TEXT
stringlengths 267
54.7k
| ICD9_CODE
sequence |
|---|---|
Admission Date : [ * * 2117 - 9 - 11 * * ] Discharge Date : [ * * 2117 - 9 - 17 * * ]
Date Birth : [ * * 2082 - 3 - 21 * * ] sex : F
Service : MEDICINE
allergy :
Levaquin
attending:[**first Name3 ( LF ) 2195 * * ]
Chief Complaint :
nausea , vomit
Major Surgical Invasive Procedure :
none
history Present Illness :
35f w/ poorly control Type 1 diabetes mellitus w/ neuropathy ,
nephropathy , HTN , gastroparesis , CKD retinopathy , recently
hospitalize orthostatic hypotension [ * * 2 - 3 * * ] autonomic
neuropathy [ * * Date range ( 1 ) 25088 * * ] ; dka hospitalization [ * * 6 - 12 * * ] [ * * 7 - 12 * * ] ,
return w/ 5d history worsen nausea , vomit
coffee - ground emesis , chill , dyspnea exertion . last
week fall hit right face . also 1 day
diarrhea , resolve early last week . find DKA
AG 30 bicarb 11 .
.
ED inital vital 09:00 0 98.2 113 181/99 22 100 % RA .
K 4.7 , HCO3 11 , Anion Gap 30 , Cr . 2.7 ( baseline 1.6 - 2.0 )
3rd L NS . insulin srip 5 unit / hr . home 22
levemir 12 difficult control sugar . bp
high . give 30 mtroprolol tartrate ED .
start insulin drip 5 unit / hr 3L NS
bolus . also aspirin 325 mg PO Morphine 4 mg ivx1 pain .
CXr clear . EKG NAD .
.
Review system : otherwise negative .
Past Medical history :
type 1 diabetes mellitis w/ neuropathy , nephropathy ,
retinopathy - 2 episode dka [ * * 6 - 12 * * ] [ * * 7 - 12 * * ]
HTN - 5 year
gastroparesis - 1.5 year
ckd - stage III , baseline Cr 2.4 - 2.5 , proteinuria
L1 vertebral fracture - [ * * 2117 - 7 - 17 * * ]
Systolic ejection murmur
Social History :
Patient live home [ * * Location ( un ) * * ] 8 / daughter
boyfriend . history EtOH , tobacco , illicit drug
use . currently unemployed seek disability .
Family history :
parent HTN T2DM . Grandfather mi
40 .
Physical Exam :
GEN : awake , alert , orient
HEENT : PERRLA . MMM . JVD . neck supple . cervical LAD
card : RRR , S1 / S2 normal . II / VI systolic ejection murmur hear
good L upper sternal border .
Pulm : ctabl crackle wheeze .
Abd : BS+ , soft , NT , rebound / guarding , HSM , [ * * Doctor Last Name 515 * * ]
sign
extremity : wwp , edema . radial , dp , PTs 2 + .
skin : rash bruising . skin tenting .
Neuro : cns II - XII intact . upper extremity : Power [ * * 5 - 6 * * ]
bilaterally . le : leave power : 4.5/5 right : power [ * * 3 - 6 * * ] . bilateral
symmetric , reduced sensation distal LE ankle .
pertinent result :
Admission Labs : [ * * 2117 - 9 - 11 * * ] 09:22AM
WBC-11.9 * RBC-4.58 HGB-13.0 HCT-36.5 MCV-80 * PLT count-466 *
lipase-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5
GLUCOSE-260 * UREA N-48 * CREAT-2.7 * SODIUM-137 POTASSIUM-4.9
CL-101 CO2 - 11 *
LACTATE-1.9
Discharge Labs : [ * * 2117 - 9 - 16 * * ] 07:10am
wbc-6.8 rbc-3.67 * Hgb-10.4 * hct-30.2 * MCV-82 Plt ct-298
Glucose-118 * UreaN-20 creat-2.3 * Na-137 K-3.7 cl-104 HCO3 - 23
angap-14
calcium-8.7 Phos-3.5 Mg-2.0
radiology :
CXR : evidence pneumonia pathological
abnormality .
pleural effusion . pulmonary edema . normal size
cardiac
silhouette .
microbiology : Urine culture negative , blood culture growth
date , stool C.difficile negative
Brief Hospital Course :
35 yo F HTN & poorly control type DM , c / b neuropathy ,
gastroparesis , nephropathy ? ? ? ? ? ? CKD , retinopathy present DKA
hypertension SBP 200s .
.
# diabetic ketoacidosis : patient control diabete home
Humalog SS long act Levemir . Sugars home recently
250s . ED , glucose 466 . UA +
ketone ? ? ? ? ? ? correct 200s , rise 300s .
treat insulin drip transition subq
tolerate pos . electrolyte replete
receive aggressive volume resuscitation . [ * * last Name ( un ) * * ] see
give slide scale recommendation implement .
source DKA find , beleive [ * * 2 - 3 * * ] gastroparesis . nausea
manage ativan , compazine , promethazine .
discharge home Insulin slide scale
instruction follow - [ * * last Name ( un ) * * ] .
# HTN : Hypertensive SBP 190s initially , attribute
DKA , experience past . improve
blood pressure normalize - start home
Lopressor Midodrine regimen .
# Coffee ground emesis : Emesis start clear ,
prolong wretching , start coffee - ground vomiting .
also occur prior admission DKA
associate vomiting . hematocrit remain stable
hematemesis self - resolve , work - defer
outpatient setting .
# Acute chronic kidney disease , Stage III : Patient 's Cr
admission 2.7 , trend 2.1 - 2.3 following fluid ,
consistent know ckd secondary diabetic nephropathy .
medication admission :
1 . citalopram 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
2 . Levemir 100 unit / mL Solution Sig : twenty two ( 22 ) unit
Subcutaneous every .
3 . Levemir 100 unit / mL Solution Sig : twelve ( 12 ) unit
Subcutaneous bedtime .
4 . humalog 100 unit / mL Solution Sig : slide scale direct
Subcutaneous four time day : please use slide scale
direct MD [ * * First Name8 ( NamePattern2 ) 767 * * ] [ * * last Name ( Titles ) * * ] .
5 . metoprolol tartrate 50 mg Tablet Sig : 1.5 Tablets po DAILY
( Daily ): take evening .
6 . promethazine 25 mg Tablet Sig : 0.5 Tablet po Q8H ( every 8
hour ) need nausea .
7 . gabapentin 300 mg Capsule Sig : one ( 1 ) Capsule po Q12H ( every
12 hour ) .
Disp:*60 Capsule(s ) * Refills:*2 *
8 . duloxetine 30 mg Capsule , Delayed Release(E.C. ) Sig : two ( 2 )
Capsule , Delayed Release(E.C. ) PO DAILY ( Daily ): please take
1 capsule daily ( 30 mg ) first 2 week treatment .
disp:*60 Capsule , delayed Release(E.C.)(s ) * Refills:*2 *
9 . oxycodone 5 mg Capsule Sig : one ( 1 ) Capsule po every eight
( 8) hour need pain .
10 . midodrine 5 mg Tablet Sig : 1.5 tablet po every four ( 4 )
hour : hold sleep .
Disp:*270 Tablet(s ) * Refills:*2 *
Discharge medication :
1 . citalopram 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
2 . gabapentin 300 mg Capsule Sig : one ( 1 ) Capsule po Q12H ( every
12 hour ) .
3 . duloxetine 30 mg Capsule , Delayed Release(E.C. ) Sig : one ( 1 )
Capsule , Delayed Release(E.C. ) PO DAILY ( Daily ) .
4 . metoprolol tartrate 25 mg Tablet Sig : three ( 3 ) Tablet PO
Daily 6 pm .
5 . midodrine 2.5 mg Tablet Sig : three ( 3 ) Tablet PO DAILY
( Daily ) .
6 . Levemir 100 unit / mL Solution Sig : direct [ * * last Name ( un ) * * ] unit
Subcutaneous direct .
discharge Disposition :
home
discharge diagnosis :
diabetic keotacidosis
hematemesis ( blood vomit )
Hypertension
Chronic renal insufficiency
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
admit hospital DKA , hypertension ,
blood vomit . initially treat ICU
insulin drip , blood sugar improve . blood
pressure medication adjust well control blood
pressure DKA , - start
home regimen discharge . blood vomit likely
secondary mechanical trauma repeat wretching ,
follow - primary care doctor discuss
whether undergo evaluation upper
endoscopy . give complaint chronic cough heartburn ,
also discuss begin trial proton pump
inhibitor Nexium Prilosec see help
symptom .
insulin regimen adjust [ * * last Name ( un ) * * ] team
. continue follow -
question concern regard insulin management .
