyn , vanc , zosyn during hospital course for cellulitis and other unclear reasons , including possible vent associated pna .
No true source found .
Afebrile > 24 hours off abx .
- culture if spikes .
No abx unless source found
a.fib with RVR - Has ppm , so can have lot of nodal agents .
Now rate controlled on metop 125 tid and dilt .
30 QID .
Titrate prn .
- continue nodal agents
- consider anti coag for cva prevention , but wait until ambulating better
CAD : on asa , b blocker , ace .
No statin .
need to clear with family
Heme - anemic .
Unclear baseline .
Possible anemia 03-02 operative blood loss .
Follow hct daily Goal > 28
Neck : never had c spine cleared by neurosurg .
Had fall pta with ? fx on initial CT , neg fx on f/u ct .
- flex / ext films done
- will clear with neursurg prior to removing hard collar
Overnight on pt 's first evening on the floor , she had episode of desaturation with inc O2 requirement ( 4L -> 6L -> sating 91% on NRB ) - CXR with worsening - non responsive to lasix .
Family meeting held and pt made clear wishes after extubation that she does not want to be intubated again and made DNR / DNI .
No BIPAP .
Now pt lethargic and min responsive .
All four children in pts room and agree on CMO - want to d/c c-collar and start morphine ggt .
Discussed with night float cover Dr. Dennis COmmander and Dr. Mike French .
Although Dr. Ray will be covering pt today , Dr. Stephanie Wilson spoke with family this morning and has noted that pt is CMO .
EP was called to deactivate pt dual chamber ICD as per family wishes .
On exam , pt lethargic , responsive to pain but not voice , with NRB in place ; obvious inc wob .
IV in R foot for access .
Family at bedside .
afebrile ;
BP : 159-161-139-98 ( after morphine )/ 69 HR : 148 --> 88 ; rr : 28-40 O2 : 94% NRB
As above , made CMO after meeting with NF team and family and reconfirmed with primary medical team on 04-02 .
Start morphine ggt and titrate to comfort .
D/c 'ed all lab draws / vitals .
Prn nebs for comfort .
Family at bedside and aware and in agreement of plan .
Morhpine ggt titrated up to 18 mg / hr by monday morning and pt expired 04-04 at 7:40 am . | [
{
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"id": "T2",
"type": "FREQUENCY",
"val": "r4",
"mod": "NA"
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"text": "'09",
"start_char": 149,
"end_char": 152,
"id": "T3",
"type": "DATE",
"val": "2009",
"mod": "NA"
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{
"text": "x 2",
"st... | null | null | null |
701 | ADMISSION DATE :
11/12/2002
DISCHARGE DATE :
11/15/2002
HISTORY OF PRESENT ILLNESS :
This is a 44 year-old right handed woman with Down 's syndrome who presents with increased falling and gait unsteadiness and an increased inability to perform her activities of daily living over the past three years .
The diagnosis of Alzheimer 's was made in 1998 .
The patient had an MRI at an outside hospital which showed enlarged lateral ventricles and the possible diagnosis of normal pressure hydrocephalus was entertained and the patient was admitted for diagnostic lumbar puncture .
HOSPITAL COURSE :
The patient was admitted to the Arkzie- Memorial for lumbar puncture .
On the night of admission lumbar puncture was attempted on the floor , but we were unable to get cerebral spinal fluid due to difficulty with compliance with the patient who was severely agitated and would not comply with the examination .
On hospital day the patient underwent conscious sedation in the operating room where lumbar puncture was performed .
Opening pressure was 17 and approximately 20-25 cc of CSF was removed .
CSF was notable for sugar level of 65 and total protein level of 56 .
OTHER LABORATORIES THAT WERE NOTABLE :
Vitamin B12 of 855 , folic acid of 15.4 .
Chem-7 was within normal limits .
Tube and requisition of the CSF labeled tube # 1 was notable for color pink , turbidity slight , xanthochromia yes , red blood cells 3,800 , white blood cells 3 , neutrophils 58 , bands 4 , lymphs 29 , monos 6 , eos 2 and basos 1 .
CSF tube labeled # 4 was notable for CSF color pink , CSF turbidity slight , CSF xanthochromia yes , CSF RBCs 3,900 , CSF white blood cells 3 , CSF neutrophils 61 , CSF bands 3 , CSF lymphs 31 , CSF monos 1 , CSF eos 3 , CSF basos 1 .
CSF gram stain was notable for no polys and no organisms seen .
The fluid culture was no growth to date .
One day prior to lumbar puncture , an aerobic culture was similarly pending .
Lyme capture was pending and at the time of discharge .
Other notable tests :
RPR card test was negative .
Because of poor compliance with the gait examination it was very difficult to assess changing gait post lumbar puncture .
The patient 's gait remained wide based and shuffling and requiring assist .
Her mental status remained similarly to her admission examination .
The patient was discharged to home on 11/15/02 with instructions to the family to observe her gait in her home environment and to observe her behavior in her home environment over the next day and to report back to the primary neurologist , Dr. Flythegach , as to changes . | [
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"type": "DATE",
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"mod": "NA"
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"text": "One day",
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{
"... | null | null | null |
502 | Admission Date :
2012-05-24
Discharge Date :
2012-06-19
Service :
NEUROSURGERY
History of Present Illness :
57 yo right handed male with seizure history since 1988 , s/p craniotomies x 3 ( most recently 05-05 ) for oligodendroglioma .
The patient began having generalized tonic - clonic seizures in 1988 , which at the time were thought to be related to asthma medications .
At this time , his head CT was negative , and he was treated with Dilantin and Phenobarbital .
However , he continued to have left arm focal motor seizures and problems thinking .
In 2001-08-31 he stopped his medication and had a generalized tonic - clonic seizure in 12/94 .
He was diagnosed by biopsy with oligodendroglioma , and gross total resection by Dr. Redner in
95 revealed a low-grade oligodendroglioma .
He was followed by Dr. Gregory Dumas , with serial MRI 's.
In 2011-05-02 , he was requiring more ativan to control his seizures , and was increasingly disoriented and forgetful with headaches .
He had a repeat total resection in 4/04 by Dr. Peter Hoadley at Hallmark Health System which revealed anaplastic oligodendroglioma grade III .
He had radiation following the resection and was doing well on monthly Temodar until 2012-04-23 when he had a marked change in behavior , his balance was off , speech slurred , and he had difficulty using the computer .
A head MRI on 2012-04-24 revealed increasing tumor infiltration with increased edema and mass effect .
He underwent a right craniotomy with resection and gliadel wafers on 2012-05-02 at Hallmark Health System by Dr. Ackley .
Came for neurosurgery follow up on 05-21 , and had been having clear fluid leaking from his incision , as well as frontal headache , imbalance , bumping into things with his left leg and worsening tremors .
He was admitted for Lumbar drain placement
Brief Hospital Course : patient was admitted on 2012-05-24 after having drainage from his incision for the last couple of days .
He was seen in the brain tumor clinic on 05-21 and stitches were placed in the incision , however it continued to leak .
He had a lumbar drain placed .
He c/o of abd pain and distension on 05-25 he had a kub done which was negative .
on 05-26 he continued to c/o of epigastric pain had a chest x-ray done to due to decreased lung sounds .
The Chest x-ray showed free air .
general surgery was consulted and the patient was taken to the OR for exploratory laproratomy .
he was found to have a perforated sigmoid diverticulum .
He had a colostomy and partial colectomy .
patient recovered well from colocetomy .
He was found to have an abd abcess which was drained via CT guidance on 06-01 .
On 06-02 his lumbar drain pulled out .
he had to have it replaced , however , because his head incision began to leak again .
On 06-03 he was taken back to the OR for debridement of his head wound with removal of the remaining gliadel waffers .
He tolerated the procedure well , postop however he had a grand mal seizure and was intubated and sent to the ICU .
ID was consulted for both the abd abcess and possible meningitis given the large amount of wbc in the csf cultures .
Patient was placed on vancomycin 1 gm IV q12 and zosyn .
He was kept on antibiotics until 06-17 .
Neurologically he slowly woke up after the seizures and was extubated on 06-03 .
He was transfered to the step down unit and had his lumbar drain slowly weaned .
The lumbar drain was d/ced on 06-14 .
He had a head Ct which remains stable and head wound remain dry .
Neurologically he is awake and alert and oriented x 3 he is 07-05 in all muscle group bilat .
He follows commands , he is out of bed ambulating with max assist .
PT and OT are recommending rehab .
He will follow up with Dr Fisher the general surgeon in two weeks and follow up in the brain tumor clinic in two weeks for stitch removal .
H ewas switched to oral CIpro for the pelvic abcess and will continue it until he has his followup with infectious disease in 2 weeks . | [
{
"text": "4/04",
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"id": "T12",
"type": "DATE",
"val": "2004-04-01",
"mod": "APPROX"
},
{
"text": "monthly",
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"id": "T13",
"type": "FREQUENCY",
"val": "RP1M",
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{
... | null | null | null |
462 | Admission Date :
2018-05-12
Discharge Date :
2018-05-14
Service :
Neonatology
HISTORY OF PRESENT ILLNESS :
Melba Barnett is the 3.710 - kg ( 8 - pound 3 - ounce ) product of a term gestation .
He was born to a 35 - year-old gravida 2 , para 1 ( now 2 ) mother .
Readmitted for hyperbilirubinemia on day of life #5 .
The pregnancy was benign with an EDC of 2018-05-07 .
Prenatal screens were O+ , antibody negative , hepatitis surface antigen negative , rapid plasma reagin nonreactive , rubella immune , group B strep positive .
The infant delivered vaginally with Apgar scores of 9 at one minute and 9 at five minutes .
Alleyne blood type is O+ / Coombs negative .
He was readmitted for phototherapy on day of life #5 for a bilirubin of 23.3 .
SUMMARY OF HOSPITAL COURSE :
RESPIRATORY :
Without issues on this admission .
Breath sounds are clear and equal .
CARDIOVASCULAR :
Without issues on this admission .
He had a regular heart rate and rhythm , no murmur , and pulses were 2+ and symmetric .
FLUIDS , ELECTROLYTES AND NUTRITION :
Alleyne birth weight was 3.710 kg ( 8 pounds / 3 ounces ).
His weight on this admission was 3.505 kg ( 7 pounds / 12 ounces ).
Linda is breast feeding every 3 hours and supplementing with expressed breast milk .
He is feeding well .
His discharge weight is 3585 grams ( 7 pounds 13 ounces ) .
GASTROINTESTINAL :
Alleyne bilirubin on 2018-05-09 was 10.4 ; at which time he was discharged to home .
At the primary pediatrician 's office on 2018-05-12 his bilirubin had been 23 , at which time he was readmitted to the HealthSouth Rehab Hospital of Western Mass. and double phototherapy was started .
His bilirubin on 05-13 was 18.4 ; and on 05-14 it was 14.7 .
Phototherapy was discontinued on 2018-05-14 , and a rebound bilirubin will be checked in the pediatrician 's office .
HEMATOLOGY :
The hematocrit on 05-12 was 48.7 with a reticulocyte count of 1.9 , and his blood type is O+ / Coombs negative .
INFECTIOUS DISEASE :
No issues on this admission .
NEUROLOGICAL :
The infant has been appropriate for gestational age .
SENSORY :
Auditory hearing screening was performed with automated auditory brain stem responses , and the infant passed both ears on his previous admission .
Hearing screens were repeated on 2018-05-13 and he passed both ears .
PSYCHOSOCIAL :
Family is invested and involved . | [
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"text": "3 hours",
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"end_char": 1202,
"id": "T5",
"type": "FREQUENCY",
"val": "RT3H",
"mod": "NA"
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{
"text": "2018-05-09",
"start_char": 1371,
"end_char": 1381,
"id": "T6",
"type": "DATE",
"val": "2018-05-09",
"mod": "NA"
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... | null | null | null |
676 | Admission Date :
02/19/1991
Discharge Date :
02/25/1991
HISTORY OF PRESENT ILLNESS :
This is an 81-year-old who presented with postmenopausal spotting and had an endometrial biopsy which was read at the Etearal Etsystems/ Hospital as showing grade I adenocarcinoma .
Accordingly she presents for operative therapy at this time .
HOSPITAL COURSE :
The patient was brought to the Operating Room on 2-19-91 where she had an exploratory laparotomy , TAH / BSO , and omental biopsy .
She had a normal abdominal exploration of a small uterus with superficial invasion on gross examination , normal ovaries .
Washings were sent .
A subfascial J-P was left .
The patient did well postoperatively and had a regular diet by the third postoperative day .
Subfascia drain was discontinued .
The patient 's postoperative Hct was 34 . | [
{
"text": "02/19/1991",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1991-02-19",
"mod": "NA"
},
{
"text": "this time",
"start_char": 318,
"end_char": 327,
"id": "T2",
"type": "DATE",
"val": "1991-02-19",
"mod": "NA"
},
{
"... | null | null | null |
11 | Admission Date :
06/11/1991
Discharge Date :
06/22/1991
HISTORY OF PRESENT ILLNESS :
Patient is a 28 year old gravida IV , para 2 with metastatic cervical cancer admitted with a question of malignant pericardial effusion .
Patient underwent a total abdominal hysterectomy in 02/90 for a 4x3.6x2 cm cervical mass felt to be a fibroid at Vanor .
Pathology revealed poorly differentiated squamous cell carcinoma of the cervix with spots of vaginal margins and metastatic squamous cell carcinoma in the cardinal ligaments with extensive lymphatic invasion .
Patient was felt to have stage 2B disease and post-operatively , she was treated with intracavitary and external beam radiation therapy and low dose Cisplatin .
On ultrasound in 02/91 , the patient was found to have bilateral cystic adnexal masses confirmed on physical examination .
She underwent exploratory laparotomy and had a bilateral salpingo-oophorectomy and appendectomy .
Pathology was negative for tumor and showed peritubal and periovarian adhesions .
The patient now presents with a three to four week history of shortness of breath and a dry non-productive cough .
She was evaluated by Dr. Mielke , a Pulmonologist , who found her to be wheezing and performed pulmonary function tests which showed an FEV1 of 1.1 and an FVC of 1.8 .
She was admitted to Weekscook University Medical Center with a diagnosis of possible asthma .
Room air arterial blood gas showed a pO2 of 56 , a pCO2 of 35 , and a pH of 7.52 .
EKG showed sinus tachycardia at 100 and echo revealed pericardial effusion , a 10 mm pulsus paradoxus was noted , and no evidence of tamponade .
Given the patient 's history of cervical cancer , the pericardial effusion was felt most likely to be malignant .
She was therefore transferred to the Retelk County Medical Center for further care .
HOSPITAL COURSE :
The patient was admitted for a new pericardial effusion which was felt most likely to be secondary to metastatic cervical cancer .
There was no evidence of tamponade .
