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the patient is a 76-year-old male who had been hospitalized at the from through of after undergoing a left femoral-at bypass graft and was subsequently discharged to a rehabilitation facility. on , he presented again to the after being found to have a systolic blood pressure in the 70s and no urine output for 17 hours... |
the patient is a 47-year-old female with a history of human immunodeficiency virus (last cd4 count 42 and a viral load of 65,000), cirrhosis, diabetes, and hypothyroidism presented with eight days of fevers to 104, chills, shortness of breath, cough, dyspnea on exertion, and fatigue. the patient states she has become ... |
50 yo m w/ type 2 dm, depression who was admitted to deaconness 4 for major depressive episode and possible . while on 4, the patient was given ativan 1 mg x 1. his klonopin was held. he was given normal dose of nph as npo for . the following am, the paitent was found to be shaking. he was given 2 mg ativan and became... |
the pt is a 24 y.o. f with esrd on hd, sle, malignant htn, history of svc syndrome, pres, recently discharged on after admission for abdominal pain, mssa bacteremia, paroxysmal hypertension and esrd line, presents with central crampy abdominal pain, chest discomfort, sob, htn to 230s. pt states that at around 11pm las... |
allergies: penicillins / percocet / morphine attending: chief complaint: altered mental status, solmolence, and relative hypotension major surgical or invasive procedure: none, hd per schedule on the day of discharge, transfused 1u prbc |
the patient is a 69 year old female with no significant past medical history who presented to hospital with acute onset of respiratory distress. the patient had been noticing an enlarging neck mass for the past three to four years. as hospital notes, the patient noticed increasing phlegm production two days prior to a... |
past medical history: 1. coronary artery disease, status post catheterization in with diffuse lad disease. the patient had a normal p mibi in . 2. history of left bundle branch block. 3. history of noninsulin-dependent diabetes mellitus. 4. hypertension. 5. anemia secondary to mgus. 6. status post left carotid endarter... |
discharge status: the patient was to be discharged to the tippete house. medications on discharge: 1. morphine 5 ml t0 10 ml of a 10-mg/5 ml solution by mouth q.4h. as needed (for discomfort). 2. ativan 0.5 mg by mouth q.4-6h. as needed (for anxiety). discharge instructions/followup: none. , m.d. dictated by: medquist3... |
mrs. is a 62-year-old female with a complicated medical history including sarcoidosis, hepatic cirrhosis, grade ii esophageal varices, hypertension, multiple orthopaedic procedures to her left hip, right hip and right knee, who presented with left thigh recently admitted to surgery for ventral hernia repair, which had... |
this is a 63 year-old female with a history of prednisone dependent sarcoid, cirrhosis, ascites with sbp who presented with one day of nausea, vomiting, diarrhea and change in mental status. she was discharged to nursing home on after admission for back pain. she has had multiple admissions including three day admissi... |
allergies: penicillins / codeine attending: chief complaint: hematemesis major surgical or invasive procedure: - egd - tips angioplasty and embolization of varices |
46 yo f w/ etoh/hcv cirrhosis, grade 1 varices and portal gastropathy who presented to the ed yesterday with 1 episode of hematemesis on , which the patient describes as "dark clots...just old blood". she subsequently left ama and returned the next day with melena x 1. of note, pt was recently admitted in with hematem... |
allergies: penicillins / codeine attending: chief complaint: cc: coffee ground emesis, black diarrhea major surgical or invasive procedure: upper endoscopy |
the patient is a 46 year old woman with etoh/hcv cirrhosis, grade 1 varices and portal gastropathy who presents with n/v/d, abdominal pain and coffee ground emesis since this am. in the ed, she was initially hemodynamically stable with maintained hct. ng lavage revealed red blood that cleared after 750 cc. she also pa... |
allergies: penicillins / codeine / optiray 350 attending: chief complaint: hcv/hcc here for liver transplant major surgical or invasive procedure: : orthotopic liver transplant |
ms. is a 50 yo f with h/o etoh/hcv cirrhosis, focal liver lesion likely hcc by imaging (path : small cell dysplasia),and tips x2 with h/o encephalopathy, meld 29, listed for a liver transplant on , now presents for liver transplant. pt is morbidly obese, and her most recent bmi was calculated at 41.6. she is 5 feet 3 ... |
allergies: penicillins / codeine / optiray 350 attending: chief complaint: reason for admission/cc: major surgical or invasive procedure: none |