Followup Instructions :
please call dr.[**last Name ( STitle ) 805 * * ] ' office schedule follow -
appointment within 7 - 10 day discharge . office number
[ * * telephone / Fax ( 1 ) 85219 * * ] .
also continue follow - [ * * last Name ( un ) * * ] doctor
need .
|
[
"5849"
] |
Admission Date : [ * * 2150 - 4 - 17 * * ] Discharge Date : [ * * 2150 - 4 - 21 * * ]
Date Birth : [ * * 2090 - 5 - 19 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 12174 * * ]
Chief Complaint :
coffee ground emesis
Major Surgical Invasive Procedure :
egd
Right IJ CVL
history Present Illness :
Mr. [ * * know lastname 52368 * * ] 59 w HepC cirrhosis c / b grade / II esophageal
varix portal gastropathy ( last egd [ * * 3-/2150 * * ] ) , p / w
coffee - ground emesis melena x2 day .
.
Pt USOH 2 - 3 day PTA , begin
experience intermittent nausea . 2 - 3 episode
coffee - ground emesis 1 episode tarry black stool
morning admission . report lightheadedness
new , deny frank hematemesis , BRBPR , abdominal pain ,
fever , chill , significant increase abdominal girth .
deny drinking medication non - compliance . also report
take naproxen back pain 2 - 3 time day recent
past .
.
ed , vital 97.4 , 93/41 , 69 , 18 , 100 % RA .
give 4L NS IV , protonix 40 mg IV , start octreotide
drip . guaiac positive brown stool rectal exam .
see liver fellow ED feel unlikely
variceal bleed recommend work infection . NG tube
attempt , however , patient unable tolerate
ED . abdominal ultrasound do show patent portal
vein , scant ascite enough tap . BP drop 80/34 ,
pt transfer MICU hemodynamic monitoring .
.
MICU , pt give 3 prbc , Hct bump 21.3 28 .
start norepinephrine gtt hour , bp
stabilize . transfer floor , remain hemodynamically
stable . feel good , deny tarry bloody bm , emesis .
Past Medical history :
HCV Cirrhosis ( tx interferon x2 response )
Portal Gastropathy
Grade II Esophageal varix
HTN
Social History :
live alone . drink alcohol , usually one session per
week . four five drink per session . tell
completely abstain alcohol , effective today .
smoke 20 cigarette per day .
Family history :
NC
Physical Exam :
admission :
vs : T95.9 hr 71 BP 83/36 RR 11 96 % 2L NC
Gen : somnolent , orient x 3 , unable assess asterixis
give somnolence
HEENT : PERRLA , EOMI
Neck : supple , JVP angle jaw ( fluid bolus run wide
open )
CV : rrr s1 s2 appreciable murmur
Lungs : CTAB
Abd : distend , non tender , rebound guarding , bowel sound
positive
Ext : 1 + pit edema bilaterally
skin : warm , diaphoretic , rash lesion note
pertinent result :
LABS admission :
[ * * 2150 - 4 - 17 * * ] 01:30PM blood wbc-17.9 * # RBC-2.78 * Hgb-8.5 * Hct-26.0 *
MCV-94 MCH-30.6 mchc-32.7 RDW-20.6 * Plt ct-186
[ * * 2150 - 4 - 17 * * ] 01:30PM blood Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2
Baso-0.9
[ * * 2150 - 4 - 17 * * ] 02:13PM blood pt-17.7 * PTT-34.5 INR(PT)-1.6 *
[ * * 2150 - 4 - 17 * * ] 01:30PM blood Glucose-92 UreaN-51 * Creat-1.3 * Na-131 *
K-5.7 * Cl-104 HCO3 - 21 * AnGap-12
[ * * 2150 - 4 - 17 * * ] 01:30PM blood ALT-126 * AST-260 * ld(ldh)-426 *
AlkPhos-157 * TotBili-3.3 *
[ * * 2150 - 4 - 17 * * ] 06:41pm blood calcium-7.5 * Phos-3.8 Mg-1.9
.
LABS discharge :
[ * * 2150 - 4 - 21 * * ] 05:00am blood WBC-10.7 RBC-2.94 * Hgb-9.6 * Hct-27.0 *
MCV-92 MCH-32.6 * mchc-35.6 * RDW-21.2 * Plt Ct-110 *
[ * * 2150 - 4 - 21 * * ] 05:00am blood pt-17.4 * PTT-35.6 * INR(PT)-1.6 *
[ * * 2150 - 4 - 21 * * ] 05:00am blood Glucose-84 UreaN-15 Creat-1.0 Na-132 *
K-4.4 Cl-99 HCO3 - 25 AnGap-12
[ * * 2150 - 4 - 21 * * ] 05:00am blood alt-113 * AST-210 * AlkPhos-111
TotBili-3.6 *
[ * * 2150 - 4 - 21 * * ] 05:00am blood Calcium-8.1 * Phos-3.8 Mg-1.7
.
LABS :
[ * * 2150 - 4 - 18 * * ] 06:25AM blood CK - MB-9 cTropnT-<0.01
[ * * 2150 - 4 - 17 * * ] 06:41pm blood CK - MB-11 * MB Indx-4.9 cTropnT-<0.01
[ * * 2150 - 4 - 17 * * ] 01:30PM blood Lipase-85 *
.
URINE :
[ * * 2150 - 4 - 17 * * ] 11:01PM URINE Color - Yellow Appear - Clear Sp [ * * last Name ( un ) * * ] -1.016
[ * * 2150 - 4 - 17 * * ] 11:01PM URINE Blood - LG Nitrite - NEG Protein - NEG
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln-2 * pH-5.5 Leuks - NEG
[ * * 2150 - 4 - 17 * * ] 11:01PM URINE RBC-63 * WBC-7 * Bacteri - none yeast - none
epi-<1
.
MICROBIOLOGY :
blood , urine culture - negative
H.pylori serum antibody - negative
.
CARDIOLOGY :
.
TTE ( [ * * 4 - 18 * * ] ):
Conclusions
left atrium dilate . leave ventricular wall thickness
cavity size normal . leave ventricular systolic function
hyperdynamic ( EF>75 % ) . right ventricular chamber size
free wall motion normal . aortic valve leaflet ( 3 )
mildly thicken aortic stenosis present . aortic
regurgitation see . mitral valve leaflet mildly
thicken . mild ( 1 + ) mitral regurgitation see .
moderate pulmonary artery systolic hypertension .
pericardial effusion .
IMPRESSION : Hyperdynamic LV systolic function . mild mitral
regurgitation . moderate pulmonary artery systolic hypertension .
.
EKG ( [ * * 4 - 17 * * ] ):
Sinus rhythm
prolong QT interval nonspecific clinical correlation
suggest
previous tracing available comparison
Intervals Axes
Rate PR QRS QT / QTc P QRS
70 160 96 462/479 70 55 52
.
GI :
EGD ( [ * * 4 - 20 * * ] ):
1 . varix low third esophagus middle third
esophagus .
2 . erythema erosion antrum pylorus compatible
non - steroidal induce gastritis .
3 . bleed pyloric ulcer pylorus compatible
non - steroidal induce ulcer ( injection , thermal therapy ) .
4 . normal mucosa duodenum .
5 . otherwise normal egd third part duodenum
.
RADIOLOGY :
.
CXR ( [ * * 4 - 17 * * ] ):
prominent bulge right heart border could due
pericardial
effusion , _ _ _ _ _ cyst , enlarge right atrium .
mediastinal
vascular engorgement suggest cardiac tamponade . Pulmonary
vasculature normal . lung clear
pleural effusion . overall heart size normal . right jugular
line end junction
brachiocephalic vein . pneumothorax pleural effusion .
.
ABD U / ( [ * * 4 - 17 * * ] ):
IMPRESSION :
1 . son[**name ( NI ) 493 * * ] evidence portal venous thrombosis . portal
vein flow hepatopetal wall - - wall .
2 . significant ascite . sliver perihepatic ascite .
3 . persistent coarsen echotexture liver consistent
know
history cirrhosis .
4 . Splenomegaly
Brief Hospital course :
Mr [ * * know lastname 52368 * * ] 59 w HCV cirrhosis w grade ii esophageal varix
admit w coffee - ground emesis melena concern ugib ,
/ p MICU stay hypotension .
.
# ugib : Pt bleed hospital . egd
reveal erythema erosion antrum pylorus
compatible non - steroidal induce gastritis . Pt remember
take increase dose naproxen backache . start
pantoprazole 40 mg po BID one week repeat endoscopy
schedule one week ( [ * * 4 - 30 * * ] ) . recommend take tylenol ( max
daily dose 2gm ) pain instead nsaid . blood pressure
med hold first , give MICU admission hypotension ,
restart discharge .