An echocardiogram was scheduled and Cardiology was consulted .
Echocardiogram showed moderate anterior pericardial effusion of approximately 600 cc with diastolic indications of the right ventricle and low velocity paradox .
Cardiology did not feel that tamponade at this time was a concern and that a tap need not be performed .
She continued to have pulmonary wheezing , unknown origin , without history of asthma .
Her steroids were tapered and Pulmonary was consulted who recommended a CT scan of the chest to evaluate the lung parenchyma , induce sputum for CBC , arterial blood gas , continuing of the beta agonist inhalers , and trial of steroid inhalers .
They felt it was most likely a malignant lymphangitic spread with pericardial involvement versus infectious , other cardiovascular causes , or viral bronchiolitis .
She had pulmonary function tests repeated which showed an FEV1 of 36% of predicted and FVC of 56% of predicted .
Room air arterial blood gas showed a pH of 7.45 , pO2 of 63 , a pCO2 of 41 , and fairly significant AA gradient .
She was continued on two liters of oxygen awaiting her CT scan on 06/14 and she developed a new junctional rhythm with a question of a new rub versus murmur on examination .
Cardiology felt she had a rub and her pulsus was still 10 .
EKG showed an ectopic low atrial P and they thought she was still stable without evidence of tamponade .
She should have a follow-up echocardiogram .
Echocardiogram showed left ventricle at the upper limits of normal for size , low normal function , moderate to mild effusion with pericardial pressures exceeding right atrial pressures , and right ventricular pressures at various points of patient 's cycle without any change in the effusion from 06/11 .
Thoracic Surgery was also consulted and they felt that there was no need for a pericardial window at the time .
She should be continued with pulmonary oximetry testing .
She underwent her CT scan .
This showed lymphangitic spread of cancer in the chest , question of pulmonary nodules in the chest , pericardial effusion , multiple liver metastases , decreased function of the left kidney , dilated left intrarenal collecting system and proximal ureter , and periaortic lymphadenopathy .
Pulmonary felt this was consistent also with lymphangitic spread and they did not feel that a bronchoscopy would be of any assistance at this time .
Chemotherapy for metastatic cervical cancer was discussed with the patient and she was started on 5-FU 800 mg per meter squared days 06/18 , 06/19 , and 06/20 .
She also received Cisplatin 35 per meter squared on 06/19 and Ifex and Mesna on 06/18 .
She was noted , on 06/16 , to have numerous erythematous maculopapules on her back and chest .
Dermatology was consulted and they felt that this was most likely steroid acne .
They therefore felt a rapid steroid taper was indicated and topical Erythromycin if desired by the patient .
The patient 's shortness of breath and wheezing continued but without change .
Her cardiac examination remained the same and there continued to be no evidence of tamponade .
Cardiology felt that follow-up echo was indicated on 06/18 as she had another echocardiogram which showed no change or evidence of tamponade .
They therefore felt that she could be continued to be followed by examination .
She had some mental status changes with confusion and hallucinations on 06/18 originating from narcotics versus decreased pO2 .
The Ifex was held as it was felt that it could have precipitated the mental status changes and that she was to receive no further Ifex .
She had no further hallucinations since stopping the Ifex .
Psychiatry was also consulted to help her with the changes she was feeling since her new diagnosis .
She was hooked up with support services in Collot Ln , Dugo , Indiana 68961 for further counselling and given Xanax for symptoms of anxiety .
She continued to have no change in her shortness of breath or cardiac examination and was discharged home on 06/22/91 after completing her 5-FU and Cisplatin chemotherapy . | [
{
"text": "a three to four week",
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"text": "06/11/1991",
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"mod": "N... | null | null | null |
272 | Admission Date :
2011-09-24
Discharge Date :
2011-09-27
Service :
ADMISSION DIAGNOSIS :
HISTORY OF PRESENT ILLNESS :
The patient was a 79 - year-old gentleman found down at home unresponsive by his wife after lunch .
He had an unwitnessed fall .
He had no history of headaches or recent illness .
He remained unresponsive when the ambulance arrived .
Systolic blood pressure was reported 250 on arrival to the Mass. Eye & Ear Infirmary Emergency Department .
He was intubated and given Versed and Fentanyl .
His GCS was reported as 3 on arrival to the Emergency Department .
HOSPITAL COURSE :
He was admitted to the Neuro Surgical Intensive Care Unit for close monitoring and Neuro-checks .
A Vent drain was placed to monitor and CP and relieved fluid .
He received 12 U of platelets .
His Intensive Care Unit stay was unremarkable .
His neurologic exam did not change significantly .
His ICPs were in the range of 11-22 , and he was weaned off the Nipride drip .
He developed extensive posturing .
A CTA showed diffuse subarachnoid hemorrhage and intraventricular blood but no evidence of an aneurysm .
A repeat CT on 09-26 showed worsening of the diffuse subarachnoid hemorrhage and a new cerebellar hemorrhage .
The family was informed of the patient 's condition and repeat scan .
A family discussion resulted in the decision to make the patient comfort measures only .
The patient was placed on a Morphine drip and extubated and passed away at 10:55 a.m. on 2011-09-27 .
The family was notified of the patient 's passing .
The medical examiner has also been notified of the passing of the patient .
Shawn B Crawford , M.D.
46-411
Dictated By : Linda P.F. Clark , M.D.
MEDQUIST36
D : 2011-09-27 11:53
T : 2011-09-27 12:41
JOB # : 63722
Signed electronically by : DR. Carlos Warner on : TUE 2011-09-27 3:42 PM
( End of Report ) | [
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717 | Admission Date :
2011-11-18
Discharge Date :
2011-11-22
Service :
CCU
HISTORY OF PRESENT ILLNESS :
The patient is a 61 - year-old Caucasian-speaking woman with a history of hypercholesterolemia and tobacco use who developed waxing and waning left substernal chest pain with radiation to the left shoulder on 2011-11-17 which lasted that entire day .
Upon waking on the morning of admission , she had 10/10 chest pain associated with nausea .
She presented to Charlton Memorial Hospital Hospital Emergency Department with inferior ST elevations ; at which time she became acutely hypotensive to a systolic blood pressure of 70 to 80 after receiving one ublingual nitroglycerin .
She then became bradycardic which responded to atropine and intravenous fluids .
In addition , she was given aspirin , Plavix , heparin , and morphine .
Immediately prior to transfer to Worcester State Hospital , she went into ventricular fibrillation arrest at 12:30 p.m. , at which time she was intubated and defibrillated back to sinus rhythm after five shocks .
She received an amiodarone bolus of 150 mg intravenously and was continued on an amiodarone drip while CMED CSRU-flighted to Boston Regional Medical Center_ where she underwent a catheterization .
The cardiac catheterization revealed a total occlusion of the proximal right coronary artery and diffuse right coronary artery disease .
She received three stents to the right coronary artery which was complicated by a proximal dissection .
She had good post percutaneous coronary intervention angiographic results .
Incidentally , an aortogram during the catheterization revealed a Debakey class I aortic ascending aneurysm , and the patient had a pulmonary capillary wedge pressure of 20 at the time of catheterization .
She was transferred to the Coronary Care Unit in stable condition and still intubated .
HOSPITAL COURSE :
1. CARDIOVASCULAR SYSTEM :
On the night of admission , the patient experienced post catheterization hypotension which required intravenous fluids and dopamine .
Electrocardiogram the following morning revealed normalization of her ST segments with evolution of Q waves .
Her dopamine was weaned off the following day , and her heparin was discontinued secondary to a right groin hematoma which had developed after the sheath had been pulled out by the fellow .
Her creatine kinases climbed ; reaching a peak of 3523 , which was down to 1500 at the time of discharge .
Also noted on the day of 11-20 , the patient self-extubated herself .
For her coronary artery disease , status post catheterization , she was given Integrilin for 18 hours .
She was continued on aspirin , Plavix , and Lipitor .
For her rhythm , amiodarone was discontinued as she was maintained in sinus rhythm after moving to the floor .
For pump , once transferred out of the Coronary Care Unit on 2011-11-20 , a beta blocker was begun at 12.5 mg of Lopressor p.o. b.i.d. which was titrated to 25 mg at the time of discharge .
Also , at the time of discharge , for increased afterload reduction , she was started on lisinopril 5 mg p.o. q.d.
On 2011-11-21 , the patient experienced atypical chest pain which was made worse with inspiration and movement .
It was not associated with any nausea or vomiting .
It did not radiate .
It was felt to be pain secondary to her self-extubation and noncardiac chest pain .
An electrocardiogram was checked which revealed no ST changes , and there was no increase in her downward trending creatine phosphokinases .
No further intervention was done .
The patient was treated with Tylenol orally as well as Ativan for anxiety that she had about going home .
She was pain free on the day of discharge .
Regarding her aortic ascending aneurysm , Cardiothoracic Surgery was consulted regarding further workup .
At their request , a CT scan of the chest with contrast was performed on the day of discharge .
Dr. Streeter from Cardiothoracic Surgery will follow up with the patient for further management in approximately one month as an outpatient .
His office will contact her to make that appointment .
2. PULMONARY SYSTEM :
As stated above , the patient self-extubated herself .
She complained of a sore throat which was likely the etiology of her atypical chest complaints .
This resolved with Tylenol and as needed doses of oxycodone .
Her lungs remained clear to auscultation bilaterally throughout the remainder of her hospital course .
At the time of this dictation , the CT of her chest was still pending .
The official result was not yet in .
3. FLUIDS / ELECTROLYTES / NUTRITION :
The patient 's electrolytes sere managed daily and repleted on an as needed basis .
She did receive intravenous K-Phos for a low phosphorous of 1.5 .
Her phosphorous rose appropriately to 3.6 at the time of discharge . | [
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{
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267 | Admission Date :
2013-09-22
Discharge Date :
2013-09-26
Service :
SURGERY
History of Present Illness :
79F Pmhx CHF,COPD , found down at home , pulseless - CPR initiated w/ conciousness regained on scene .
At OSH ABG 7.19/94/110 , BiPAP started .
Pt found to be hypothermic w/ WBC 17 ( pt on steroids ) pnuemobilia and thickening of sigmoid .
Currently on Nasal cannula 02 + hemodymamically stable .
Brief Hospital Course :
79F w/ a multiple medical problems including Sylvia ( EF20% ) , COPD ( on home O2 ) , found down at home , pulseless - CPR initiated w conciousness regained on scene .
At OSH ABG 7.19/94/110 , BiPAP started .
Pt found to be hypothermic w/ WBC 17 ( pt on steroids ) pnuemobilia and thickening of sigmoid .
Pt was transferred to The Hospital for Orthopedics for further management with wishes from the pt and family to reverse DNR/DNI status if surgery was indicated .
On transfer , the pt had VSS with a mildly tender abdomen without peritoneal signs .
It was decided to treat her conservatively with bowel and IV antibiotics .
She improved and was tolerating PO 's without difficulty after passing a swallow study .
Her Cpine was clearly with both a negative CT Cspine and clinical exam .
Her groin CVL was DC 'd after a L SC SVL was palced .
CXR confirmed good position and no PTx .
Overnight on HD 3 , pt became mildly agitated and an ABG was drawn which showed a severe resp acidosis and BiPAP was initiated .
The pt subsequently developed severe hypoxia with hypotension .
A CXR was obtained which showed complete collapse of the L lung thought to be a result of bursting a bleb associated with her severe COPD .
Family did not want a chest tube placed and decided to make the pt CMO measures .
On HD 4 pt continued to show a severe respiratory acidosis , was continued on a morphine drip , and was difficult to arouse .
At 6pm pt 's respiratory status worsened and she died . | [
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"text": "Overnight",
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273 | Admission Date :
2014-10-14
Discharge Date :
2014-10-17
Service :
CCU
HISTORY OF PRESENT ILLNESS :
This is a 55 - year-old Caucasian speaking male who is a smoker and has a family history of coronary artery disease , as well as a personal history of hypertension , who experienced multiple episodes of 10/10 substernal chest pain radiating down his left arm last night with his daily activities .
Each episode lasted approximately 15 minutes in duration and resolved on their own .
This morning while landscaping the patient had unremitting 12-05 pain with shortness of breath and diaphoresis .
He presented to Deaconess-Nashoba Hospital Hospital and the first EKG was found to have ST elevations in V1-V3 of 1-2 mm with T wave inversions in V4-6 , I and L , which progressed to 3-0167 W. Seventh Ave. elevations within 20 minutes .
Heparin and nitroglycerin drip were started with 10 mg of IV Retavase half dose .
He was transferred to the North Adams Regional Hospital for catheterization .
Once at Hahnemann General Hospital he received heparin and Integrilin .
Coronary angiography revealed left main , left circumflex and RCA normal and left LAD with 99% midstenosis .
A Hepacoat stent was placed with no residuals but good flow after nitroglycerin and diltiazem .
The chest pain persisted afterwards and a relook catheterization was performed that revealed no occlusions .
The right heart catheterization revealed a cardiac output index of 4.11 and 2.15 respectively .
RA pressure was 13 , RV pressure 45/7 , wedge 27 and PA pressures of 42/21 .
He was transferred to the CC for monitoring and he denied having further pain , shortness of breath , nausea or vomiting .
At baseline the patient denies any previous chest pain , pressure , dyspnea on exertion , orthopnea , PND or palpitations .
HOSPITAL COURSE :
For his coronary artery disease , aspirin was started at 325 .
Plavix was started at 75 mg a day , Lipitor 20 mg per day , metoprolol 25 mg twice a day to be titrated up as tolerated and on day two of admission an ACE inhibitor was started .
Captopril 6.2 3 x a day and titrated up .
A lipid panel was checked and found to be within normal limits , although it was noted this was in the post MI setting and the lipid panel could be falsely low .
Serial CK s were followed with a CK peak of 433 .
Hypertension was managed with beta blocker and ACE inhibitor and Integrilin was continued post MI for 18 hours .
Rhythm was maintained at normal sinus , monitored on telemetry without ectopy .
EKG s were followed for normalization .
The patient had an echocardiogram on day two of admission , which revealed a mildly dilated left atrium , mild symmetric LVH , normal LV cavity size , mild region LV systolic dysfunction , arresting regional wall motion abnormality including focal apical hypokinesis , a normal right ventricular chamber size and free wall motion , a moderately dilated aortic root , a mildly dilated ascending aorta , normal aortic valve leaflet , normal mitral valve leaflet and no pericardial effusions .
The patient was normal volume and displayed no evidence CHF signs or symptoms .
The risk factors were addressed .
The patient was told repeatedly that he needed to stop smoking and was given a nicotine patch and his primary care provider was called to discuss outpatient plans to help the patient stop smoking .
The patient was advised to have a low fat / low cholesterol diet , was cleared by PT and advised to do cardiac rehabilitation .