51f pmhx hcv/hcc cirrhosis now pod10 s/p olt discharged to rehab 5 days prior to readmission with post-operative course remarkable for acute renal insufficiency and hyponatremia which were resolving at time of discharge. per report, pt with acute change in mental status this morning at rehab facility described as conf... |
*allergies: pcn, codeine neuro: pt a&o x3, follows commands, moves in bed by self, perrl 3mm/brisk. complaints of discomfort, worrying about the alarms, lines, iv's and not able to get comfortable. also complaints of pain in feet, neuropathy, on neurontin @ home, started here as well. given 2.5mg ambien @ 0430 to help ... |
*allergies: pcn, codeine *access: r ant 16g, r ant 20g, rij trauma line neuro: pt lethargic/sleeping most of shift following tips procedure in ir w/ fentanyl used throughout procedure, also did not sleep last night here in icu. easily arousable, a&ox3, perrl 3mm/brisk, moves self in bed, no complaints of pain this shif... |
allergies: penicillins / codeine attending: chief complaint: tarry black stools major surgical or invasive procedure: egd tips |
46 year old woman with etoh/hcv cirrhosis who was recently admitted on with coffee ground emesis and black colored stools. . today the patient called her pcp and reported 3 episodes of jet black diarrhea, which was similar to her prior episode of ugib. she denied hematemesis, but reported diffuse abdominal pain and po... |
allergies: penicillins / codeine / rifaximin attending: chief complaint: melena and coffee ground emesis. major surgical or invasive procedure: revision of tips embolization of duodenal varix egd intubated bronchoscopy |
46 year old female with a history of alcohol and hcv cirrhosis, esophageal and duodenal varices, multiple gi bleeds, status post tips. recently admitted on with hematemesis and melena. per report, on day of admission , the patient had originally experienced episodes of vomiting "coffee ground" material, which was prec... |
allergies: nafcillin / aminoglycosides / bactrim / ceftriaxone / penicillins attending: chief complaint: respiratory distress, change in mental status major surgical or invasive procedure: 1. intubation |
83-year-old female with myasthenia, dementia, afib not on coumadin, chf, s/p mvr who has been having recurrent aspiration pna presented with cough, low-grade fever. patient unable to give any history. per family, the patient had been more somnolent and coughing for more than 1 week. the family also noted that she has ... |
allergies: nafcillin / aminoglycosides / bactrim / ceftriaxone / penicillins attending: chief complaint: hypoxic respiratory failure major surgical or invasive procedure: s/p intubation and extubation x 2 peg tube placement |
83yo f with baseline dementia, myasthenia on prednisone, asp pna, splenectomy, hx of mvr (porcine valve), cva, afib, hx endocarditis who presents with hypoxic respiratory failure. the pt's family states that one month ago, the pt saw her neurologist; at that time they requested that decreased the prednisone dose. pt's... |
allergies: iron dextran complex attending: chief complaint: fevers major surgical or invasive procedure: -l ij central line -av fistulagram with recannalization attempt by interventional radiology -ct with contrast -echocardiogram -pericardiocentesis -thrombectomy of av graft thrombus |
ms. is a pleasant 77-year-old female who was recently diagnosed with nonsmall cell lung cancer in , and is status post four treatments consisting of taxol, carboplatin and xrt to the right pretracheal mediastinal area, who presents to the emergency department with fever and decreased blood pressure along with some con... |
allergies: patient recorded as having no known allergies to drugs attending: addendum: podiatry performed an osteotomy on left second toe. there were no complications. patient still ready for rehab. swab from still reporting: gram + cocci to id or sensitivities discharge disposition: extended care facility: health of -... |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral foot ulcers major surgical or invasive procedure: right below knee amputation left5 sfa to pt bypassgraft with issvg, left sfa endartectomy, angioscopy angio with bilateral lower extremity runoff picc line rt. |
hpi: mr. is a 57 year-old man with hx of esrd on hemodialysis since who presented with 1 day history of fever to 101 at home and 1 week history of cough. the patient reports he developed a cough approximately one week ago that has been productive of copius white sputum. he describes daily episodes of coughing upon wak... |
allergies: iron dextran complex attending: chief complaint: esrd major surgical or invasive procedure: attempted renal transplant/aborted |
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