.
# HCV cirrhosis : appear progress liver failure ,
elevated INR 1.6 , decrease albumin 2.6 , tbili
slightly elevate 3.6 , chronic LE edema . Pt continue
prophylactic medication .
.
# full code
Medications admission :
FUROSEMIDE 20 mg daily
LISINOPRIL 10 mg daily
SPIRONOLACTONE 100 mg daily
Discharge medication :
1 . phenol 1.4 % Aerosol , Spray Sig : one ( 1 ) spray mucous
membrane PRN ( need ) .
2 . Lactulose 10 gram/15 ml Syrup Sig : thirty ( 30 ) ML po TID ( 3
time day ) .
3 . thiamine HCl 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
4 . Folic Acid 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
5 . spironolactone 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
6 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet po day .
7 . Acetaminophen 325 mg Tablet Sig : 1 - 2 tablet po every [ * * 6 - 15 * * ]
hour need : 6 tablet regular strength
tylenol per day .
8 . terbinafine 1 % Cream Sig : one ( 1 ) Appl Topical [ * * hospital1 * * ] ( 2 time
day ) 1 week .
Disp:*qs * Refills:*0 *
9 . Nadolol 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
10 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) po twice day 1 week :
take 1 tablet daily .
Disp:*60 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
11 . Camphor - Menthol 0.5 - 0.5 % Lotion Sig : one ( 1 ) Appl Topical
QID ( 4 time day ) need itching .
Disp:*qs * Refills:*0 *
12 . lisinopril 10 mg Tablet Sig : one ( 1 ) Tablet po day .
discharge Disposition :
home
discharge Diagnosis :
peptic ulcer
gi bleed
discharge condition :
asymptomatic
Discharge instruction :
admit bleed ulcer stomach .
ulcer least partially cause naproxen .
stop take naproxen take tylenol pain .
take NSAIDS pain include ibuprofen , naproxen ,
aleve , motrin , aspirin , toradol , advil . okay take
tylenol take 4 extra strength tylenol day
( 2gram daily maximum ) .
.
follow medication change make :
take naproxen
take pantoprazole 40 mg twice daily one week . take 40
mg daily .
.
schedule get repeat endoscopy next week . prior
procedure anything drink eat
midnight .
.
please return er chest pain ,
lightheadeness , fever , chill , bloody black stool
concern symptom .
Followup Instructions :
Provider : [ * * Name10 ( NameIs ) * * ] [ * * apartment address(1 ) * * ] ( ST-3 ) GI ROOMS Date / time:[**2150 - 4 - 30 * * ] 1:30
Provider : [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern1 ) 7290 * * ] , MD phone:[**telephone / fax ( 1 ) 463 * * ] Date / time:[**2150 - 4 - 30 * * ]
1:30
Provider : [ * * Name10 ( NameIs ) * * ] [ * * last Name ( namepattern4 ) 2424 * * ] , MD phone:[**telephone / fax ( 1 ) 2422 * * ]
Date / time:[**2150 - 5 - 7 * * ] 11:00
complete by:[**2150 - 4 - 24 * * ]
|
[
"2851",
"5715",
"4019"
] |
Admission Date : [ * * 2108 - 4 - 6 * * ] Discharge Date : [ * * 2081 - 4 - 7 * * ]
Date Birth : [ * * 2059 - 5 - 7 * * ] sex : F
Service : MED
CHIEF COMPLAINT : Dyspnea .
history PRESENT ILLNESS : 48 year old african
american female history multiple myeloma
admit respiratory distress . patient
recently discharge one week ago outside hospital ( [ * * Hospital3 7900 * * ] ) respiratory distress . back [ * * hospital3 7362 * * ] ,
give nebulizer , antibiotic steroid . also
elevate INR give medication lower INR
although evidence bleeding .
last night , report increase difficulty
breathing . also cough . deny fever
chill . patient admit decrease p.o . intake
recently sedimentary . deny swelling
leg . patient note wheezing take
Albuterol inhaler without effect .
Prednisone taper report cough
thick sputum .
go primary care provider today could say
sentence send Emergency Department .
Emergency Department , tachypneic wheeze
heart 120 blood pressure 127/82 . receive
Solu - Medrol continue nebulizer treatment .
improve , seem tire . abg do
show ph 7.41 ; PCO2 , 40 ; PO2 , 92 . speak full
sentence still make wheezing . require
continue nebulizer treatment deny chest pain ,
nausea , vomiting , diarrhea abdominal pain . feel weak
general .
PAST MEDICAL history :
1 . multiple myeloma diagnose [ * * 2107 - 12 - 9 * * ] ,
increase protein bone marrow biopsy . receive
Decadron 40 mg q every week .
2 . Pulmonary embolism , [ * * 2108 - 1 - 2 * * ] .
3 . Asthma . pft .....................
4 . history steroid psychosis .
5 . Pneumonia require intubation [ * * 2107 - 12 - 9 * * ] .
MEDICATIONS UPON admission :
1 . Coumadin 2.5 mg p.o . q d.
2 . Serevent two puff q.i.d .
3 . Albuterol inhaler one two puff q 6 hour prn .
4 . dexamethasone 10 mg p.o . q d.
allergy : know drug allergy .
SOCIAL history : socially , live child
work home home health aid . twenty year
two pack day smoking history quit [ * * 2107 - 12 - 9 * * ] .
drink occasional alcohol .
FAMILY history : family history show father die
myocardial infarction . Sister ovarian cancer .
PHYSICAL EXAMINATION UPON admission : Temperature , 96.6 ;
heart rate , 122 ; blood pressure , 127/82 ; respiratory rate ,
24 ; O2 saturation , 99 % . Head , eye , ear , nose throat ,
pupil equal , round , reactive light
accommodation extraocular movement intact . accessory
muscle use . Neck supple without
lymphadenopathy . Pulmonary , diffuse wheezing bibasilar
crackle left great right . Cardiac , regular
rate rhythm normal S1 S2 . murmur thrill
note . Abdomen soft , nontender , nondistende normal
active bowel sound . extremity , edema , cyanosis
club note . neurologically , patient somnolent
orient x 3 . focal defect note .
laboratorie UPON admission : white count , 9.6 ; neutrophil ,
66 % ; lymphocyte , 5 % ; bandemia , 21 % ; monocyte , 1 % . Sodium ,
131 ; potassium , 4.4 ; chloride , 92 ; bicarbonate , 24 . BUN , 14 ;
creatinine , 0.8 . Glucose , 131 . INR , 1.3 . PTT , 29.1 . ABG ,
7.41 ; PCO2 , 40 ; PO2 , 92 .
HOSPITAL COURSE :
1 . Pulmonary - Dyspnea secondary chronic obstructive
pulmonary disease / emphysema hospital course .
Briefly , patient receive BIPAP , .................... ,
intravenous Solu - Medrol , nebulizer treatment inhaler
treatment Intensive Care Unit . able
wean oxygen back room air , sate
93 94 percent .
though chest x - ray show hyperinflation sign
infection , give five day worth Zithromax .
echocardiogram rule cardiac wheeze
show ejection fraction great 55 % , mild right
ventricular dilation mild pulmonary arterial pressure .
Pulmonary function test perform show obstructive
pattern FEC 2.56 93 % predict
FEV1 0.9 43 % predict FEV1 FEC
ratio 46 % .
patient transfer Medical Floor , CT
perform show evidence pulmonary embolism
show sign emphysema . Sputum culture send
show growth organism . Alpha antitrypsin send
still pende .
2 . Pulmonary Embolism - patient continue
Coumadin INR 2 3 . since
subtherapeutic , start Lovenox become
therapeutic Coumadin .
3 . Psychiatry - Anxiety . patient quite anxious
hospital course . Psychiatry call consult
recommend Risperidone 0.25 mg q hs .
patient well medication .
4 . Oncology - Multiple myeloma . protein electrophoresis
do show monoclonal IGG capa gammaglobulinopathy
( 60 % total protein [ * * 2108 - 1 - 8 * * ] , 66 %
total protein [ * * 2108 - 4 - 9 * * ] , despite q weekly
dexamethasone treatment . bone marrow biopsy do
reveal 70 80 percent plasma cell . give
finding , patient transfer [ * * Hospital Ward Name 516 * * ]
start chemotherapy Vincristine ,
................... Decadron preparation bone
marrow transplant do .