He was advised the importance of each of his and compliance with each of these medications and was told he needed close followup with a cardiologist .
For renal , his creatinine was monitored and the dye load and the catheterization .
It was normal and did not increase .
Gastrointestinal :
The patient was given a low fat / low cholesterol diet .
His electrolytes were monitored and repleted carefully .
He had normal bowel movements and had GI prophylaxis throughout his stay .
For hematology , the patient 's hematocrit and platelets were monitored after the catheterization .
They were normal and did not change and the patient received pneumatic boots for DVT prophylaxis .
On day two of admission , the patient ambulated with PT and was moved to the regular floor .
On day three of admission , the patient felt that his strength was back to baseline .
He denied ever having any chest pain , chest pressure , shortness of breath , dyspnea on exertion and he was discharged to home .
He was told to return to the emergency department if he had any chest pain , pressure , difficulty breathing , nausea , light-headiness or dizziness .
He was advised to take all of his medications .
An appointment was established for him to see his primary care doctor , Dr. Stella Booth on Maynard , 2014-10-20 and the patient was referred to Dr. Granville Hamers , at Ware in cardiology to be seen in two weeks .
Dr Marcus assistant was called and she stated that she would call the patient with an appointment .
FINAL DIAGNOSES :
1. ST elevation myocardial infarction .
2. Hypertension .
MAJOR SURGICAL AND INVASIVE PROCEDURES :
Cardiac catheterization and stent placement in the mid left anterior descending artery . | [
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"t... | null | null | null |
313 | ADMISSION DATE :
06/22/94
DISCHARGE DATE :
07/04/94
HISTORY OF PRESENT ILLNESS :
This 68 year old female had rheumatic fever in the past , and has had chronic atrial fibrillation .
She has had progressive heart failure and an evaluation demonstrated worsening mitral stenosis with severe pulmonary hypertension .
Because of her deteriorating status , she underwent prior cardiac catheterization , which confirmed severe mitral stenosis with secondary tricuspid valve regurgitation due to pulmonary hypertension .
She was referred for valve surgery .
HOSPITAL COURSE :
The patient was brought to the Operating Room , on April 22 .
She underwent a mitral valve replacement , utilizing a 27 mm .
St. Jude prosthesis , and tricuspid valve reconstruction by ring anuloplasty .
She weaned from cardiopulmonary bypass with good hemodynamics .
She initially awoke after surgery , with good hemodynamics .
She was transiently in sinus rhythm , but atrial fibrillation recurred .
She was extubated on the third postoperative day , and was initially slightly agitated and confused , largely due to an Intensive Care Unit psychosis .
She continued to improve , with mobilization of fluid .
She was initially noted to have a slow ventricular response in atrial fibrillation , but this gradually improved over time .
She was initially noted to be somewhat anemic , and received transfusions .
Coumadin was restarted , and her anticoagulation came into range .
She was ultimately discharged with a heart rate in the 90 's , and with resolving edema and a clear chest . | [
{
"text": "the third postoperative day",
"start_char": 1008,
"end_char": 1035,
"id": "T3",
"type": "DATE",
"val": "1994-06-25",
"mod": "NA"
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{
"text": "06/22/94",
"start_char": 19,
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307 | Admission Date :
2014-04-19
Discharge Date :
2014-04-20
Service :
CMED CSRU
HISTORY OF PRESENT ILLNESS :
Baby Thomas Moss was born at 39 and 1/2 weeks gestation to a 20-year-old gravida IV , para III , now IV woman .
The mother 's prenatal screens were blood type B positive , antibody negative , rubella immune , RPR nonreactive , hepatitis surface antigen negative and group B strep negative .
This pregnancy was complicated by a prenatal diagnosis of a congenital cystic adenomatoid malformation
( CCAM ).
The mother was followed in the Massachusetts General Hospital Advanced Fetal Care Center and was followed by Dr. Ralph Wilson .
The mother had spontaneous onset of labor and progressed to a spontaneous vaginal delivery .
The infant emerged vigorous with Apgars of 9 at one and five minutes .
His birth weight was 2905 grams . | [
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... | null | null | null |
38 | Admission Date :
2012-05-21
Discharge Date :
2012-05-25
Service :
CMED CCU
HISTORY OF PRESENT ILLNESS :
This is a 55-year-old female with multiple prior admissions for pneumonia , COPD , asthma exacerbation , over 3 weeks of upper respiratory like infection unremitting with increased nebulizer treatments at home .
The patient saw her PCP and was known to have an oxygen saturation of 82 to 85 percent on room air .
She was referred to the Emergency Department .
In the Emergency Department , the patient received Zithromax , ceftriaxone , and Flagyl .
Chest x-ray was remarkable for a questionable left lower lobe infiltrate .
The patient received nebulizer treatment with oxygen saturations increasing up to 98 percent on room air .
HOSPITAL COURSE :
Shortness of breath .
The patient was maintained on albuterol nebulizer treatments and Ipratropium nebulizer treatments , as this was apparently thought to be related to her chronic obstructive pulmonary disease .
Given the presence of consolidation on chest x-ray , however , and previous history of pneumonia , the patient was maintained on antibiotics of Zithromax 500 mg daily and ceftriaxone .
The patient was also started on Solu-Medrol IV for active airway disease component of her shortness of breath .
The patient was maintained on supplemental oxygen and sputum production was maximized with the help of an Acapella device and respiratory therapy .
Mucomyst was also considered as a mucolytic component towards secretions .
Adrenal insufficiency .
The patient was maintained on IV Solu - Medrol 60 mg q. 8 h.
Chest soreness .
The patient describes chest discomfort without any significant EKG changes .
The patient was maintained on Percocet p.r.n. for pain relief .
This was thought to be related to musculoskeletal .
There was no evidence of acute rib factors on her chest x-ray .
GI .
The patient was maintained on PPI for reflux disease and known gastritis .
CMED .
The patient has a history of neurogenic bladder and , therefore , she required a Foley catheterization .
Endocrine .
The patient was on Levoxyl at home as her home dose for hyperthyroidism .
CMED CSRU transfer .
The patient was transferred on the evening of 2012-05-22 to the ICU given persistent carbon dioxide retention and respiratory acidosis and the intermittent mental status changes .
The patient had had ABG on the floor , which prompted her to transfer to the ICU .
Her pH was 7.23 , PCO2 73 , PO2 146 on a nonrebreather .
The patient had BiPAP initiated once she reached the unit , but did not tolerate it , becoming apneic and obstructing .
The patient was switched to 2 liters nasal cannula and oxygen saturating at 98 to 100 percent .
After BiPAP was initiated , the patient became hypotensive down to 75/28 and bradycardiac , responding to 3 fluid boluses over the course of the night .
The patient was started on Florinef for concern of adrenal insufficiency ; however , she was hemodynamically stable that morning and was transferred back out to the floor .
It was thought that the patient may have been mucous plugging during her stay in the ICU .
Hematologic .
The patient has a history of high MCV and megaloblastic cells on smear in the setting of anemia ; question B12 deficiency , the patient also has a history of borderline low B12 levels .
The patient was diagnosed for B12 deficiency due to her long history of poor p.o. intake .
Methylmalonic acid levels were sent , the results are pending at the time of discharge . | [
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"... | null | null | null |
336 | ADMISSION DATE :
11/04/2000
DISCHARGE DATE :
11/09/2000
HISTORY OF PRESENT ILLNESS :
Mr. State is an 81-year-old man with a history of restrictive and obstructive lung disease , dilated cardiomyopathy , inferior myocardial infarction , and anterior mediastinal masses admitted with acute onset of pulmonary edema .
In the setting of inadvertently decreasing Lasix from 80 mg. po 40 mg. a day Mr. State had sudden onset dyspnea after approximate day and a half prodrome culminating in severe dyspnea .
Upon arrival in the Emergency Room Mr. State 's saturations were in the mid 80s and he was promptly rendered more comfortable with high flow oxygen , morphine , and nitrates and intravenous Lasix .
Chest x-ray was relatively unrevealing for interstitial or alveolar edema and with clinical improvement ensued with the immediate therapy in the Emergency Room as noted .
The patient denied angina , syncope , preceding worsening orthopnea , paroxysmal nocturnal dyspnea , palpitations , chest pain , hematemesis or melena .
HOSPITAL COURSE :
The patient was admitted to the Hospital and underwent an approximate 1.5 liter diuresis within the first 24 hours with improvement in his symptoms and improvement in his oxygen saturations .
After a long discussion with the patient and his family it was determined that a cardiac catheterization would be prudent .
Prior to catheterization a VQ scan was performed which revealed a moderate probability for PE with a subsegmental defect in the lingular on the left lung .
Subsequent lower extremities noninvasive studies and D-dimer test were both negative rendering the probability of acute pulmonary embolism less than 2 percent .
It was not felt that the patient would be in need of chronic Coumadin therapy in lieu of this low probability findings in toto .
Coronary angiography revealed occlusion of the right coronary artery proximally with insignificant plaquing in the left anterior descending artery and circumflex arteries .
After a approximate 3 liter total diuresis the right atrial pressure was 5 , pulmonary capillary wedge pressure 14 , pulmonary vacuolar resistance 353 and the cardiac output depressed at 2.95 liters per minute , or a cardiac index of 1.7 liters per minute .
Based upon these findings it was felt that Mr. State most likely has multi-factorial dyspnea owing to both his ventilatory limitation and to a chronic low output state .
In Hospital he was seen by both Speech Therapy , physical therapy , and the Uspend Harmemewood Medical Center Congestive Heart Failure Nurse Practitioner Program .
His Isordil was increased in Hospital and blood pressure control was relative episodic with systolic pressures ranging between 100 and 160 .
Future adjustments will be made at home pending his blood pressure measures .
At a goal weight of 142 pounds , Mr. State 's filling pressures appeared ideal with a wedge pressure of 14 and his goal weight range will be between 142 and 44 pounds at home .
The patient will be followed by Dr. State within a week of discharge and by Nieie Naebrand Freierm of the Dyathenslycha Medical Center . | [
{
"text": "the first 24 hours",
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"val": "2000-11-04",
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256 | ADMISSION DATE :
4/14/94
DISCHARGE DATE :
4/20/94
DISCHARGE DATE :
4/20/94
HISTORY OF PRESENT ILLNESS :
Mr. Le is a seventy three year old male who presents to the Fairm of Ijordcompmac Hospital , following a self inflicted gunshot wound to the head .
Mr. Le was found in bed with a 32 caliber revolver at his side .
The patient was apparently alone at home , his neighbors heard a single shot , and the paramedics were called .
Upon arrival , they found the patient in bed , with notes nearby , listing his funeral home preferences and information on his next of kin .
The patient indicates that his neighbors were making excessive noise upstairs from his dwelling , and he found it unbearable .
He therefore decided to take his life with a gun which he had found in the house .
Apparently , the gun belonged to his father .
On further questioning , the patient described that his father passed away approximately forty to fifty years prior to his admission , and the gun was found in a box in their home .
The patient expressed concern that he had several utility bills that he was unable to pay .
The patient 's sister died eight years prior to the patient 's admission of leukemia , and he otherwise has no next of kin with the exception of one brother in Washington , with whom his relationship is tenuous .
On initial questioning , however , the patient denies any recent losses .
On admission , the patient denies any suicidal or homicidal ideation .
HOSPITAL COURSE :
The patient was admitted to the Fairm of Ijordcompmac Hospital , on the Neurological Surgery Service of Lupevickette L. Ca , M.D.
Prior to his admission , the patient 's gunshot wound was sutured close in the emergency room .
The patient was placed on suicide precautions , and was hydrated with an infusion of intravenous fluid .
The patient was seen in consultation by the Psychiatry Service , who began a battery of testing , which continues at the time of discharge .
The Consulting Psychiatrist recommended a minimum of 2 point restraints at all times , and recommended the patient be monitored by a sitter .
Allowing the patient to ambulate was not recommended .
From a medical standpoint , the patient did well .
He was initially admitted to the Neurological Intensive Care Unit where he was closely monitored during the first two days of his hospitalization .
The chief obstacle was bringing his blood pressure under control and this was ultimately achieved with a combination of Captopril and Nifedipine .
After his blood pressure had stabilized , the patient was transferred to the Neurology Ward .
Close monitoring demonstrated his blood pressure to be stable and within an acceptable rang on his dosage regimen .
The Psychiatry Service followed up extensively with the patient , and his Psychiatric progress is detailed in the Psychiatry transfer note .
By the 7th hospital day , the patient was medically stable .
He had undergone full Psychiatric evaluation , and was prepared for transfer to a Psychiatric Hospital .
Therefore , because of his need for intense psychiatric care , the patient is discharged to the Vo Black Doylestrictshore Ft. Clinics Medical Center on the 7th hospital day . | [
{
"text": "eight years",
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{
"text": "4/14/94",
"start_char": 18,
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"id": "T0",
"type": "DATE",
"val": "1994-04-14",
"mod": "NA"
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"te... | null | null | null |
242 | Admission Date :
2017-01-10
Discharge Date :
2017-01-16
Service :
Medical ICU
HISTORY OF PRESENT ILLNESS :
Patient is a 53 - year-old female found down in hotel room by EMS with change in mental status and lethargy .
A suicide note found at the scene referenced multiple medical problems as well as suggested ingestion of beta blocker , muscle relaxant , and Neurontin .
Vital signs were stable on arrival in the David , but the patient was minimally responsive and subsequently intubated for airway protection .
Patient initially given 2 mg of Narcan , 4 amps of sodium bicarb , and 5 grams of activated charcoal .
Patient 's blood pressures were noted to decrease systolics to the 80s , which responded to IV fluids and insulin / glucose drips .
Also noted to be bradycardic to the 50s , which responded to atropine .
HOSPITAL COURSE :
In summary , patient is a 53 - year-old female with multiple medical problems and history of depression with intentional overdose of barbiturates , opiates , Tylenol , and beta blocker .
CMED :
Patient was maintained on insulin , D10 and glucagon drips to maintain her hemodynamics .
This was achieved with good effect , and they were subsequently weaned off .
Patient was able to be extubated on hospital day three .
Psychiatry was consulted after the patient was extubated , and felt that patient had a high suicide risk , and plan was for her to be admitted to the Psychiatry service once medically stable .
Patient 's renal function remained stable and her CKs trended down gradually .
Patient remained on suicide precautions , but was deemed not to need ICU level monitoring , and was transferred to the floor on 01-11 .
In the a.m. of 01/08 , the patient experienced episode of tongue biting , unresponsiveness , disorientation .
Was loaded on Dilantin .
Became progressively hypoxic and tachypneic throughout the day with respiratory rates of 30-40 with a max respiratory rate of 116 , tachycardia to 120s .
Patient subsequently was transferred back to the CMED CCU on 2017-01-13 for further monitoring .
Patient 's hypoxia was felt most likely to be caused by pneumonia .
She was started on appropriate antibiotics .
Etiology of patient 's tachypnea was unclear .
Initially , the patient 's etiology of seizure was not quite clear , but thought possibly secondary to alcohol and benzodiazepine withdrawal .
She received EEG , MRI , LP .
Subsequently EEG was noted to have no seizure activity .
MRI was suboptimal due to motion artifact and LP was unremarkable .
Despite absence of seizure activity on EEG , patient was continued on Dilantin .
Her delirium was felt possibly secondary to withdrawal versus toxic metabolic , but gradually improved slowly , and therefore patient did not receive treatment for barbiturate withdrawal .
Her mental status , tachypnea , and hypoxia all improved , and patient was subsequently transferred back to the floor medical team on 2017-01-15 .
While on the floor , the patient 's mental status was noted to be improved back at baseline compared to that back to the CMED CCU , and she exhibited no evidence of barbiturate withdrawal .
She was continued on suicide precautions with a one-to-one sitter , and plan was for psychiatric admission when medical issues had resolved .
On 2017-01-16 , the night float intern was called to see the patient as she was unresponsive .
Patient unresponsive to verbal command , sternal rub .
Pupils were fixed and dilated .
Patient noted to be without corneal reflexes , spontaneous breathing , heart sounds , or palpable pulses .
Patient was pronounced dead at 6:15 a.m. on 2017-01-16 .
Patient 's family was notified and declined autopsy .
Given the sudden unexpected nature of patient 's death , the medical examiner was contacted and the case was accepted .
Of note at time of death , patient was DNR / DNI .
This was initiated after several conversations with the patient 's mother , who stated that the patient had desired to be DNR / DNI for many years , not just in the recent past .
These facts were confirmed via separate conversations with both the patient 's lawyer and her primary care physician .
Michael N Sawyer , M.D.
86-331
Dictated By : Rebecca S Jefcoat , M.D.
MEDQUIST36
D : 2017-03-08 10:57
T : 2017-03-10 07:01
JOB # : 53408
( cclist )
***************************
Please note that all of the conversations regarding code status took place during we icu admit ; and that this patient passed away in early am hours of night she was called back out to the medicine floor , therefore she had not yet been re-evaluated by the floor medicine attending , but had been earlier that day by the icu attending .
Signed electronically by : DR. Dorothy Desalvo on : WED 2017-04-26 7:22 AM
( End of Report ) | [
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726 | Admission Date :
08/16/1998
Discharge Date :
08/18/1998
HISTORY OF PRESENT ILLNESS :
The patient is an 88 year-old woman undergoing treatment for a right lower extremity cellulitis who was transferred from Child for worsening cellulitis and new confusion .
The patient has a history of severe aortic stenosis and was recently admitted to the Retelk County Medical Center for a Nafcillin sensitive Staphylococcus aureus cellulitis of the right leg treated with a course of Nafcillin and Levofloxacin .
There was also a right leg fluid collection that was incised and drained on August 1 , 1998 .
The patient was sent to rehabilitation on Levofloxacin orally .
Although details were not available at the time of admission , apparently , she had done well until the 24 hours proceeding admission when the cellulitis was felt to be worsening .
She had also been noted to be confused and combative during that 24 hour period .
As her baseline mental status is completely alert and oriented , this caused concern amongst the staff of the rehabilitation center and the patient was transferred to the Retelk County Medical Center .
HOSPITAL COURSE :
1) Mental status changes :
On admission to the emergency room , the patient was somewhat argumentative and confused as well as uncooperative with procedures .
A neurologic work-up was undertaken which included a CT scan of the head which revealed no acute bleed and a lumbar puncture which revealed a glucose of 72 , protein 65 , white blood cell count 19 , red blood cell count 11,500 with no evidence of xanthrochromasia .
The Neurology Service evaluated the patient who felt that her agitation was most likely due to infection , her multiple medications , or her metabolic condition .
The patient 's mental status slowly began to recover , however on the morning of the first day of admission , August 16 , 1998 , the patient was found after having fallen .
A neurological examination was performed which revealed no abnormality and imaging included a head scan which revealed no bleed and a cervical spine series which revealed degenerative joint disease but no obvious fracture .
The patient decided not to pursue further testing with a neck CT scan .
At the time of discharge , the patient 's mental status is back to its baseline .
2) Right lower extremity cellulitis :
The patient was evaluated by the Surgical Service who felt that the wound was clean with some erythema but without evidence of true cellulitis .
The patient 's antibiotics were discontinued with the thought that prolonged antibiotics only put her at more risk for infection .
3) Cardiac :
The patient has a history of critical aortic stenosis and mitral regurgitation .
Fortunately , these issues were not active during the present admission .
4) Status post fall :
The patient did fall while inhouse .
A head CT scan and cervical spine series were negative .
The patient appeared to have no deficits at the time of discharge .
5) Atrial fibrillation :
The patient 's Coumadin was continued .
6) Abnormal liver function tests :
On admission , the patient was noted to have elevated bilirubins in the 3 range and mildly elevated alkaline phosphatase consistent with a cholestatic picture .
These liver function tests will be followed closely as an outpatient . | [
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"text": "the morning of the first day of admission , August 16 , 1998",
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... | null | null | null |
492 | Admission Date :
2016-02-14
Discharge Date :
Date of Birth :
Service :
ADMISSION DIAGNOSIS :
HISTORY OF PRESENT ILLNESS :
The patient is a 63 year old gentleman who had initially presented with exertional chest pressure several weeks prior to this admission that would resolve with rest .
Stress echocardiogram demonstrated an ejection fraction of 40% , hypokinesis of distal anterior wall , akinesis of distal inferior wall and apex .
The patient had a cardiac catheterization which revealed three vessel disease and the patient now presents for elective coronary artery bypass grafting .
HOSPITAL COURSE :
The patient was initially admitted to the medical service for optimization prior to his coronary artery bypass graft .
The patient was given stress dose steroids on the day prior to his surgery .
He was closely followed from his admission through to his discharge by the renal service for his transplant issues .
On 2016-02-15 , the patient was taken to the operating room and had an off pump coronary artery bypass graft performed with the left internal mammary artery to the left anterior descending , saphenous vein graft to obtuse marginal and posterior descending artery .
For details of this operation , please see the previously dictated operative note .
Postoperatively , the patient was transferred to the CSRU for close monitoring .
On the evening of postoperative day number zero , the patient had decreased urine output and was placed on a Lasix drip for diuresis .
The patient tolerated this well .
The renal service continued to follow close management of his immunosuppression .
On postoperative day number one , the patient was extubated and awakened from sedation .
He did well on this and his Levophed drip was weaned to off as tolerated .
Over the course of his Intensive Care Unit stay , the patient received six units of packed red blood cells for a low hematocrit .
He otherwise had a fairly uncomplicated postoperative course .
On postoperative day number three , the patient was transferred to the floor .
On postoperative day number four , the patient was noted to have a low platelet level of 43,000 .
Heparin induced thrombocytopenia antibody panel was sent .
Other than this , the patient did very well .
Chest tubes were removed when output was low .
Pacing wires were removed .
Physical therapy saw the patient and cleared the patient for discharge .
Ultimately , the patient was discharged on postoperative day number six tolerating a regular diet , adequate pain control on p.o. pain medications , and ambulating well with clearance of physical therapy . | [
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"mod": "END"
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"text": "postoperative day number one",
"start_char": 1606,
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"id": "T5",
"type": "DA... | null | null | null |
337 | Admission Date :
2017-06-12
Discharge Date :
2017-06-14
Service :
MEDICINE
History of Present Illness :
70 y/o F w/ tracheobronchomalacia , COPD , PMR , recurrent pneumonias who was recently discharged from Hallmark Health System to Pocasset Mental Health Center
06-07 after tracheobronchoplasty / tracheostomy and pigtail catheter placement for pleural effusions .
Since discharge pt has continued at rehab on ps vent settings but pigtail catheter fell out today so pt was referred here for monitoring .
On ROS , she notes feeling poorly , nausea , and diarrhea since d/c .
She has pleuritic chest pain which she has had since she arrested during her admission here and had CPR .
Per husband she has no cardiac history , and had a stress test ( unclr how recent ) that was normal
Brief Hospital Course:
Pleural effusion : s/p pigtail cath drain .
Imaging indicated that the pleural effusions had resolved .
Thoracics agreed to no need for pigtail placement .
CHF :
Patient was seen by CHF ( echo results are detailed above ) .
They recommended continuing beta-blocker and titarting ace as tolerated .
Patient should be kept euvolemic once peripheral edema resolves ( may use lasix to decrease edema ).
She will need a repeat echo in 3-6 months ( since this echo showed a question of focal wall motion abnormality ).
Also , patient was started on amiodarone and digoxin was held secondary to high levels ( please restart when level less than 2 )
Diarrhea :
Stool c. diff neg x1 .
She will need two more specimens .
COPD : cont nebs .
PAF : started on amio , cont b-blocker , and patient was started on coumadin - levels ( inr ) should be monitored .
Nutrition :
Patient should be started on tube feeds at rehab
Rash :
Patient developed a diffuse erythematous rash , though to be an ID reaction to a recent fungal infection .
She has been satrted on benadryl and hydrocort for sx relief .
Please monitor this ( may need dermatology consult ).
Also a drug reaction is in the ddx but unlikely as rash started at rehab prior to receiving drugs here . | [
{
"text": "3-6 months",
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"end_char": 1245,
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"type": "DATE",
"val": "2017-10-29",
"mod": "APPROX"
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"mod": "NA"
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... | null | null | null |
647 | Admission Date :
2016-02-15
Discharge Date :
2016-02-21
Service :
NEONATOLOGY
HISTORY OF PRESENT ILLNESS :
The infant is a 32 and 03-05 week male , twin A , who was admitted to the Neonatal Intensive Care Unit for management of prematurity .
The infant was born to a 38 year old , gravida V , para III , woman .
Serologies :
A positive , antibody negative , hepatitis B surface antigen negative , RPR nonreactive , rubella immune , GBS unknown .
Pregnancy notable for:
1. Gestational carrier for brother and his wife ( donor eggs ).
2. IVF with diamniotic , dichorionic twins .
3. At 29-30 week gestation concern for fetal decelerations of twin A , admitted to Cambridge Health Alliance , completed a course of Betamethasone , discharged to home .
4. Elevated one hour glucose tolerance test , normal three hour glucose tolerance test .
5. Declined triple screen and amniocentesis .
Gestational carrier for brother and sister-in-law as noted above .
Presented with spontaneous , premature rupture of membranes .
No maternal fever .
Clear fluid .
Delivery by cesarean section secondary to twin B breech presentation .
Apgars eight at one minute and eight at five minutes .
HOSPITAL COURSE :
1. Respiratory - The infant has remained in room air throughout this hospitalization with respiratory rates 40 s to 50 s, oxygen saturation greater than 94% .
One apnea and bradycardia event which was self resolved on day of life four .
2. Cardiovascular - The infant was noted on CR-monitor to have premature ventricular contractions which resolved spontaneously .
A twelve lead electrocardiogram was recommended if this persists .
No murmur .
Heart rates 140 s to 150 s.
Mean blood pressure has been 46 to 54 .
3. Fluid , electrolytes and nutrition - The infant was started on enteral feedings on day of life one and advanced to full volume feedings by day of life four .
The infant was initially started on 80 cc / kg / day of intravenous fluid D10W and advanced to 150 cc / kg / day by day of life four .
The infant tolerated feeding advancement without difficulty .
The infant did not receive parenteral nutrition .
The most recent electrolytes on day of life two showed a sodium of 145 , chloride 111 , potassium 3.8 , bicarbonate 21 .
The infant is currently receiving breast milk 22 calories per ounce or premature Enfamil 22 calories per ounce , 150 cc / kg / day p.o. and gavage .
The most recent weight today is 1810 grams which was no change from the previous day .
4. Gastrointestinal - The infant was started on single phototherapy on day of life two for a maximum bilirubin level of 9.1 with a direct of 0.3 .
Phototherapy was discontinued on day of life five and the rebound bilirubin level on day of life six is 7.7 with a direct of 0.2 .
5. Hematology - The most recent hematocrit on day of life two was 45.8% .
Hematocrit on admission was 54.0% .
The infant has not received any blood transfusions this hospitalization .
6. Infectious disease - The infant received 48 hours of Ampicillin and Gentamicin for rule out sepsis .
The complete blood count on admission showed a white blood cell count of 8.0 , hematocrit 54.0% , platelet count 190,000 , 11
neutrophils , 0 bands .
A repeat complete blood count on day of life two showed a white blood cell count of 6.3 , hematocrit 45.8% , platelet count 199,000 , 37 neutrophils , 0 bands , 53 lymphocytes .
Blood cultures remained negative to date .
7. Neurology - Normal neurologic examination .
The infant does not meet criteria for head ultrasound .
8. Sensory - Hearing screening is recommended prior to discharge .
9. Psychosocial - As noted above , paternal aunt was the gestational carrier .
The infants are legally under the parents ' names and they are involved with the infant 's care .
The gestational carrier is not involved .
Noted in the chart are legal documents .
The contact social worker can be reached at ( 756 ) 599-4849 . | [
{
"text": "one minute",
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"id": "T11",
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"mod": "NA"
},
{
"text": "five minutes",
"start_char": 1158,
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... | null | null | null |
121 | ADMISSION DATE :
09-07-93
DISCHARGE DATE :
09-08-93 PATIENT DIED ON 9/8/93 .
HISTORY OF PRESENT ILLNESS :
Date of birth :
10/4/88 .
This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9/5/93 at 21:16 hours with a 2-3 day history of chills , fevers , cough , vomiting and weakness ( unable to walk ) .
At Noughwell Entanbon Health , her temperature was 101 , pulse 135 , blood pressure 94/74 , respiratory rate 20 .
Positive findings of physical examination include chicken pox lesions on thorax , sunken eyes , thick nasal discharge , dry lips , tongue and mucous membranes , red tonsils .
The remainder of the physical examination was considered within normal limits .
Admission diagnosis at Ni Hospital 's :
vomiting and dehydration , hypokalemia , hyponatremia , tonsillitis .
A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted .
Oral cyanosis and shallow respirations were noted on 9/7/93 at 2:45 a.m.
Therefore the patient was intubated at 3:45 a.m. on 9/7/93 .
Chest x-ray was unremarkable .
Cardiovascular stable , significant hypertension was noted on 9/7/93 at 5:10 a.m. and therefore 10 cc's per kilo albumin was given .
The patient was admitted was started on clear fluids , tolerated , with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc 's per hour for 9 hours . ( 100 cc's per kilo ) .
Sodium and potassium at this time were 128/1.5 .
At Labor Day , 9:30 a.m. , the fluids were increased to 100 cc's per hour ( 200 cc's per kilo for 5 hours ) .