[ * * Name6 ( MD ) * * ] [ * * last Name ( namepattern4 ) 5837 * * ] , M.D. [ * * MD Number(1 ) 8285 * * ]
dictate by:[**first Name3 ( LF ) 30667 * * ]
medquist36
: [ * * 2108 - 4 - 17 * * ] 15:47
: [ * * 2108 - 4 - 17 * * ] 15:46
JOB # : [ * * Job number 30668 * * ]
|
[
"486",
"2761"
] |
Admission Date : [ * * 2145 - 3 - 31 * * ] Discharge Date : [ * * 2145 - 4 - 7 * * ]
Date Birth : [ * * 2071 - 6 - 4 * * ] sex : F
Service : SURGERY
allergy :
Penicillins / Dilantin
attending:[**first Name3 ( LF ) 301 * * ]
Chief Complaint :
severe abdominal back pain
unable take oral intake .
flatus bowel movement .
abdominal distention .
Major Surgical Invasive Procedure :
Exploratory Laparotomy
Lysis adhesion
Small Bowel Resection
Jejunosotomy
history Present Illness :
Ms [ * * know lastname * * ] 73 year old female history multiple
abdominal surgery , pancreatitis previous SBO .
present Emergency Department [ * * 2145 - 3 - 30 * * ] complaint
[ * * 11 - 10 * * ] abdominal pain , radiate back begin
morning . complain distention , inability bowel
movement , inability take oral intake , fever , chill
diarrhea .
Past Medical history :
Chronic Pancreatitis
Migraines
surgical history :
pancreatic diversion , cholecystectomy , appendectomy ,
small bowel obstruction .
Social History :
marry , live husband retire pediatric
infectious disease doctor .
Family history :
Father : deceased , leukemia
Brother : colon cancer
Physical Exam :
: 97.9 hr : 79 bp : 153/60 RR : 22 spo2 100 % RA
Constitutional : pain
Head / eye : mucous membrane dry
ENT / Neck : neck supple
Chest / Respiratory : clear auscultation Bilaterally
GI / abdominal : Tender light palpation . multiple well heal
scar + guard , hypoactive bowel sound
GU : costovertebral angle tenderness
Musculoskeletal : WNL
Skin : Dry
Neuro : alert & oriented
Pertinent result :
[ * * 2145 - 3 - 30 * * ] 09:15pm blood Glucose-116 * UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3 - 25 angap-15
[ * * 2145 - 3 - 31 * * ] 10:26am blood wbc-12.3 * # rbc-4.01 * Hgb-12.3 Hct-37.1
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259
[ * * 2145 - 3 - 30 * * ] 09:15pm blood ALT-12 AST-22 AlkPhos-89 amylase-169 *
TotBili-0.3
[ * * 2145 - 4 - 2 * * ] 06:15AM blood Amylase-107 *
[ * * 2145 - 3 - 31 * * ] 10:26am blood Calcium-8.9 Phos-4.2 Mg-1.6
[ * * 2145 - 3 - 31 * * ] 12:44AM blood lactate-3.1 *
[ * * 2145 - 4 - 2 * * ] 02:10PM blood lactate-1.9
[ * * 2145 - 3 - 30 * * ] 11:35PM urine blood - NEG Nitrite - NEG Protein - NEG
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln - NEG pH-8.0 Leuks - NEG
.
ABDOMEN ( SUPINE & ERECT )
impression : nonspecific bowel gas pattern without evidence
obstruction .
.
CT ABDOMEN W / CONTRAST ; CT PELVIS W / CONTRAST
IMPRESSION :
1 . high grade small - bowel obstruction . unusual configuration
loop small bowel mid abdomen concern
close loop obstruction . moderate amount free
fluid within abdoman .
2 . ill - define opacity right middle lobe represent
infection BAC evaluate PET CT .
3 . thickening first portion duodenum , uncertain
clinical significance .
.
CHEST ( portable AP ) [ * * 2145 - 4 - 2 * * ] 1:51 pm
impression : right low lobe airspace opacity , could
represent pneumonia appropriate clinical setting . small
bilateral pleural effusion . followup assure resolution
recommend .
.
CT Chest [ * * 2145 - 4 - 2 * * ]
IMPRESSION :
1 . new right low lobe pneumonia . small bilateral pleural
effusion leave basilar atelectasis .
2 . ill - define opacity right middle lobe represent
either infection BAC evaluate
acute issue resolve .
3 . evidence pulmonary embolus aortic dissection .
4 . small mediastinal axillary lymph node , meet
CT criterion pathologically enlargement .
CXR [ * * 2145 - 4 - 6 * * ]
IMPRESSION :
1 . improve airspace consolidation right low lung
field consistent resolve pneumonia .
2 . small bilateral pleural effusion .
Brief Hospital course :
Ms [ * * know lastname * * ] admit emergency room [ * * 2145 - 3 - 31 * * ]
take operating room . undergo uncomplicated
exploratory laparatomy small bowel resection , jejunosotomy
lysis adhesion , see op report detail .
stabilize PACU , transfer sicu POD#1 .
extubate , pain well control morphine PCA ,
remain NPO NGT foley catheter . initiate
Cefazolin / Flagyl x 24 hour .
POD#2 develop confusion decrease oxygen saturation ,
require 3L nasal cannula . narcotic stop , CXR CT
chest obtain reveal right low lobe pneumonia ,
see pertinent result detail . Vanc / Levo / Flagyl
initiate well ID medicine consult .
transfer SICU . pod#[**4 - 4 * * ] remain SICU , mental
status respiratory status improve . POD#4 NGT
remove transfer [ * * Hospital Ward Name 121 * * ] 9 , wean
room air . pain well control tylenol small
dose oxycodone . POD#5 report flatus follow
multiple loose stool . stool C diff negative .
start sip , tolerate easily . POD#6 tolerate
clear liquid long want take antibiotic due
frequent stool . CXR repeat show resolve
pneumonia . tolerate regular diet evening without
difficulty . infectious disease team recommend completion 7
day Levofloxacin . clip remove POD#7 ,
discharge home stable condition antibiotic , pain
medication appropriate follow appointment .
medication admission :
Ramipril 1.25 mg Capsule Sig : two ( 2 ) Capsule po DAILY ( Daily ) .
Trazodone 50 mg Tablet Sig : three ( 3 ) Tablet PO HS ( bedtime )
need .
Gabapentin 400 mg Capsule Sig : one ( 1 ) Capsule PO Q6H ( every 6
hour ) .
6 . Trileptal
resume home dose trileptal
Discharge medication :
1 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : 0.5 - 1 Tablet PO
Q4 - 6h ( every 4 6 hour ) need .
disp:*30 Tablet(s ) * Refills:*0 *
2 . Ramipril 1.25 mg Capsule Sig : two ( 2 ) Capsule po DAILY
( Daily ) .
3 . trazodone 50 mg Tablet Sig : three ( 3 ) Tablet PO HS (
bedtime ) need .
4 . Acetaminophen 325 mg Tablet Sig : 1 - 2 tablet PO q4 - 6h ( every
4 6 hour ) need .
5 . 7 . Levaquin 500 mg Tablet Sig : one ( 1 ) Tablet po day .
Disp:*7 Tablet(s ) * Refills:*0 *
Gabapentin 400 mg Capsule Sig : one ( 1 ) Capsule PO Q6H ( every 6
hour ) .
6 . Trileptal
resume home dose trileptal
Discharge Disposition :
home
discharge diagnosis :
small bowel obstruction
internal hernia necrotic jejunum
Pneumonia
Discharge condition :
good
Discharge instruction :
please call surgeon develop chest pain , shortness
breath , fever great 101.5 , foul smelling colorful
drainage incision , redness swelling , severe
abdominal pain distention , persistent nausea vomiting ,
inability eat drink , symptom
concern .
tub bath swimming . may shower . clear
drainage incision , cover dry dressing . leave
white strip incision place , allow fall
.
activity : heavy lifting item [ * * 11 - 15 * * ] pound
follow
appointment doctor .
medication : resume home medication . problem
constipation , take stool softener , Colace 100
mg twice daily need . give pain medication
may make drowsy . driving take pain
medicine .