Electrolytes at this point were sodium 132 , potassium 1.8 .
At 9/6/93 , 2:30 p.m. , fluids were decreased to 75 cc's per hour , 150 cc's per kilo , 40 mEq of K phosphate added to the intravenous fluids .
Electrolytes at this point were a sodium of 143 and potassium 1.7 .
On 9/6/93 , 22:00 , fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc 's per hour .
This rate was maintained for 11 hours .
Electrolytes at this time were a sodium of 148 , potassium 1.7 .
At 9/7/93 , 1:00 a.m. , intravenous fluids rate was decreased to 50 cc's per hour , total fluids given during the first 24 hours were 140 to 150 cc's per kilo per day .
At this time , sodium was 147 , potassium 2.6 , total sodium given during the first 24 hours 20 mEq per kilo per day .
On 9/7/93 at 4:00 a.m. , albumin bolus 5% 10 cc's per kilo was given , a total of 120 cc's , electrolytes were sodium 155 , potassium 3.1 .
At 9/7/93 at 5:00 a.m. , sodium bicarbonate given 60 mEq , calcium bolus 10 cc's given .
On 9/7 , 5:30 a.m. , D5 quarter normal saline , and 40 of K phosphate at 100 cc's per hour was given .
The patient was taking PO initially until 9/6/93 at 17:45 .
There were no abnormal findings in abdominal exam .
On 9/5/93 , hematocrit 48 , white blood count 11.2 , neutrophiles 67 , bands 14 , lymphs 11 , monos 6% , meta 2% , platelets 220,000 .
Copious urine output , BUN 1.0 , creatinine .8 .
Normal neurologic exam on admission , then lethargic on 9/6/93 at 17:45 , then patient became unresponsive , areflexic and limp at 9/6/93 , at 17:45 to 22:00 .
Patient was having seizures , twitching of face and rapid movements of eyes .
Pupils dilated and sluggish .
Valium was given at 9/7/93 , 00:02 .
IV ampicillin , chloramphenicol , ceftriaxone , and culture were sent .
Finally , Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9/7/93 , 6:30 a.m. , and on arrival patient was seizing with rhythmic eye movement to left .
The patient was unresponsive , poor perfusion .
Temperature was 101.8 .
A second intravenous was started and given normal saline bolus , change in intravenous fluids to D5 water with 80 mEq of bicarbonate , plus 40 mEq of KCL at 45 cc's per hour , bicarbonate given 2 mEq per kilo , attempted to start dopa for poor perfusion but worsening perfusion .
Therefore , dopa was stopped .
Total volume given as bolus 50 cc's per kilo , sodium bicarbonate at 2 mEq per kilo was given .
Last ABG there was 6.98 , 31 , 171 , bicarbonate of 7 .
Phenobarbital and Dilantin given for seizure control .
Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176 , potassium 2.5 , chloride 140 , bicarbonate 14 , calcium 7.2 , magnesium 2.7 .
Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9/7/93 , 11:15 a.m.
Lines placed were a right femoral triple lumen , endotracheal tube 4.0 , arterial line , right radial line , Foley placed , peripheral intravenous line , nasogastric tube .
On admission to Fairm of Ijordcompmac Hospital , temperature 100.2 , pulse 149 , respiratory rate 50 , blood pressure 98/66 , mean arterial pressure of 73 , weight 12 kilos .
HOSPITAL COURSE :
On admission , FI02 was 50-60% , PID 30-32/PEEP of 5.7 , total volume was between 140 to 210 during Intensive Care Unit stay .
Chest x-ray showed right upper lobe pneumonia .
Cardiovascular :
CVP on admission was 1 cm of water .
Then during the Intensive Care Unit stay , the CVP remained between 7 to 8 after volume resuscitation .
Dopamine and epinephrine given for cardiovascular support .
Her electrocardiogram findings were compatible with hypokalemia ( flattening T waves and ST changes ) .
Fluids / electrolytes/nutrition :
On admission to Fairm of Ijordcompmac Hospital , hypernatremia and hypovolemic shock .
Fluids of D5 water with 30 mEq of sodium acetate per liter , 30 ml per liter of phosphate , and 30 mEq of K acetate per liter at 90 cc's per hour was given .
Free water deficit over 48 hours was given , plus maintenance , plus adjusting the ongoing losses .
Pediatric Nephrology recommended on 9/7/93 , 5:50 p.m. , 10 cc 's per kilo of 150 mEq of sodium bicarbonate per liter , ( 1.5 mEq per kilo bicarbonate , one dose of Lasix and volume as needed ) .
The patient required multiple boluses of albumin for hypotension , patient also required multiple boluses of calcium because of hypocalcemia and hypotension .
Magnesium 2.0 mEq per liter , phosphate 8 mg / dl .
Gastrointestinal :
Normal .
NPO .
Albumin was 4.9 .
Globulin was 1.6 , uric acid was 6.5 , alkaline phosphatase 150 , SGPT 11 , SGOT 85 , LDH 524 , CK 152 , NH3 81 .
Hematologic :
White cell count 9.4 , hematocrit 42 , platelets 151,000 .
Differential was polys 59 , bands 3 , lymphs 25 .
Repeat white cell count 6.4 , hematocrit 34 , platelets 103 .
PT 11.6/10.1 , repeat PT 12.8/10.5 .
PTT 36.4 , repeat PTT 50.9 .
Fibrinogen 211 .
Renal :
Urine output was about 5 to 8 cc's per kilo per hour .
Renal ultrasound was scheduled during the Intensive Care Unit stay .
Urinalysis showed specific gravity 1.005 , pH 8.0 , positive proteins , positive red blood cells , negative white cell count , positive glucose .
Neurologic :
Patient did not receive sedation or muscle relaxant since admission to the Pediatric Intensive Care Unit .
Phenobarbital levels were 31.4 , 30.2 , and 50 .
Dilantin level was 22.6 , 20.2 , 20 .
Neurology consultation on the evening of 9/7/93 revealed supple neck , no response to external rub .
Pupils were 3.5 OD , and 3.0 OS , irregular and non reactive .
Corneal reflexes and oculocephalic reflexes were absent .
There was no gag .
Muscle tone was increased throughout , and the legs were both extended and internally rotated .
Deep tendon reflexes could not be elicited and plantar responses were silent .
Repeat neurological examination revealed no spontaneous movement and no response to voice or noxious stimulation .
Pupils were dilated and non reactive .
Disc margins appeared blurred on funduscopic exam .
A non contrast head CT scan was obtained and CT revealed severe cerebral edema with thalamic mid brain , pons , medullar low attenuation , diffuse cerebral edema , loss of gray white matter differentiation .
Cerebral blood flow was done on 9/7/93 at 2:30 p.m. , revealed complete absence of blood flow to brain .
There was a tiny region of activity in what appears to be anterior scalp .
Infectious Disease :
Ampicillin and chloramphenicol were given at Noughwell Entanbon Health , and ceftriaxone was given at Fairm of Ijordcompmac Hospital .
Acyclovir was started , also considering the varicella at 120 mg intravenously every 8 hours .
Urine cultures , blood cultures and sputum cultures were sent .
The patient finally died .
The situation of the patient was extensively discussed with the parents , and the attending physician from Neurology , Dr. Breunkote , and the attending physician from Pediatric Intensive Care Unit , Dr. Boormcose , and the decision was finally made with the family and attendings to disconnect the patient from the mechanical ventilation due to severe neurological injury and poor prognosis .
ZAKAY COUGH , M.D.
TR :
jx / bmot
DD :
10-20-93
TD :
10/21/93
CC :
edited 10/24/93 rc | [
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123 | Admission Date :
2013-11-21
Discharge Date :
2013-11-26
Service :
PLASTIC
History of Present Illness :
MS. Marshall IS A 64-YEAR OLD , MENTALLY RETARDED , FEMALE WHO PRESENTED WITH AN AQUIRED DEFECT OF THE RIGHT NASAL ALA AND MEDIAL CHEEK REGION AFTER BASAL CELL CARCINOMA WAS RESECTED BY DERMATOLOGY .
Brief Hospital Course :
UPON ADMISSION , THE PATIENT WAS PRE-OP 'D AND MADE NPO / IVF .
SHE WENT TO SURGERY THE NEXT MORNING AND TOLERATED THE SURGERY WELL .
HOWEVER , SHE WAS SLOW TO AWAKE FROM ANESTHESIA , AND WAS ADMITTED TO THE CMED CCU OBSERVATION .
SHE WAS TRANSFERED TO THE FLOOR POST-OP DAY 2 WHERE SHE HAD BEEN AFEBRILE WITH NORMAL VITALS , MAKING GOOD URINE , AND TOLERATING A REGULAR DIET .
HER WOUND HAS REMAIND DRY AND CLOSED , WITHOUT EVIDENCE OF INFECTION OR BREAKDOWN .
SHE HAS BEEN WATCHED BY A SITTER AT ALL TIMES . | [
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"start_char": 412,
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692 | Admission Date :
2009-11-10
Discharge Date :
2009-11-12
Service :
CCU
HISTORY OF PRESENT ILLNESS :
The patient is a 61 - year-old white male with a history of coronary artery disease , status post 5-vessel coronary artery bypass graft on 2009-09-11 , who presents for elective right heart catheterization and pericardiocentesis .
The patient did well after his coronary artery bypass graft .
On 10-14 , the patient had a transthoracic echocardiogram which revealed a new , moderate-to-large sized pericardial effusion .
The patient was asymptomatic at this time , and the decision was made to monitor him and to start him on Lasix .
The patient had follow-up transthoracic echocardiogram on 11-04 which revealed a slightly large effusion .
A few days later , on 11-07 , the patient began to develop dyspnea on exertion with normal activity .
He also noted a new two to three-pillow orthopnea and paroxysmal nocturnal dyspnea .
On 11-08 , he had an episode of acute shortness of breath with chest pressure which he describes as different from his typical angina with minimal exertion .
The patient spoke with his cardiologist who referred him for pericardiocentesis for persistent and symptomatic pericardial effusion .
On right heart catheterization , the patient was noted to have elevated right-sided and left-sided filling pressures with a pulmonary capillary wedge pressure of 19 and a right atrial pressure of 16 .
After 600 cc of serosanguineous pericardial fluid was removed , the patient was noted to have a pulmonary capillary wedge pressure of 9 and a right atrial pressure of 2 ; indicating resolution of tamponade physiology .
HOSPITAL COURSE :
The patient was transferred to the Coronary Care Unit after his therapeutic pericardiocentesis .
He was hemodynamically stable and without any complaints .
He was continued on his home cardiac regimen , but was started on indomethacin for post pericardiotomy syndrome .
Over the course of the night the patient drained an additional 400 cc of serosanguineous fluid from his pericardial drain pouch .
By the next morning , the degree of drainage had decreased considerably with only 60 cc drained over six hours .
The patient had a repeat transthoracic echocardiogram prior to drain removal which revealed the following :
A trivial / physiologic pericardial effusion one day post pericardiocentesis with no change from the study immediately post pericardiocentesis .
The pericardial drain was removed without any difficulty .
The pericardial fluid bag was removed without any difficulty with the decision to monitor the patient overnight and repeat the echocardiogram prior to discharge .
The patient had an enlarged left pleural effusion which was noted to layer on a lateral decubitus film .
We decided to perform a therapeutic thoracentesis .
The patient was prepped and draped in a sterile fashion , and 1150 cc of fluid were drained .
A chest x-ray was obtained post thoracentesis which revealed a significant decrease in the size of the left pleural effusion .
No evidence of pneumothorax .
On the morning of admission the patient had a markedly improved lung examination with increased air movement in the left base .
He denied any shortness of breath and had oxygen saturations in the 90 s on room air .
He had a repeat echocardiogram which revealed a trivial / physiologic pericardial effusion .
The patient was without any complaints and remained stable . | [
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{
"text": "the course of the night",
"start_char": 1933,
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36 | Admission Date :
02/01/2002
Discharge Date :
02/08/2002
HISTORY OF PRESENT ILLNESS :
Saujule Study is a 77-year-old woman with a history of obesity and hypertension who presents with increased shortness of breath x 5 days .
Her shortness of breath has been progressive over the last 2-3 years .
She has an associated dry cough but no fevers , chills , or leg pain .
She has dyspnea on exertion .
She ambulates with walker and a cane secondary to osteoarthritis .
She becomes short of breath just by getting up from her chair and can only walk 2-3 steps on a flat surface .
She feels light headed when getting up .
Her shortness of breath and dyspnea on exertion has been progressive for the past several years .
It has not been sudden or acute .
She sleeps in a chair up right for the last 2 1/2 years secondary to osteoarthritis .
She has orthopnea as well but noparoxysmal nocturnal dyspnea .
She occasionally feels chest twinges which are nonradiating but are sharp .
They last a few seconds on the left side and are not associated with sweating , nausea , vomiting or syncope .
She has had lower extremity edema for thelast several years with multiple episodes of cellulitis .
Her lower extremity edema has increased for the several weeks prior to admission secondary to an inability to elevate her legs due to a broken chair at home .
She denies any pleural chest pain .
REVIEW OF SYSTEMS :
Negative for headaches , vision changes , numbness , tingling , dyspnea , hematuria , abdominal pain , diarrhea , melena or hematochezia .
HOSPITAL COURSE :
The patient was admitted to the hospital for acute and chronic shortness of breath .
1. Cardiovascular :
The patient was found to be in congestive heart failure and thought likely secondary to diastolic dysfunction secondary to hypertension .
The patient was also found to have pulmonary hypertension .
She ruled out for myocardial infarction with 3 negative enzymes .
On admission , she was diuresed with Lasix and was negative 1-2 liters per day for several days .
The diuresis was backed off when her bicarbonate increased from 36 to 39 .
She was restarted on 20 mg p.o. q day prior to discharge .
Her lipids were checked with a total cholesterol of 110 , triglycerides 59 , HDL32 , LDL 64 .
The patient had a D-dimer greater than 1000 with lower extremity non-invasive studies which were positive for a small right common femoral clot .
It was unclear whether this was old or new .
A TTE showed an ejection fraction of 60% , mild mitral regurgitation , left atrial enlargement , mild tricuspid regurgitation , pulmonary artery pressures of 44 plus right atrial pressure .
There was an intra-atrial shunt from the right to the left through a patent foramen ovale .
Chest CT was a poor study but did not show a pulmonary embolus .
The patient had subsequent dobutamine MIBI which was positive for inducible ischemia in the distribution of posterior descending coronary artery and posterolateral coronary artery with a small to medium perfusion defect in the inferolateral wall and basal inferior wall which was partially reversible .
The cardiology service saw the patient and recommended medical management only without catheterization .
Her blood pressure was high so Captopril was titrated up to 50 mg p.o. t.i.d. .