Followup Instructions :
Provider : [ * * Name10 ( NameIs ) 4267 * * ] [ * * last Name ( namepattern4 ) 4268 * * ] , MD , PHD[**MD Number(3 ) 708**]:[**telephone / Fax ( 1 ) 657 * * ]
Date / Time:[**2145 - 4 - 20 * * ] 2:00
appointment see Dr. [ * * last Name ( STitle ) * * ] Friday , [ * * 2145 - 4 - 23 * * ]
3:30 . phone # : [ * * telephone / Fax ( 1 ) 2723 * * ] .
please see primary care physician regard follow
CT scan within 1 month . CT result discharge
summary fax .
complete by:[**2145 - 4 - 7 * * ]
|
[
"486",
"4019"
] |
Admission Date : [ * * 2162 - 5 - 16 * * ] Discharge Date : [ * * 2162 - 5 - 21 * * ]
Date Birth : [ * * 2101 - 7 - 30 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 1505 * * ]
Chief Complaint :
Angina
Major Surgical Invasive Procedure :
[ * * 2162 - 5 - 17 * * ] : CABGx4 LIMA- > LAD , RSVG- > Diagonal , Posterior
Descending Artery , Obtuse marginal
[ * * 2162 - 5 - 19 * * ] : right atrial lead placement
history Present Illness :
60yo man know coronary disease ( AMI [ * * 2143 * * ] [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ]
LCx [ * * 2155 * * ] ) . well last week develop angina
initially exertion progress rest angina .
episode releive SL NTG , episode last 5
minute . present cardiologist treatment .
admit MWMC , cardiac catheterization reveal 3 vessel
disease . transfer [ * * Hospital1 18 * * ] coronary bypass
grafting .
Cardiac Catheterization : date : [ * * 2162 - 5 - 11 * * ] Place : MWMC
-LAD- chronic total occlusion proximally(distal fill via
collateral )
-rca- chronic total occlusion non - dominant RCA 90 %
-LCx- new complex 90 % stenosis prox LCx involve
bifurcation LCx proper large OM2 .
old stent LCx widely patent
-mod LV systolic dysfx , anterior , apical , infero - apical
AK reduce EF 30 %
LVEDP 36mmhg
valvular dz
Past Medical History :
CAD-(AMI [ * * 2143 - 7 - 3 * * ] , [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] LCx [ * * 6-/2155 * * ] )
Cardiomyopathy- EF 35 - 45 % depend study
Ventricular tachycardia / p AICD [ * * 8-/2155 * * ]
Atrial flutter / p ablation [ * * 8-/2155 * * ]
Hypertension
Dyslipidemia
Insulin dependent diabete Mellitus
Obesity
Conduction disease - LAFB
Peripheral vascular disease / p right fem-[**doctor last Name * * ] bypa [ * * 3-/2161 * * ]
leave leg claudication
Right thigh tumor / p radiation excision [ * * 2141 * * ] 's
Social History :
race : caucasian
Last Dental Exam :
live : wife
Occupation : [ * * name2 ( NI ) 56028 * * ] own company
tobacco : 2ppd x20 yrs quit [ * * 2143 * * ]
ETOH : occaisional
Family history :
Father die 50yo cirrhosis , mother die 42yo MI
Physical Exam :
pulse : 58 Resp : 16 O2 sit : 97%-ra
B / p right : 124/76 leave :
height : 5'[**62 * * ] " Weight : 259 lbs
General :
skin : Dry [ x ] intact [ x ]
HEENT : PERRLA [ x ] EOMI [ x ]
Neck : Supple [ x ] full rom [ x ]
chest : lung clear bilaterally [ x ]
heart : rrr [ x ] Irregular [ ] Murmur
Abdomen : Soft [ x ] non - distended [ x ] non - tender [ x ] bowel sound
+
[ x ]
extremity : Warm [ x ] , well - perfuse [ x ] Edema -none
varicosity : None [ x ] . well heal right vein harvest site .
Neuro : grossly intact
pulse :
Femoral right : +2 Left:+2
dp Right:+2 Left:+2
PT [ * * Name ( NI ) 167 * * ] : +2 Left:+2
Radial right : +2 Left:+2
Carotid Bruit none right : +2 Left:+2
pertinent result :
[ * * 2162 - 5 - 17 * * ] :
Prebypass
left atrium dilate . spontaneous echo contrast see
body left atrium leave atrial appendage .
spontaneous echo contrast see body right
atrium .
atrial septal defect see 2D color Doppler . leave
ventricular wall thickness normal . left ventricular
cavity severely dilate .
moderate regional left ventricular systolic dysfunction
hypokinesis apex septum . overall left
ventricular systolic function mildly depressed ( LVEF=30 - 35 % ) .
estimate cardiac index depressed ( < 2.0l / min / m2 ) . focal
abnormality see mid apical anteroseptal wall ,
apical anterior wall , mid apical inferoseptal wall , apical
inferior wall . thrombus see LV apex .
right ventricular chamber size free wall motion normal .
descending thoracic aorta mildly dilate .
aortic valve leaflet ( 3 ) mildly thicken focal
calcification non - coronary cusp move poorly .
minimally increase gradient consistent minimal aortic
valve stenosis . aortic regurgitation see .
mitral valve leaflet mildly thicken . mild moderate
( [ * * 1 - 3**]+ ) mitral regurgitation see . mitral valve
prolapse flail segment . pericardial effusion .
Postbypass
patient - pace phenylephrine infusion .
biventricular systolic function unchanged . mitral
regurgitation remain mild - - moderate . thoracic aorta
intact post decannulation .
[ * * 2162 - 5 - 20 * * ] 05:00am blood wbc-10.9 RBC-3.73 * Hgb-11.2 * Hct-31.7 *
MCV-85 MCH-30.1 MCHC-35.4 * RDW-13.9 Plt ct-114 *
[ * * 2162 - 5 - 20 * * ] 05:00am blood Glucose-151 * UreaN-19 Creat-0.7 Na-135
k-3.9 cl-100 HCO3 - 28 AnGap-11
[ * * 2162 - 5 - 16 * * ] 05:00pm blood ALT-66 * AST-55 * LD(LDH)-206 AlkPhos-73
TotBili-0.3
Brief Hospital course :
patient admit hospital bring
operating room [ * * 2162 - 5 - 17 * * ] patient undergo Coronary
artery bypass graft x 4 . see operative note detail .
overall patient tolerate procedure well
post - operatively transfer CVICU stable
condition recovery invasive monitoring . POD 1 find
patient extubate , alert oriented breathe comfortably .
electrophysiology team consult due non
capturing atrial lead permanent pacemaker initially
interrogate epicardial wire remove . ventricular lead
ICD function appropriately . right atrial lead
revise [ * * 5 - 19 * * ] without complication . follow
device clinic [ * * hospital1 * * ] 2 week - operative note give
patient bring follow appointment . patient
neurologically intact hemodynamically stable inotropic
vasopressor support . beta blocker initiate
patient gently diurese toward preoperative weight .
Lisinopril restart well blood pressure . patient
transfer telemetry floor recovery .
Chest tube discontinue without complication post
operative day 3 . patient evaluate physical
therapy service assistance strength mobility .
time discharge POD 4 patient ambulate
freely , sternal pacer pocket wound heal pain
control oral analgesic . continue 1 week
antibiotic per EP / p atrial lead placement . patient
discharge home vna service good condition
appropriate follow instruction . follow appointment
arrange .
medication admission :
Lisinopril 20 '
Atenolol 100 '
Vytorin [ * * 10/2131 * * ] QHS
fenofibrate 200 '
ASA 325 '
NTG - sl / PRN
Insulin - NPH 22u QAM/24u qpm- follow [ * * last Name ( un ) * * ]
Insulin- humalog SS
MVI
Calcium 600 '
plavix - last dose:[**2162 - 5 - 12 * * ]
allergy : NKDA
Discharge medication :
1 . fenofibrate 160 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*0 *
2 . simvastatin 80 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
3 . ezetimibe 10 mg Tablet Sig : one ( 1 ) Tablet PO HS (
bedtime ) .
disp:*30 Tablet(s ) * Refills:*1 *
4 . multivitamin Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*100 Tablet(s ) * Refills:*0 *
5 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
6 . magnesium hydroxide 400 mg/5 ml Suspension Sig : thirty ( 30 )
ML po HS ( bedtime ) need constipation .
7 . ranitidine HCl 150 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2
time day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
8 . oxycodone - acetaminophen 5 - 325 mg Tablet Sig : 1 - 2 tablet po
Q4H ( every 4 hour ) need pain .
Disp:*65 Tablet(s ) * Refills:*0 *
9 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
disp:*100 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
10 . cephalexin 500 mg Capsule Sig : one ( 1 ) Capsule PO Q6H ( every
6 hour ) 7 day .
Disp:*28 Capsule(s ) * Refills:*0 *
11 . Lasix 40 mg Tablet Sig : one ( 1 ) Tablet po day 7
day .
Disp:*7 Tablet(s ) * Refills:*0 *
12 . potassium chloride 20 meq Tablet , ER Particles / Crystals Sig :
one ( 1 ) Tablet , ER Particles / Crystals PO day 7 day .
Disp:*7 Tablet , ER Particles / Crystals(s ) * Refills:*0 *
13 . metoprolol tartrate 25 mg Tablet Sig : one ( 1 ) Tablet PO BID
( 2 time day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
14 . acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q4H
( every 4 hour ) need pain .
15 . nph insulin human recomb 100 unit / mL Suspension Sig : one ( 1 )
Subcutaneous twice day : take 22 unit 24 unit
PM .
disp:*q 1 month * Refills:*0 *
16 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
discharge Disposition :
Home Service
Facility :
[ * * Location ( un ) 1110 * * ] VNA
Discharge Diagnosis :
Coronary Artery Disease
CAD-(AMI [ * * 2143 - 7 - 3 * * ] , [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] LCx [ * * 6-/2155**]),cardiomyopathy- EF
35 - 45 % Ventricular tachycardia / p AICD [ * * 8-/2155 * * ] , atrial flutter
/ p ablation [ * * 8-/2155 * * ] , Hypertension , Dyslipidemia , insulin
dependent diabete Mellitus , Obesity , Conduction disease - LAFB ,
Peripheral vascular disease / p right fem-[**doctor last Name * * ] bypa [ * * 3-/2161 * * ] , leave
leg claudication , right thigh tumor / p radiation excision
[ * * 2141 * * ] 's
discharge condition :
alert orient x3 nonfocal
ambulate steady gait
incisional pain manage Percocet
incision :
Sternal - heal well , erythema drainage
Leg Left - heal well , erythema drainage .
1 + Edema
discharge instruction :
please shower daily include wash incision gently mild
soap , bath swimming clear surgeon . look
incision daily redness drainage
please lotion , cream , powder , ointment incision
morning weigh evening
take temperature , write chart
drive approximately one month take
narcotic , discuss follow appointment
surgeon able drive
lifting 10 pound 10 week
please call question concern [ * * telephone / Fax ( 1 ) 170 * * ]
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Followup Instructions :
schedule follow appointment
surgeon : Dr [ * * last Name ( STitle ) * * ] [ * * 6 - 10 * * ] 1:45pm [ * * telephone / Fax ( 1 ) 170 * * ]
Cardiologist : Dr. [ * * last Name ( STitle ) 1295 * * ] [ * * 6 - 14 * * ] 3:30pm
EP [ * * Hospital 19721 * * ] Clinic [ * * hospital1 * * ] [ * * 1 - 3 * * ] week : call appointment
-
[ * * telephone / Fax ( 1 ) 6256 * * ]
Wound check appointment [ * * Hospital * * ] medical office building
[ * * telephone / Fax ( 1 ) 170 * * ]
Date / Time:[**2162 - 5 - 26 * * ] 12:00
please call schedule appointment
Primary Care Dr. [ * * last Name ( STitle ) 27187 * * ] [ * * 4 - 6 * * ] week [ * * telephone / Fax ( 1 ) 3658 * * ]
follow [ * * Hospital * * ] [ * * Hospital 982 * * ] Clinic arrange patient
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
complete by:[**2162 - 5 - 24 * * ]
|
[
"4111",
"2859",
"4019",
"2720"
] |
Admission Date : [ * * 2177 - 8 - 29 * * ] Discharge Date : [ * * 2177 - 9 - 12 * * ]
Date Birth : [ * * 2156 - 2 - 27 * * ] sex :
Service : SURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 2534 * * ]
Chief Complaint :
helmete motocyclist hit tree
Major Surgical Invasive Procedure :
[ * * 2177 - 8 - 29 * * ]
1 . irrigation debridement inclusive
bone , right open femur fracture .
2 . Retrograde intramedullary nailing Synthes 11 x 360
nail .
3 . open reduction internal fixation patella fracture
k - wire figure - of-8 tension band construct .
[ * * 2177 - 9 - 4 * * ]
Tracheostomy
IVC filter
[ * * 2177 - 9 - 12 * * ]
PICC right bascilic vein
history Present Illness :
21 y.o . male helmete moped rider strike tree
report GCS 6 scene . Patient transport OSH
note right side open femur fracture . receive
antibiotic intubate prior transfer .
Patient transport radiographic study perform
show right femur fracture , SAH , grade II liver lac ,
pulmonary contusion , small PTX . Patient reportedly receive
1 unit prbcs ED place traction splint
RLE .
Past Medical history :
none
Social History :
tobacco none
ETOH none
family history :
Non - contributory .
Physical Exam :
96.9 130 150/97 20 100 %
intubated sedate
HEENT - L eye abrasion , pupil nonreactive bilaterally
CTA b / l
rapid HR , regular rhythm
SNDNT
pelvic fracture
+ palpable distal pulse
pertinent result :
[ * * 2177 - 8 - 29 * * ] 04:35am blood WBC-17.7 * RBC-4.76 Hgb-15.2 Hct-45.5
MCV-96 MCH-32.0 mchc-33.5 RDW-13.2 Plt ct-314
[ * * 2177 - 8 - 30 * * ] 12:50AM blood wbc-7.6 RBC-2.73 * hgb-9.0 * hct-25.0 *
MCV-92 MCH-32.8 * MCHC-35.9 * RDW-13.5 Plt ct-188
[ * * 2177 - 8 - 31 * * ] 01:49AM blood wbc-9.4 RBC-2.42 * Hgb-7.8 * Hct-21.7 *
MCV-89 MCH-32.1 * MCHC-35.9 * RDW-14.5 Plt Ct-148 *
[ * * 2177 - 9 - 1 * * ] 03:13AM blood WBC-9.2 RBC-2.87 * hgb-9.0 * hct-25.6 *
MCV-90 MCH-31.6 MCHC-35.3 * RDW-15.0 Plt ct-128 *
[ * * 2177 - 9 - 2 * * ] 01:40am blood WBC-7.7 RBC-2.78 * Hgb-8.8 * hct-24.6 *
MCV-88 MCH-31.5 MCHC-35.7 * RDW-15.4 Plt ct-164
[ * * 2177 - 9 - 3 * * ] 12:53am blood WBC-8.9 RBC-2.94 * Hgb-9.3 * Hct-26.2 *
MCV-89 MCH-31.8 mchc-35.6 * RDW-15.7 * Plt ct-220
[ * * 2177 - 9 - 4 * * ] 01:08am blood WBC-7.7 rbc-2.99 * Hgb-9.5 * hct-27.3 *
MCV-91 MCH-31.7 mchc-34.7 RDW-15.5 Plt Ct-313
[ * * 2177 - 9 - 5 * * ] 02:32AM blood wbc-8.4 RBC-2.91 * Hgb-9.0 * hct-26.9 *
MCV-92 MCH-30.9 mchc-33.5 RDW-15.6 * Plt ct-412
[ * * 2177 - 9 - 6 * * ] 01:58am blood WBC-12.1 * RBC-2.86 * hgb-9.0 * Hct-26.5 *
MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt ct-418
[ * * 2177 - 9 - 7 * * ] 02:12AM blood WBC-14.4 * RBC-3.00 * Hgb-9.3 * Hct-27.6 *
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt ct-556 *
[ * * 2177 - 9 - 8 * * ] 01:59am blood WBC-14.7 * RBC-3.25 * Hgb-10.0 * Hct-29.7 *
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748 *
[ * * 8 - 29 * * ]
CT head - multiple foci parenchymal hemorrhage well
small amount
likely subarachnoid hemorrhage . location
foci [ * * Doctor Last Name 352**]-white matter interface concern
diffuse axonal injury
CT Cspine - fracture traumatic malalignment
cervical spine
CT torso - extensive pulmonary contusion , bad right
left . hepatic laceration small amount
abdominal pelvic free fluid intermittent density .
Bilateral rib fracture .
right femur / knee xray - mid shaft femoral fracture
mild varus angulation distal fragment relative
proximal . also medial subluxation ~ 1 cortical
width .
[ * * 9 - 2 * * ]
MRI cspine - Edema interspinous ligament C3 - c4
C7 - T1 , without evidence distraction . lobal central
canal narrowing due congenital short pedicle .
slightly exacerbate disc bulge C3 - 4 . cord signal
abnormality . moderate right C4 - 5 neural foraman narrow due
uncovertebral osteophyte .
[ * * 9 - 3 * * ]
Bilateral LE leni - deep venous thrombosis involve
right leave low extremity .
LUE LENI - deep venous thrombosis left upper
extremity .
[ * * 9 - 7 * * ]
CT Abdomen / Pelvis - right pleural effusion associate
compressive atelectasis . considerable improvement
appearance right lobe liver laceration . small
amount free fluid pelvis . fracture left first
right fourth fifth rib . fracture
right transverse process T1 .
Brief Hospital course :
patient admit trauma ICU .
[ * * 8 - 29 * * ] - Patient admittd ICU . take
operation room ortho ORIF right femur ( see
operative report full detail ) . Neurosurgery consult
ICP place . start dilantin q1 hour
neurocheck .