She will be discharged on Lisinopril with further titration as an outpatient .
She is on hydrochlorothiazide 50 mg p.o. q day .
Her atenolol was stopped due to bradycardia on admission but this may be restarted as an outpatient in gentle doses with careful monitoring of heart rate .
She is on an aspirin .
She will be discharged on Lasix 20 mg for continued control of her edema .
2. Pulmonary ;
Pulmonary hypertension as seen on echocardiogram .
Unclear whether there are chronic pulmonary embolus but did have positive test for deep venous thrombosis and will be treated with Coumadin .
An ABG was done which showed pH 7.34 , pCO2 78 , pO2 92 on 2 liters .
Her bicarbonate peaked at 39 and generally is in the 36-38 range .
She has severe sleep apnea and falls asleep midsentence .
She has episodes of not breathing .
BIPAP was attempted for 3 nights in a row and the patient did not tolerate this .
She will need pulmonary function studies as an outpatient as these were not done in the hospital .
The pulmonary team saw the patient and only recommended the above testing .
She needs home oxygen and is currently at 2 liters nasal cannula oxygen .
3. Infectious disease :
Evidence for cellulitis on her legs , likely due to distention from edema and poor perfusion .
She was originally started on cefazolin which was then changed to Keflex with good improvement .
She will need to continue for at least 10 more days or as clinically indicated by the course of her cellulitis .
4. Hematology :
D-dimer in the emergency room was greater than 1000 and a right common femoral clot was seen .
This clot was small and it was questionable as to whether it was old or new .
She was started on anticoagulation given the positive D-dimer .
Chest CT was nondiagnostic but did not show pulmonary embolus .
It was a poor study .
Heparin was maintained during her hospital course and then Lovenox was started .
Her dose was increased to 7.5 mg q day the day prior to discharge .
She will be discharged on this dose in addition to 1 day of Lovenox .
Discharge INR 1.8 .
Goal INR is 2.0-3.0 .
5. Fluids / electrolytes / nutrition :
Low salt diet .
Low cholesterol , low fat diet . | [
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"text": "the several weeks",
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321 | ADMISSION DATE :
01/04/96
DISCHARGE DATE :
01/10/96
HISTORY OF PRESENT ILLNESS :
This 78-year-old woman had stage IIIB carcinoma of the cervix and she has known periaortic and splenic metastases .
She was discharged from the hospital about 18 days prior to her admission , following a month long stay .
When her cancer was diagnosed , she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic lymphadenectomy .
She had extensive disease of the uterus , ovarian tubes , omentum and the periaortic lymph nodes .
Postoperatively , she developed ileus , then finally she recovered and she was discharged to the nursing home .
She was readmitted because of a problem with uremia and high BUN and creatinine when she seen in the office and the BUN and creatinine was ordered .
The BUN was 70 and creatinine was 4.6 and for this reason she had ultrasound of the kidney which showed bilateral hydronephrosis .
The patient was admitted to the hospital for ureteral stent placement .
On the day of admission , she was generally stable and she had no evidence of disease in the pelvis , no bleeding and no other abnormality .
HOSPITAL COURSE :
Dr. Jescdrig was called and a consultation was done and he placed bilateral ureteral stents in her kidneys .
Postoperatively , she diuresed very well .
She had dropped her BUN and creatinine to normal and she was found to have may be metastatic disease to her skin on the right paraumbilical area .
Because of her age and mental condition and the fact that she had cerebral atrophy , the decision was made for comfort unless she has any further problem and no further chemotherapy or treatment will be given .
The possibility that she may need to receive radiation therapy to this area to prevent her from getting further obstruction was also brought up .
Her family felt that at the present time , because her condition was no good , they would like to just take her home so that she could enjoy the quality of life .
Indeed , at the time of discharge she was conscious and she was cooperative and she was able to communicate very nicely with everyone including her family , except for the mental instability that she had because of her cerebral atrophy due to senility .
FOLLOW-UP :
She will be followed in the Centu Fairgmer Queen Medical Center .
AZEL U. HIBBSKAYS , M.D.
DICTATING FOR :
EARNRA HAWNSPANTKOTE , M.D.
TR :
yq
DD :
01/26/96
TD :
01/30/96 12:18 P
cc :
AZEL USANNE HIBBSKAYS , M.D. EARNRA HAWNSPANTKOTE , M.D. | [
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"text": "the day of admission",
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"val": "1996-01-04",
"mod": "NA"
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"text": "01/04/96",
"start_char": 18,
"end_char": 26,
"id": "T1",
"type": "DATE",
"val": "1996-01-04",
"mod": "NA"
}... | null | null | null |
532 | Admission Date :
2012-03-01
Discharge Date :
2012-03-13
Service :
CMED CCU
HISTORY OF PRESENT ILLNESS :
Patient is a 26 - year-old female with a past medical history significant for nonischemic dilated cardiomyopathy with an ejection fraction of 15-20% , who presents with a one-week history of progressive shortness of breath .
She reports orthopnea with an increasing pillow requirement of 2-4 with paroxysmal nocturnal dyspnea .
Patient also reports a 6-pound weight gain over the last four days with associated lower extremity edema .
She also reports positional chest pain , which is worse with lying down and relieved with sitting up .
She denies any pain with activity .
She also reports a cough productive of green sputum for approximately one week .
She does report chills , but no fevers .
In the Emergency Department , she was started on a nesiritide drip and responded well with 2000 cc urine output .
HOSPITAL COURSE :
1. Congestive heart failure :
Patient was diuresed effectively with nesiritide and Lasix .
Patient 's weight on admission was 250 pounds , and on the day of discharge was 244 pounds which was back to her dry weight .
She had lost the 6 pounds that she reported gaining in the four days prior to her hospitalization .
Patient was continued on her Toprol , her lisinopril , and her digoxin .
Patient 's Coumadin was held for right heart catheterization and biopsy , and then EP study with ICD placement .
Patient did have Woodrow Betty , SPEP , and anticardiolipin antibody sent for further workup of the etiology of her cardiomyopathy .
The Courtney , SPEP , and anticardiolipin antibody were all negative .
Her CKs did trend down over the course of her hospital stay , and in the setting of her known clean coronaries on cardiac catheterization in 2011-11-19 , it was believed that a myocarditis might be the cause of her elevated cardiac enzymes and also could have exacerbated her congestive heart failure .
Patient did receive a right heart catheterization , which showed elevated wedge pressures and biopsy specimens were obtained of the right ventricle .
The results of these biopsies are still pending in pathology .
Post right heart catheterization and right ventricular biopsy , the patient was sent to the CCU for a Swan - guided therapy in the setting of her elevated wedge pressures and low cardiac output .
In the CCU , she was put on milrinone with good results .
Patient was also seen by the Pulmonary service here and had pulmonary function tests done as part of a pretransplant workup .
There is no pulmonary process to exclude her from the transplant list as noted by the Pulmonary service .
Patient did receive an ICD during this hospital admission without complication .
Patient was in bigeminy during the course of her hospital stay , and did have frequent runs of ectopy as noted on telemetry .
2. Her right lower lobe infiltrate :
Patient did report a cough productive of green sputum on admission .
She received a full course of azithromycin for this with resolution of her cough and sputum production .
On discharge , the patient was restarted on her Coumadin , which was held for her right heart catheterization , and her biopsy , and her ICD placement .
She was also continued on all her heart failure medications including her Toprol , her lisinopril , her digoxin , and her Lasix . | [
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"id": "T5",
"type": "DATE",
"val": "2012-03-13",
"mod": "NA"
},
{
"text": "the four days",
"start_char": 1205,
"end_char": 1218,
"id": "T6",
"type": "DURATION",
"val": "P4D",
"mod": "N... | null | null | null |
526 | Admission Date :
09/26/2001
Discharge Date :
10/06/2001
HISTORY OF PRESENT ILLNESS :
The patient is a 60-year-old male with a past medical history notable for coronary artery disease and CABG x2 in 2001 .
The patient has felt unwell since 7/21 after his non-Q wave MI .
The patient , at this time , was started on Statin and developed in arthritis approximately one month later with joint pain , myalgia and fatigue .
No clear diagnosis was made .
The patient was presumed to have a rheumatoid factor negative , rheumatoid arthritis and he was prescribed Naprosyn , prednisone and sulfasalazine .
He had a CABG review in 2/21 .
His first CABG was in 02/89 .
Since 2/21 , he has had increasing weight loss of 30-49 pounds , night sweats which he attributed to the prednisone and increased fatigue and myalgias .
The patient has gradually taken to bed with decreasing activity .
In late 7/22 , sulfasalazine was started at one tab three times a day .
The patient subsequently developed diffuse abdominal pain , nausea , vomiting , and decreased p.o. intake .
A guaiac positive stool was also noted in the month of July .
10 days prior to admission , the patient 's primary care physician increased his sulfasalazine dose to two tabs three times a day .
The patient 's prednisone was increased to 60 mg q.d. as the patient was diagnosed with an arthritis flare .
The prednisone dose was gradually tapered to 20 mg q.d.
The day before admission , the patient developed a fever to 102 degrees and increasing abdominal pain .
He presented to an outside hops where he was noted to be leukopenic with a white blood cell count of 0.6 , 0 neutrophils , a hematocrit of 32 , platelets of 326 , a MCV of 79 , and RDW of 22 .
The patient was given IV fluids and treated with imipenem , transferred to Ca Valley Hospital ED , where it was noted that the patient had face and neck swelling , as well as erythema and cervical lymphadenopathy .
The patient states that his swelling of his face began two days prior to admission and has doubled since then .
In the emergency department , CT of head , neck and abdomen were performed .
The CT of the abdomen was without lymphadenopathy , revealed a right renal cyst , otherwise unremarkable .
The CT of head and neck was likewise unremarkable showing no evidence of fasciitis or deep tissue thread .
No abscesses were noted .
REVIEW OF SYSTEMS :
The patient denies shortness of breath , chest pain , orthopnea , no dysuria , hematuria , no visual changes , no rashes , no blurry vision .
HOSPITAL COURSE :
The patient was started on ceftazidime , nafcillin and Flagyl for concern of a soft tissue infection .
Neutropenic precautions were taken .
The patient had a bone marrow biopsy which showed myeloid arrest and probable neutropenia from a drug-related cause presumed to be the sulfasalazine .
Over the course of the hospitalization , the patient 's white blood cell count rose from 0.4 to 6.3 after he was given G-CSF , a course lasting from 9/28/01 until 9/30/01 .
After the G-CSF , the absolute neutrophil count was greater than 8000 .
On 10/3/01 , the patient had a repeat head and neck CT , which showed a right parotitis and left submandibular lymphadenopathy with some necrosis .
No frank abscesses .
The patient 's antibiotics were changed to clindamycin 300 mg q.i.d. and patient was also put on sialagogue .
Over the course of the hospitalization , the swelling and tenderness and erythema have steadily decreased .
Recommendations on antibiotics were made by infectious disease team , who was consulted .
Rheumatology was also consulted for patient and after workup , it was believed that arthritis may be a rheumatoid factor negative , rheumatoid polyarthritis .
Rheumatology recommended a taper of his prednisone to 20 mg q.d. and the patient will be followed by the rheumatology service .
The oncology service was also consulted for patient and performed a bone marrow biopsy .
Throughout his course during this hospitalization , the patient was also followed by the ENT service .
The ENT physicians did not recommend any procedures , incision and drainage for his right parotitis or left submandibular cervical lymph node necrosis .
The ENT team recommended watching patient in-house for two days after his repeat imaging on 10/3/01 , and to continue antibiotic coverage with clindamycin .
The patient had no positive blood cultures during his hospitalization and remained afebrile after the second day of admission . | [
{
"text": "July",
"start_char": 1113,
"end_char": 1117,
"id": "T11",
"type": "DATE",
"val": "2001-07",
"mod": "NA"
},
{
"text": "10 days",
"start_char": 1120,
"end_char": 1127,
"id": "T12",
"type": "DURATION",
"val": "p10d",
"mod": "NA"
},
{
"text"... | null | null | null |
491 | Admission Date :
11/03/1993
Discharge Date :
11/07/1993
HISTORY OF PRESENT ILLNESS :
The patient is a 69-year-old male with multiple medical problems and known transfusion dependent secondary to myelodysplastic syndrome admitted with decreased hematocrit .
The patient has had multiple previous admissions for cardiac and pulmonary disease .
He has had chronic anemia since 1990 , but a bone marrow biopsy in 07-92 , was consistent with myelodysplastic syndrome .
Over the past several months , the patient has had increasing transfusing requirements .
His transfusions have been complicated by fluid overload and congestive heart failure , secondary to ischemia cardiomyopathy .
His last admission was 9-14-93 , for a transfusion without complications , and prior to admission the patient reports having several days of increasing weakness , dizziness and fatigue .
His wife says his hands and lips have been blue .
Apparently , he had had a low hematocrit as an outpatient and was checked two weeks prior to admission but was not given transfusion because the patient did not want to come in at that time .
Aside from the above , the patient had felt that baseline without fever and chills or change in chronic cough .
He had no increase in his congestive heart failure symptoms , no chest pain , and no hemoptysis or changed in arthritis .
The patient did report taking a po antibiotic ( Ciprofloxacin ) for right great toe infection ( question of cellulitis vs. paronychia ) .
HOSPITAL COURSE :
The patient was admitted and placed in isolation on neutropenic precautions .
He was transfused with 1/2 units of packed red blood cells and given Lasix periodically to prevent him from going into congestive heart failure has he had on his prior transfusion .
Because his need for multiple transfusionsm he was transfused with radiated Leuco four units .
The patient had a good bump in his hematocrit , more than expected from 22 to high 20 's range next day after 3 1/2 units , but later that evening had a drop in his hematocrit so was given 4 more 1/2 units at this point for a total of 4 units packed red blood cells .
He again did not bump his hematocrit sufficiently and remained in the high 20 's after a total of 4 units , so he was given 2 more total units in 1/2 units segments the following day .
His hematocrit subsequently bumped to greater than 30 and was discharged with hematocrit of 32 on 11-7-93 .
The patient remained asymptomatic from a CHF stand point and felt much better after the transfusions .
It is unclear why the patient did not bump his hematocrit more but he did not appear to be hemolyzing from laboratory data , that is his LDH was within normal limits .
In addition , multiple stools were guaiaced and were all guaiac negative .
The patient was discharged with follow-up with his Hematologist , Dr. Eci Area and Rheumatologist , Dr. Taange Peter , and Cardiologist , Dr. Peter . | [
{
"text": "that time",
"start_char": 1098,
"end_char": 1107,
"id": "T9",
"type": "DATE",
"val": "1993-10-20",
"mod": "APPROX"
},
{
"text": "11/03/1993",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1993-11-03",
"mod": "NA"
},
{... | null | null | null |
308 | ADMISSION DATE :
12/02/2002
DISCHARGE DATE :
12/04/2002
HISTORY OF PRESENT ILLNESS :
The patient is an 81 year old female with a history of cerebrovascular accident , atrial fibrillation , hypothyroidism and dementia who is status post laparoscopic cholecystectomy one week ago who currently presents with a 4 day history of no bowel movement .
She has complaints of abdominal distention , emesis , and constipation .
She has no chest pain , shortness of breath or fever .
She has no nausea or vomiting , chills , dysuria , hematochezia , or melena .
She was discharged from the hospital on 11/28/02 to a short term rehabilitation facility .
She was found to have normal bowel sounds .
She presented to the Ponta,itri- University Medical Center Emergency Department on 12/01/02 for evaluation of this constipation .
HOSPITAL COURSE :
The patient presented to the operating room late at night on 12/01/02 and was admitted to the floor early on the morning on 12/02/02 .
She was placed on a bowel regimen of Dulcolax , Fleet enema , and Colace .
On 12/03/02 the patient underwent a repeat KUB which was suggestive of volvulus .
She then underwent a CT scan which showed no evidence of volvulus .
Rigid sigmoidoscopy revealed no obvious mucosal abnormalities but during the time of the procedure 22cc of mucous like stool was evacuated with a large amount of gas .
Subsequent to that the patients abdomen was significantly less distended and her pain decreased as well .
On the following day , hospital day number 3 , the patient was doing well .
The abdomen was again far less distended .
She was tolerating clear liquids ad lib .
She was afebrile with stable vital signs .
A repeat KUB was performed which showed no evidence of volvulus .
She was discharged back to a rehabilitation facility in good condition . | [
{
"text": "12/03/02",
"start_char": 1048,
"end_char": 1056,
"id": "T3",
"type": "DATE",
"val": "2002-12-03",
"mod": "NA"
},
{
"text": "the following day",
"start_char": 1472,
"end_char": 1489,
"id": "T9",
"type": "DATE",
"val": "2002-12-04",
"mod": "NA"
... | null | null | null |
452 | Admission Date :
2012-04-27
Discharge Date :
2012-04-30
Service :
Neurosurgery
HISTORY OF PRESENT ILLNESS :
Patient is a 79 - year-old female with a history of cataracts , glaucoma , and diabetes , who fell and tripped over a wheelchair of a friend with no loss of consciousness , no dizziness , no chest pain , and no shortness of breath .
PHYSICAL EXAM :
She was afebrile .
Heart rate was 77 .
Blood pressure 132/48 .
Respiratory rate was 17 .
Sats 96% on room air .
Her temperature was 97.6 .
She neurologically , she had a nonfocal neurologic examination .
Her cardiovascular was regular rate and rhythm .
Her pulmonary :
Chest was clear to auscultation bilaterally .
Extremities :
No cyanosis , clubbing , or edema .
Head CT showed a front focal hemorrhage in the left occipital lobe adjacent to the falx with intraparenchymal hemorrhage or epidural or subdural hemorrhage near the falx with no shift .
CT of the C spine was negative and her cervical spine was cleared .
HOSPITAL COURSE :
She was admitted to the ICU for close neurosurgical and neurological observation .
She remained neurologically stable .
Repeat head CT showed stable bleed .
The patient was transferred to the regular floor .
She was out of bed ambulating , tolerating a regular diet , voiding spontaneously .
She will be discharged to home with followup with Dr. Wilson in two weeks with a repeat head CT .
MEDICATIONS ON DISCHARGE :
1. Levofloxacin 250 mg p.o. q.24h. x3 days .
2. Dilantin 100 mg p.o. t.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Timoptic 0.25 one drop O.U. b.i.d.
5. Lantoprost 0.005 ophthalmic solution one drop O.U. q.h.s.
6. Zantac 150 mg p.o. b.i.d.
7. Insulin-sliding scale as well as 40 units of Humalog in the a.m. and 20 at night .
CONDITION ON DISCHARGE :
Stable .
FOLLOW-UP INSTRUCTIONS :
She will follow up with Dr. Perez in two weeks with repeat head CT .
Danvers T Sharp , M.D.
16-530
Dictated By : David GA Crane , M.D.
MEDQUIST36
D : 2012-04-30 11:30
T : 2012-05-01 08:13
JOB #: 10027
Signed electronically by : DR. Margarita Martin on : TUE 2012-06-05 8:08 AM
( End of Report ) | [
{
"text": "two weeks",
"start_char": 1351,
"end_char": 1360,
"id": "T0",
"type": "DATE",
"val": "2012-05-14",
"mod": "APPROX"
},
{
"text": "q.24h. x3 days",
"start_char": 1440,
"end_char": 1454,
"id": "T3",
"type": "FREQUENCY",
"val": "R3P24H",
"mod": "NA"... | null | null | null |
23 | Admission Date :
2014-04-23
Discharge Date :
2014-04-28
Service :
MEDICINE
History of Present Illness :
HPI :
Ms. Franklin is a 34 - year-old woman with Bipolar disorder and group home resident who by way of EMS for apparent alprazolam overdose .
In the St. Margaret 's Center for Women & Infants , the patient was lethargic and unable to give a history .
She was promptly intubated for airway protection and in order to administer charcoal .
Patient was found at group home in am laying on floor by bed unresponsive , last seen awake 8 hours prior at dinner .
Group home states that patient " may have taken too many Xanax .
Patient has a history of suicidal ideations and self mutilation .
Later patient told CMED CCU that she was feeling down and impulsively ingested 5 days worth of medications , she states that her intent at that time was to end her life .
Brief Hospital Course :
CMED CSRU Course :
Patient was intubated in John for airway protection and administation of charcoal .
Toxicology consulted and felt that patient most likely had benzo overdose .
ABG revealed widened A-a gradient so a d-dimer was sent which was elevated .
Patient had CTA which showed bilateral pulmonary embolisms .
Patient was started on heparin drip and bilateral lower extremeties were done which were negative for DVT .
Patient was exubated after 1 day in ICU after waking up .
Overnight in the ICU patient was noticed to have painful bullae on hands and arm along with swelling .
Dermatology and plastic surgery were consulted who felt that symptoms were due to trauma ; it was not felt that patient had compartment syndrome .
Patient was splinted and UE were kept elevated .
Patient was gradually put back on her outpatient xanax dose of 1 mg qid and clozaril was restarted .
Patient was transferred to floor after spending 1 day in the ICU .
Once on the floor patient stable .
Plastic did not feel that patient had any compartment syndrome and recommended aggresive upper extremity elevation for swelling reduction .
While on the floor patient 's hands improved with good range of motion of left hand , however Jones some poor range of motion of right .
X-ray of the hands and wrist were obtained which were negative .
Patient seen by PT and OT who recommended hand exercises and splints for patient .
Patient was put on coumadin that was bridged with lovenox unti lINR theraputic 01-23 .
Patient conitnued to have SI while on floor and was transferred to psychiatry .
While on the floor patient 's urinalysis suggestive of UTI and was put on 6 day course of levofloxacin . | [
{
"text": "1 day",
"start_char": 1340,
"end_char": 1345,
"id": "T4",
"type": "DURATION",
"val": "p1d",
"mod": "NA"
},
{
"text": "Overnight",
"start_char": 1371,
"end_char": 1380,
"id": "T5",
"type": "DURATION",
"val": "p12h",
"mod": "APPROX"
},
{
"... | null | null | null |
122 | ADMISSION DATE :
05/09/2004
DISCHARGE DATE :
05/16/2004
HISTORY OF PRESENT ILLNESS :
The patient is an 84-year-old woman with a history of diverticulitis who was found to have colon cancer on colonoscopy , which was performed in March of 2004 .
An invasive moderately differentiated adenocarcinoma was noted in the transverse colon at 80 cm .
The patient reports a history of bloating and flatulence as well as increased fatigue .
She has also had some discomfort in her left lower abdomen and notes diarrhea every 4-5 days .
She says that her appetite is good and has noted no weight loss .
HOSPITAL COURSE :
The patient was consented for surgery and on the day of admission was taken to the operating room for transverse colectomy for tumor .
The patient tolerated the procedure well and there are no complications .
Her postoperative course was unremarkable .
She was maintained on an epidural and PCA for pain control .
She was kept NPO initially and her diet was slowly advanced as tolerated .
When she was taking clear liquids , her pain medication was switched to p.o. pain regimen with good affect .
For blood pressure control she was maintained on metoprolol at the request of her primary care physician and enalapril was discontinued .
With the help of physical therapy the patient was ambulated and on postoperative seven , with the patient tolerating a post surgical soft diet and with pain well controlled on oral pain medications , she was discharged to rehabilitation facility . | [
{
"text": "postoperative seven",
"start_char": 1314,
"end_char": 1333,
"id": "T5",
"type": "DATE",
"val": "2004-05-16",
"mod": "NA"
},
{
"text": "05/09/2004",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2004-05-09",
"mod": "NA"
... | null | null | null |
126 | ADMISSION DATE :
09/08/96
DISCHARGE DATE :
09/17/96
HISTORY OF PRESENT ILLNESS :
This 82 year old retired engineer has had multiple admissions to the Ph University Of Medical Center for multiple strokes and a spontaneous subdural hematoma and prostatic hypertrophy .
He has been managing at home on restricted activity but able to get around with a walker but on the day before admission he became increasing dyspneic and on the day of admission he collapsed and was unable to walk to his bed .
For this he was admitted .
HOSPITAL COURSE AND TREATMENT :
The patient was started on Clindamycin intravenous and Cefuroxime intravenous with clearing of his fever but persistence of cough , choking , and intermittently many coarse rales in his base with no clearing by x-ray .
His ambulation was minimal and always with assistance but he had a transurethral resection of the prostate on 09/14/96 .
He is transferred to Louline Mauikings Medical Center for future rehabilitation and hopeful return home with considerable support and assistance . | [
{
"text": "09/08/96",
"start_char": 18,
"end_char": 26,
"id": "T1",
"type": "DATE",
"val": "1996-09-08",
"mod": "NA"
},
{
"text": "the day",
"start_char": 364,
"end_char": 371,
"id": "T0",
"type": "DATE",
"val": "1996-09-07",
"mod": "NA"
},
{
"text... | null | null | null |
697 | Admission Date :
2015-04-16
Discharge Date :
2015-04-24
Service :
SURGERY
History of Present Illness :
This 78 year old Mexican speaking female presented to the emergency department on 2015-04-16 .
Her family memebers stated that she was found at home with altered mental status and diaphoresis .
She is diabetic .
Mental status improved after binasal cannula oxygen applied , at which time she localized right upper quadrant pain .
She developed leukocytosis and transaminasemia .
Brief Hospital Course :
Ms Malek was admitted on 2015-04-16 due to altered mental status and acute right upper quadrant abdominal pain .
Gallbladder ultra sound revealed a distended 1.6 cm_ non mobile stone in the neck .
HD # 01 20 She was monitored closely in the CMED .
On 2015-04-17 she was taken to the OR for lap converted to open cholecystectomy .
She tolerated the procedure well , see op report for details .
She was extubated and recovered well in PACU .
She remained NPO with IV fluids , foley catheter and Dilaudid IV for pain control , Unasyn for antibiotic coverage .
She returned to CMED for further monitoring .
She was noted to have low urine output at times .
She responded well to fluid bolusing .
POD#1 she was transferred to CC6 for further recovery .
She remained afebrile , she was given ice chips .
Physical therapy was consulted for strength and mobility .
POD#2 her pain was somewhat uncontrolled , she was placed on Dilaudid PCA with fair effect .
Urine output remained adequate .
She was monitored on telemetry for mild tachycardia and recieved IV beta blockers .
She ambulated with assistance .
POD#3 she was advanced to sips and clears , foley catheter was discontinued .
POD#4 , bilious drainage was noted in her JP .
She had worsening abdominal pain on exam .
She was held NPO .
She was taken to ERCP where sphincterotomy was performed and biliary stent was placed .
She tolerated the procedure well and returned to CC6 post-procedure .
JP remained intact with serosainguinous drainage .
POD#5 she c/o difficulty voiding , pt was straight cathed after bladder scan was obtained and revealed > 600 ccs urine .
POD# 05 25 she continued with intermittent complaints of urinary retention .
However she was able to void .
Renal function remained normal .
She did not require further straight catheterization .
She was advanced to clear liquids again without nausea or vomiting .
Her pain was well controlled by Tylenol .
Her home regimen of lantus was resumed for elevated blood glucose .
POD#6 , her diet was advanced to regular .
She required disimpaction and had hard stool in the rectum .
She was initiated on a bowel regimen and had no further incidents of diarrhea or constipation .
POD#7 she was discharged to rehab in stable condition .
Appropriate follow up appointments are recommended as well as prescriptions .
She should return in 6 weeks for removal of biliary stent . | [
{
"text": "POD#1",
"start_char": 1199,
"end_char": 1204,
"id": "T0",
"type": "DATE",
"val": "2015-04-18",
"mod": "NA"
},
{
"text": "POD#2",
"start_char": 1364,
"end_char": 1369,
"id": "T7",
"type": "DATE",
"val": "2015-04-19",
"mod": "NA"
},
{
"tex... | null | null | null |
318 | ADMISSION DATE :
8/21/93
DISCHARGE DATE :
8/23/93
HISTORY OF PRESENT ILLNESS :
This 68 year old female has rheumatic heart disease .
Mitral and possibly tricuspid valve surgery is scheduled for Labor Day by Dr. Riemund C. Kennedy .
Her history is detailed in the discharge summary of August 10 of this year .
She is admitted now for a neuro-interventional radiology procedure to decrease the likelihood of epistaxis on Coumadin .
HOSPITAL COURSE :
The interventional neuro-radiology procedure was performed by Dr. A Skizeis , on August 22 , via the right femoral artery .
The right internal maxillary artery supply to the nasal mucosa was embolized .
The left external carotid artery was occluded at its origin , with collaterals from the internal carotid artery .
Thus , embolization on the left side was not possible .
The patient received Coumadin , 10 mg. , on the evening following the procedure , and is discharged the next day .
Her prothrombin time will be rechecked on August 27 by her primary care physician , Dr. Naka Gift .
Once her prothrombin time is in therapeutic range , she will be observed for epistaxis .
She will take her last dose of Coumadin on September 1 in anticipation of cardiac surgery .
If her prothrombin time does not come into therapeutic range promptly , then surgery may be delayed . | [
{
"text": "September 1",
"start_char": 1169,
"end_char": 1180,
"id": "T8",
"type": "DATE",
"val": "1993-09-01",
"mod": "NA"
},
{
"text": "8/21/93",
"start_char": 18,
"end_char": 25,
"id": "T0",
"type": "DATE",
"val": "1993-08-21",
"mod": "NA"
},
{
... | null | null | null |
481 | ADMISSION DATE :
09/09/2003
DISCHARGE DATE :
09/12/2003
HISTORY OF PRESENT ILLNESS :
The patient is an 84 year old male , with a history of hypertension , who was discovered to have an asymptomatic 7 cm abdominal aortic aneurysm on CT scan obtained in the emergency room back in May .