[ * * date range ( 1 ) 58392 * * ] - patient transfuse 4u PRBC decrease
Hct . right femur hematoma expand
limb soft fear compartment symdrome .
Hct stabilize . Head CT stable .
[ * * 9 - 1 * * ] - ICP discontinue neurosurgery sign .
Head CT stable .
[ * * 9 - 2 * * ] - MR head c - spine perform .
[ * * 9 - 3 * * ] - Bilateral LE LUE leni perform
demonstrate DVT .
[ * * 9 - 4 * * ] - patient go acute care service
tracheostomy IVC filter placement .
[ * * 9 - 6 * * ] - Patient dc'e dophoff tube twice .
[ * * 9 - 7 * * ] - CT / p do persistent fever rise
white count . source fever identify . Patient
put trach collar .
[ * * 9 - 8 * * ] : awake , - verse , follow command . pass S&S
regular diet Passy [ * * last Name ( un ) 87596 * * ] valve . BAL culture grow MRSA , keep
Vanc . patient ready transfer floor ,
wait bed . `
follow transfer surgical floor continue make
slow progress . trach tube plug PMV
tolerate well . confirm aspiration video
swallow tolerate regular diet thin liquid .
Physical Therapy Occupational Therapy service follow
daily basis increase mobility increase
cognitive ability . memory decrease
occasionally confusion improve day .
PICC line place [ * * 2177 - 9 - 12 * * ] IV antibiotic
require Vancomycin thru [ * * 2177 - 9 - 16 * * ] MRSA pneumonia .
minimal secretion undergo nebulizer treatment .
potentially IVC filter remove Dr. [ * * last Name ( STitle ) * * ]
evaluate week therefore need return
[ * * Hospital 2536 * * ] Clinic . also follow Neuro cognitive clinic
Dr. [ * * First Name ( STitle ) * * ] follow discharge rehab .
lonfg hospitalization transfer rehab
[ * * 2177 - 9 - 12 * * ] therapy goal return home soon .
medication admission :
none
Discharge medication :
1 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q6H ( every
6 hour ) need temp > 101.5 .
2 . Bisacodyl 10 mg Suppository Sig : one ( 1 ) Suppository Rectal
HS ( bedtime ) need constipation .
3 . Docusate Sodium 50 mg/5 ml Liquid Sig : ten ( 10 ) ml po BID ( 2
time day ) .
4 . Bacitracin Zinc 500 unit / g Ointment Sig : one ( 1 ) Appl Topical
QID ( 4 time day ) need abrasion .
5 . Heparin ( Porcine ) 5,000 unit / mL Solution Sig : 5000 ( 5000 )
unit Injection TID ( 3 time day ) .
6 . Albuterol Sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) neb Inhalation Q6H ( every 6 hour ) .
7 . Ipratropium Bromide 0.02 % solution Sig : one ( 1 ) neb
Inhalation Q6H ( every 6 hour ) .
8 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
9 . Vancomycin 1,000 mg Recon Soln Sig : 1500 ( 1500 ) mg
Intravenous every eight ( 8) hour : thru [ * * 2177 - 9 - 16 * * ] .
10 . Morphine Concentrate 20 mg / mL Solution Sig : fifteen ( 15 ) mg
PO Q2H ( every 2 hour ) need pain .
11 . HYDROmorphone ( Dilaudid ) 1 - 2 mg IV Q2H : PRN pain
please use breakthrough PO / NG MSIR .
12 . Heparin Flush ( 10 unit / ml ) 2 ml IV PRN line flush
PICC , heparin dependent : flush 10ml Normal Saline follow
Heparin daily PRN per luman .
discharge Disposition :
Extended Care
Facility :
[ * * hospital3 1107 * * ] [ * * Hospital * * ] Hospital - [ * * Location ( un ) 38 * * ]
discharge diagnosis :
/ P scooter v tree
1 . leave eye abrasion
2 . rib fracture right [ * * 5 - 5 * * ] , leave 1
3 . bilat pulmonary contusion
4 . grade 2 liverlaceration
5 . open right femur fracture
6 . right thigh laceration
7 . right patellar fracture
8 . right metatarsal neck fracture [ * * 3 - 7 * * ]
9 . small SAH
10.right tp fracture T1
11.[**doctor First Name * * ]
12.acute blood loss anemia
Discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Bed assistance chair
wheelchair .
Discharge instruction :
* admit hospital multiple injury
follow accident include head trauma , rib fracture ,
knee fracture liver laceration .
* make alot progress need
rehabilitation return home .
* breathe well trach tube
plug hopefully remove improve .
* continue work physical therapy increase
mobility .
Followup Instructions :
please follow [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , NP orthopaedic 1
month , please call [ * * telephone / Fax ( 1 ) 1228 * * ] schedule appointment .
call [ * * Hospital 2536 * * ] Clinic [ * * telephone / Fax ( 1 ) 600 * * ] follow appointment
[ * * 3 - 5 * * ] week
call Vascular Surgery Clinic [ * * telephone / Fax ( 1 ) 1237 * * ]
appointment 2 week Dr. [ * * last Name ( STitle ) * * ] .
call [ * * hospital 4695 * * ] Clinic [ * * telephone / Fax ( 1 ) 1669 * * ] follow
appointment 6 week Dr. [ * * First Name ( STitle ) * * ] . need Head CT
prior appointment . secretary book .
call Dr. [ * * First Name ( STitle ) * * ] Neuro cognitive Clinic [ * * telephone / Fax ( 1 ) 1690 * * ]
appointment discharge rehab
complete by:[**2177 - 9 - 12 * * ]
|
[
"2851"
] |
Admission Date : [ * * 2177 - 3 - 12 * * ] Discharge Date : [ * * 2177 - 3 - 22 * * ]
Date Birth : [ * * 2109 - 6 - 26 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Shellfish
attending:[**first Name3 ( LF ) 1505 * * ]
Chief Complaint :
exertional angina
Major Surgical Invasive Procedure :
[ * * 2177 - 3 - 14 * * ]
Coronary artery bypass GRAFTING x3 : Left Internal Mammary
Artery left Anterior Descending Artery , Saphenous Vein Graft
Obtuse Marginal Artery , Saphenous Vein Graft Posterior
Descending Artery
history Present Illness :
67 year old man know coronary artery disease - / p stent x
6(2004x5 [ * * 11 - 21 * * ] ) develop exertional angina
walk [ * * 3 - 9 * * ] . Angina resolve w/
rest minute . Angina recur [ * * 3 - 11 * * ] , patient bring
[ * * Hospital * * ] Med Ctr enzyme negative . cardiac
catheterization show : taper distal lm,70 % osteal
lad,90 % mid RCA . LVEF 60 % LVgram .
transfer [ * * Hospital1 18 * * ] surgical management
coronary artery disease . time transfer pain
free .
Past Medical history :
Coronary artery disease(PCI / stent x6 ) , Hypertension ,
HYPERCHOLESTEROLEMIA , CA- leave vocal cord(RT / chemo)[**3 - 20 * * ]
PSH : leave knee arthroscopy , leave chest Portacath
Social History :
work administrator [ * * University / College 33918 * * ] .
marry , 2 child .
Tob : former smoker , quit 30 yrs ago .
ETOH : drink beer cocktail per night .
drug
family history :
brother : mi 60 , uncle : mi 50
mother : htn
Physical Exam :
pulse : Resp : O2 sit :
B / P Right:130/72 leave : 128/72
Height : 70 " Weight:175 #
General : WDWN , NAD
skin : Dry [ ] intact [ x ]
HEENT : PERRLA [ x ] EOMI [ x]glasses
neck : Supple [ x ] full rom [ x ]
chest : lung clear bilaterally [ x ]
heart : rrr [ x ] Irregular [ ] Murmur n
Abdomen : Soft [ x ] non - distended [ x ] non - tender [ x ] bowel sound
+ [ x ]
extremity : Warm [ x ] , well - perfuse [ x ] Edema varicosity :
None [ x ]
Neuro : grossly intact
pulse :
Femoral Right:2 Left:2
dp Right:2 Left:2
PT [ * * Name ( NI ) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit right : n leave : n
pertinent result :
Admission Labs :
[ * * 2177 - 3 - 12 * * ] 04:05PM pt-11.7 PTT-23.8 INR(PT)-1.0
[ * * 2177 - 3 - 12 * * ] 04:05PM PLT count-199
[ * * 2177 - 3 - 12 * * ] 04:05PM neuts-78.7 * LYMPHS-9.6 * MONOS-5.6 EOS-5.6 *
basos-0.5
[ * * 2177 - 3 - 12 * * ] 04:05PM WBC-6.9 rbc-3.93 * HGB-14.0 HCT-38.2 * MCV-97 #
mch-35.6 * MCHC-36.6 * RDW-13.5
[ * * 2177 - 3 - 12 * * ] 04:05PM % HbA1c-5.2 eag-103
[ * * 2177 - 3 - 12 * * ] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7
[ * * 2177 - 3 - 12 * * ] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK
phos-100 TOT BILI-2.0 *
[ * * 2177 - 3 - 12 * * ] 04:05PM GLUCOSE-123 * UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 chloride-100 TOTAL CO2 - 27 anion gap-14
[ * * 2177 - 3 - 12 * * ] 04:33PM URINE blood - NEG NITRITE - NEG protein - NEG
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG ph-6.0
LEUK - NEG
[ * * 2177 - 3 - 12 * * ] 04:33PM URINE COLOR - Yellow APPEAR - Clear SP [ * * last Name ( un ) 155**]-1.020
Discharge Labs :
Radiology Report CHEST ( PORTABLE AP ) Study Date [ * * 2177 - 3 - 17 * * ] 7:29
Final Report : comparison study [ * * 3 - 15 * * ] ,
monitoring support device remove except
leave subclavian catheter right IJ sheath . chest
tube remove , evidence pneumothorax . residual
opacification left base consistent atelectasis
effusion .