At that time he had presented with abdominal pain , and was found to have acute cholecystectomy .
He underwent an uncomplicated laparoscopic cholecystectomy .
He presents at this time for endovascular repair of this abdominal aortic aneurysm .
HOSPITAL COURSE :
The patient was admitted to Vascular Surgery Service as a same day admission , and taken to the operating room for an uncomplicated endovascular repair of his abdominal aortic aneurysm , and Anurx modular bifurcated graft was placed , and both common femoral arteries were repaired in the usual fashion .
He had pulsatile pulse volume recordings , in both lower extremities , and both renal arteries were noted to be patent , as were both internal iliac arteries .
His angiogram in the operating room , revealed no evidence of an endo leak .
Postoperatively , his course was relatively uncomplicated .
He did have an episode of a prolonged sinus pause in the recovery room , which resulted in transient loss of consciousness .
He responded to a Neo-Synephrine bolus , and had no further complications from this standpoint .
Dr. Rosean Fletcher , of the Cardiology Department was consulted , and it was his opinion that the sinus pause was related to increased vagal tone postoperatively , perhaps secondary to the epidural , as well as the patient 's Atenolol use .
His Atenolol was held , and he had no further pauses during his stay .
His postoperative CT scan showed no evidence of endo leak , or graft kinking .
He maintained good peripheral pulses and warm feet postoperatively .
However , he did develop significant ecchymosis in both groins , extending down into his scrotum .
There was no evidence of significant groin hematomas .
He tolerated a regular diet .
His pain was adequately controlled with oral medications .
Accordingly , the patient was discharged to home on postoperative day 2 .
He will be visited by LDAMC for blood pressure and incision checks .
He will follow up with Dr. Dye in the Clinic . | [
{
"text": "09/09/2003",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2003-09-09",
"mod": "NA"
},
{
"text": "postoperative day 2",
"start_char": 2133,
"end_char": 2152,
"id": "T6",
"type": "DATE",
"val": "2003-09-12",
"mod": "NA"
... | null | null | null |
522 | Admission Date :
2011-10-17
Discharge Date :
2011-10-31
Service :
Cardiothor
HISTORY OF PRESENT ILLNESS :
This is a 56 year-old gentleman with severe aortic stenosis , reports having been told he had a heart murmur many years ago but just recently diagnosed with aortic stenosis .
He has had mild dyspnea on exertion increasing over the past couple of months prior to admission .
An echocardiogram in 2011-09-05 revealed a left ventricular ejection fraction of 20 to 25% . | [
{
"text": "2011-10-17",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2011-10-17",
"mod": "NA"
},
{
"text": "many years ago",
"start_char": 216,
"end_char": 230,
"id": "T2",
"type": "DATE",
"val": "1991",
"mod": "APPROX"
},
{
... | null | null | null |
721 | Admission Date :
08/07/1992
Discharge Date :
08/10/1992
HISTORY OF PRESENT ILLNESS :
This is an 81 year old female with a right breast mass with a discharge .
A mammogram of the right breast with shadow biopsy was negative .
In the fall of 1991 , nipple changes and discomfort was again noted .
A mmamogram showed no change on right , but new biopsy was positive .
On the left , there was a new shawdown but the biopsy was negative .
The patient presents now for right modified radical mastectomy with impant .
HOSPITAL COURSE :
The patient was taken to the Operting Room on 8/7/92 , where a right modified radical mastectomy was performed .
Subsequently a saline-filled right breast implant was performed .
The patient tolerated the procedure extremely well .
Two drains were used .
One drain was removed on postoperative day number two , and the second drain she will be discharged to home with . | [
{
"text": "08/07/1992",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1992-08-07",
"mod": "NA"
},
{
"text": "the fall of 1991",
"start_char": 229,
"end_char": 245,
"id": "T2",
"type": "DATE",
"val": "1991-10",
"mod": "APPROX"
},
... | null | null | null |
331 | ADMISSION DATE :
10/15/1999
DISCHARGE DATE :
10/18/1999
HISTORY OF PRESENT ILLNESS :
Mr. Factor is a 76 year old white male with acute inferior myocardial infarction , who was urgently transferred by Dr. Lenni Factor for cardiac catheterization and possible angioplasty .
His only cardiac risk factor includes hypertension .
The night of Oct 14 , 1999 the patient developed chest discomfort associated with shortness of breath .
On October 15 , 1999 at 6 AM the patient was admitted to No Verlmerver Medical Center .
An electrocardiogram showed acute inferior myocardial infarction .
Due to unknown duration of the chest pain thepatient was transferred urgently to the TGCHO for cardiac catheterization .
Shortly after Aggrastat was started , the patient became pain free .
HOSPITAL COURSE AND TREATMENT :
The patient was directly admitted to the cardiac catheterization laboratory .
Coronary angiography , right heart catheterization and percutaneous intervention of the RCA were performed from the right groin without complications .
The proximal RCA was totally occluded with good left to right collaterals .
The LAD showed a 40% stenosis in the proximal segment .
The circumflex showed mild atherosclerotic .
The RCA occlusion was successfully dilated and sent using a 3.0 X 23 mm Duet with post stent dilatation up to 16 atmospheres .
Following intervention right heart catheterization was performed to rule out RV infarct .
The RA was 5 .
PA was 19/7 with a mean of 13 .
PCW was 11 .
Of note there was a clear A wave in the RV tracing , suggestive of RV infarct .
The next day the patient was quite confused and disoriented , which gradually disappeared .
An echocardiogram was performed to evaluate the LV function , which showed an ejection fraction of 53% with inferoposteriorakinesis / hypokinesis .
The next day the patient 's mental status came back to baseline and he remained free of angina .
ASHEE SHOULTSNER , M.D.
Electronically Signed ASHEE SHOULTSNER , M.D.
11/07/1999 11:06
TR :
ghu
DD :
10/18/1999
TD :
10/18/1999 10:59
Acc :
ASHEE SHOULTSNER , M.D. Dr. Lenni Factor No Verlmerver Medical Center Dr. Tomedankell Flowayles No Verlmerver Medical Center STAT | [
{
"text": "The next day",
"start_char": 1571,
"end_char": 1583,
"id": "T1",
"type": "DATE",
"val": "1999-10-16",
"mod": "NA"
},
{
"text": "10/15/1999",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "1999-10-15",
"mod": "NA"
},
{
... | null | null | null |
682 | Admission Date :
2013-04-25
Discharge Date :
2013-05-11
Service :
CMED CSRU
HISTORY OF PRESENT ILLNESS :
The patient is a 49 year old man who was admitted to the Medical Intensive Care Unit status post cardiac arrest .
History was obtained per the Emergency Department report as well as from the patient 's family .
Information was very limited regarding the circumstances of his cardiac arrest .
Reportedly , the patient was at a local restaurant where he was noted to be unresponsive .
EMS was called and reported to arrive on scene within three minutes .
The patient was asystolic but regained a perfusing rhythm after 2 mg of Epinephrine and 2 mg of Atropine .
He was intubated in the field and brought to the Emergency Department .
He remained unresponsive despite the administration of Narcan .
CT examinations of the head , chest , abdomen and pelvis were all unremarkable .
Initial chest x-ray showed a left retrocardiac opacity and prominent interstitium though his lung volumes were low .
Subsequent chest x-ray showed right main stem intubation with left lung collapse which had corrected with withdrawal of the endotracheal tube .
The patient was then transferred to the Medical Intensive Care Unit for induced hypothermia given his hemodynamic stability , ongoing unresponsiveness and recent out of hospital cardiac arrest .
HOSPITAL COURSE :
Cardiac arrest - His arrest was of unknown etiology at the time of admission .
No further history was ever gained about his cardiac arrest throughout his hospitalization .
CT angiogram had been negative for pulmonary embolism .
The patient had an echocardiogram on 2013-04-26 , which showed a normal ejection fraction and trivial mitral regurgitation ; otherwise no obvious abnormalities were seen .
Given the patient had an out of hospital arrest , remained unresponsive despite hemodynamic stability , he was treated with induced hypothermia and with cold packs and a cooling blanket were placed with goals of reducing his core body temperature to 32 degrees Celsius for a period of twelve hours at which point he would be rewarmed over the subsequent six hours .
This was done , however , as in problem number two below , we were not successful in any neurologic recovery .
Neurology - The patient remained unresponsive after the induced hypothermia , the patient was noticed to develop myoclonic jerks and occasional fluttering of his eyelids .
Electroencephalogram revealed the patient was experiencing persistent seizure activity .
Neurology was consulted and the patient was treated very aggressively , loaded with multiple drugs , including Ativan and Propofol drips .
The patient continued to demonstrate seizure activity despite this .
He was loaded with Dilantin and ultimately was treated with a Pentobarb coma .
After multiple attempts of weaning the Pentobarb , the patient was continually reverting to status epilepticus which was never able to be suppressed .
Infectious disease - Over the course of his hospital stay , the patient 's white blood cell count rose to a peak of 17 .
Multiple cultures were done and the patient was ultimately found to have methicillin resistant Staphylococcus aureus bacteremia , pneumonia , and urinary tract infection .
For all these infections , the patient was treated with Vancomycin and he was also on Levofloxacin and Flagyl for presumed aspiration pneumonia at the time of his admission .
Blood cultures cleared by 2013-05-03 .
Sputum culture as late as 2013-05-10 , however was still positive for coagulase positive Staphylococcus which was methicillin resistant Staphylococcus aureus .
The patient remained gravely ill throughout his hospital stay and had multiple meetings were held with his family with his son being his next of kin .
Ultimately it was decided that the patient 's wishes would be to not be maintained in a vegetative state and given his poor prognosis ultimately the decision was made to pursue comfort measures only .
With these goals of care , the patient expired on 2013-05-11 .
The family did consent to a postmortem examination . | [
{
"text": "2013-04-26",
"start_char": 1622,
"end_char": 1632,
"id": "T3",
"type": "DATE",
"val": "2013-04-26",
"mod": "NA"
},
{
"text": "2013-04-25",
"start_char": 18,
"end_char": 28,
"id": "T1",
"type": "DATE",
"val": "2013-04-25",
"mod": "NA"
},
{
... | null | null | null |
26 | Admission Date :
12/11/2005
Discharge Date :
12/13/2005
Service :
ORT
HPI :
Hibbskote has severe low back pain radiating down the right leg .
She has been suffering from this problem for the last few weeks .
A week and half ago , she had a steroid injection in an efforts to ameliorate the pain .
She presents now with worsening low back pain radiating down the right leg .
She denies numbness or weakness in any part of the body .
She denies fever .
She denies nausea , vomiting , and diarrhea .
She denies chest pain .
She says the pain is sharp in character , and radiates with a shock like intensity down the right leg .
She says that oral analgesics have been of little help .
On detailed review of systems , she admitted to one episode of urinary incontinence .
She denied any changes in bowel habits .
HOSPITAL COURSE :
Patient was evaluated by the orthopedic service .
An MRI of the spine showed L4/5 facet enhancement .
It was evaluated by the IR radiology .
Thad lesion was read as a facet hypertrophy and not an infectious process .
Patient remained afebrile .
ESR was within normal limits and CPR was mildly elevated .
An AP of pelvis and R hip films were unremarkable .
Physical examination of the RLE showed mild pain in right hip with some movements .
When patient was distracted , some maneuvers were not painful .
Patient remained cardiovascularly stable .
Patient was weaned from supplemental oxygen and tolerated a regular diet prior to discharge .
The patient received pneumoboots and lovenox for DVT prophylaxis . .
Patient was instructed by PT on the correct way to ambulate , weight bearing as tolerated in the RLE . .
Patient was able to void and ambulated without assistance as directed by P.T.
The team decided that the patient was ready for discharge .
Patient should follow up with her pain doctor , Dr. Maa Bloch 381-389-5852 , for her chronic pain management | [
{
"text": "12/11/2005",
"start_char": 18,
"end_char": 28,
"id": "T0",
"type": "DATE",
"val": "2005-12-11",
"mod": "NA"
},
{
"text": "few weeks",
"start_char": 197,
"end_char": 206,
"id": "T2",
"type": "DURATION",
"val": "P3W",
"mod": "APPROX"
},
{
... | null | null | null |
641 | ADMISSION DATE :
4/16/93
DISCHARGE DATE :
4/23/93
HISTORY OF PRESENT ILLNESS :
The patient is a generally healthy 85 year old female , who has had a five year history of right hip pain , worsening over the past several months .
Her pain is located in the groin and thigh .
It is aggravated by activity and improved by sitting or lying down .
It is associated with rest pain as well .
She uses a cane or walker for ambulation , and is limited to one to two blocks .
She does stairs one at a time and only with help .
She has difficulty with shoes and socks and foot care .
The patient 's pain has not been relieved by Darvocet and Advil .
Radiographs demonstrate right hip osteoarthritis .
Having failed conservative management , the patient presented for elective right total hip replacement .
HOSPITAL COURSE :
The patient was admitted to the Orthopedic Service on 4/16/93 .
On that day she underwent clearance from the Cardiology Service , Dr. Shuff .
It was his impression that the patient 's hypertension was controlled on hydrochlorothiazide .
Given the patient 's low potassium level of 2.4 on the day of admission , he suggested supplementation with potassium .
The patient was cleared from surgery from a cardiology standpoint .
On the following morning 4/17/93 , the patient was taken to the operating room where she underwent a right total hip replacement , using a hybrid S-ROM system .
Postoperatively , the patient did extremely well .
The patient was seen in consultation with the physical therapy service initially for routine rehabilitation after a total hip replacement .
Her hemovac drains were removed on postoperative day # 2 as was her Foley catheter .
Her hematocrit remained stable in the low to mid 30 's and she did not require a transfusion .
The patient did have postoperatively hypokalemia to a level of 2.7 and subsequently was corrected with oral and intravenous potassium on 4/22/93 , the patient underwent a duplex ultrasound examination , which showed no evidence of of deep venous thrombosis .
The patient 's Coumadin was thus stopped and she was switched to Bufferin .
The patient 's hospitalization was uncomplicated .
She was discharged to the Encharlea Il Medical Center in New Hampshire . | [
{
"text": "the day",
"start_char": 1116,
"end_char": 1123,
"id": "T8",
"type": "DATE",
"val": "1993-04-16",
"mod": "NA"
},
{
"text": "morning 4/17/93",
"start_char": 1270,
"end_char": 1285,
"id": "T9",
"type": "DATE",
"val": "1993-04-17",
"mod": "START"
... | null | null | null |
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