[ * * Hospital1 18 * * ] echocardiography REPORT
Echocardiographic measurement
result measurement Normal Range
Left Ventricle - Ejection Fraction : 55 % > = 55 %
finding
right ATRIUM / INTERATRIAL SEPTUM : color - flow imaging
interatrial septum raise suspicion atrial septal
defect , could confirm basis
study .
LEFT VENTRICLE : normal regional LV systolic function . overall
normal LVEF ( > 55 % ) .
right ventricle : borderline normal RV systolic function .
AORTIC VALVE : three aortic valve leaflet . . Trace AR .
MITRAL VALVE : MS . mild ( 1 + ) MR .
TRICUSPID VALVE : Physiologic TR .
PULMONIC VALVE / PULMONARY ARTERY : pulmonic valve well see .
PERICARDIUM : small pericardial effusion .
GENERAL comment : tee perform location list
. certify present compliance HCFA
regulation . patient general anesthesia throughout
procedure . tee relate complication . patient appear
sinus rhythm . result personally review
MD care patient .
Conclusions
focus intraoperative TEE chest exploration
post - operative bleeding .
color - flow imaging interatrial septum raise
suspicion atrial septal defect , could
confirm basis study .
regional left ventricular wall motion normal . overall left
ventricular systolic function normal ( lvef>55 % ) .
borderline normal RV free wall function .
three aortic valve leaflet . aortic valve
stenosis . trace aortic regurgitation see .
Mild ( 1 + ) mitral regurgitation see .
small pericardial effusion .
Dr. [ * * last Name ( STitle ) * * ] notify person result .
Brief Hospital course :
Mr [ * * know lastname 732 * * ] transfer fro [ * * Hospital * * ] Med Ctr surgical
management coronary artery disease . usual
pre - operative workup bring operating room
coronary artery bypass graft [ * * 2177 - 3 - 14 * * ] . please see
operative report detail . summmary : Coronary
Artery Bypass Grafting x3 Lwft Internal Mammary Artery
leave Anterior Descending Artery , Saphenous Vein Graft Obtuse
Marginal Artery , Saphenous Vein Graft Posterior
Descending Artery . cardiopulmonary bypass time 51
minute crossclamp time 39 minute . tolerate
operation well post - operatively transfer
cardiac surgery ICU stable conditio . remain
hemodynamically stable immediate post - op period . wake
anesthesia neurologically intact extubate
operative day .
POD1 continue significant drainage chest
tube bring back operating room mediastinal
exploration - source bleeding find . tolerate
procedure well return cardiac surgery ICU
stable condition . recover anesthesia
extubate shortly surgery complete . remain
hemodynamically stable throughout period .
tube line drain remove per cardiac surgery
protocol . POD 3 transfer ICU
stepdown floor continued post - op care recovery . physical
therapy work patient advance activity
daily living improve strength endurance .
POD # 4 , Pt develope drainage sternal incision .
start IV Vancomycin . betadine cleanse TID
start . POD # [ * * 4 - 19 * * ] , pt wound improve .
discharge PO keflex x 10 day . wound DC without
drainage .
POD 10 discharge home visit nurse .
follow Dr [ * * last Name ( STitle ) * * ] 3 week , sternal check
[ * * 3 - 26 * * ] [ * * Hospital Ward Name * * ] 6 . follow cardiologist , appt
make , also instruct follow PCP .
medication admission :
Lisinopril 20 mg daily ,
Lipitor 80 mg daily ,
Plavix 75 mg [ * * last Name ( LF ) * * ] ,
[ * * first Name3 ( LF ) * * ] 325 mg daily ,
Discharge medication :
1 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
disp:*30 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
2 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
Disp:*60 Capsule(s ) * Refills:*2 *
3 . atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO HS (
bedtime ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . [ * * last Name ( un ) 1724 * * ]
Lisinopril 20 mg daily , EcASA 325 mg daily , Lopressor 25 mg
[ * * hospital1 * * ] , Plavix 75 mg daily , NTG prn , lipitor 80 mg daily
5 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
6 . metoprolol tartrate 25 mg Tablet Sig : three ( 3 ) Tablet PO BID
( 2 time day ) .
Disp:*180 Tablet(s ) * Refills:*2 *
7 . furosemide 20 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) 7 day .
Disp:*14 Tablet(s ) * Refills:*0 *
8 . potassium chloride 8 meq Tablet Extended Release Sig : one ( 1 )
Tablet Extended Release po twice day 7 day .
disp:*14 Tablet Extended release(s ) * Refills:*0 *
9 . Keflex 250 mg Capsule Sig : one ( 1 ) Capsule po four time
day 10 day .
Disp:*40 capsule(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
[ * * Location ( un ) 1110 * * ] VNA
Discharge Diagnosis :
Coronary Artery Disease / p Coronary Bypass Grafting x3
PCI / stents(6 )
PMH :
Hypertension ,
HYPERCHOLESTEROLEMIA ,
CA- leave vocal cord(RT / chemo)[**3 - 20 * * ]
PSH : lt knee arthroscopy , LT chest portacath
Discharge condition :
alert orient x3 nonfocal
ambulate steady gait
incisional pain manage
incision :
Sternal - heal well , erythema drainage
Leg Right / left - heal well , erythema drainage .
Edema
discharge instruction :
please shower daily include wash incision gently mild
soap , bath swimming clear surgeon . look
incision daily redness drainage
please lotion , cream , powder , ointment incision
morning weigh evening
take temperature , write chart
drive approximately one month take
narcotic , discuss follow appointment
surgeon able drive
lifting 10 pound 10 week
please call question concern [ * * telephone / Fax ( 1 ) 170 * * ]
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Followup Instructions :
schedule follow appointment
surgeon : Dr [ * * First Name ( STitle ) * * ] [ * * Name ( STitle ) * * ] [ * * 2177 - 4 - 10 * * ] 9am [ * * hospital1 * * ]
Cardiologist : [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 5874 * * ] [ * * 2177 - 4 - 16 * * ] 3PM
please call schedule appointment
Primary Care Dr [ * * last Name ( STitle ) * * ] , [ * * first Name3 ( LF ) 488 * * ] J. [ * * telephone / Fax ( 1 ) 8036 * * ] [ * * 4 - 15 * * ] week
wound check schedule [ * * 5 - 26 * * ] 1000 hrs ,
please come [ * * Hospital Ward Name * * ] 6 scheduled time . thw midleveler
look wound see stable .
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Labs : PT / INR Coumadin ? ? ? ? ? ? indication
Goal INR
first draw
result phone fax
complete by:[**2177 - 3 - 22 * * ]
|
[
"4019",
"2720"
] |
Admission Date : [ * * 2188 - 5 - 24 * * ] Discharge Date : [ * * 2188 - 5 - 30 * * ]
Date Birth : [ * * 2132 - 11 - 19 * * ] sex :
Service : MEDICINE
allergy :
Ampicillin / Thorazine
Attending:[**Last Name ( NamePattern4 ) 290 * * ]
Chief Complaint :
Respiratory Failure
Major Surgical Invasive Procedure :
Trach change
mechanical ventilation
history Present Illness :
Mr. [ * * know lastname 89172 * * ] 55 yo man PMH significant Downs
Syndrome , MRSA pneumonia respiratory failure [ * * 10/2187 * * ]
result tracheostomy reverse [ * * 2188 - 5 - 13 * * ] ,
transfer / p intubation [ * * hospital1 * * ] [ * * Location ( un ) 1110 * * ] today .
Patient predominantly rehab since develop MRSA
pneumonia [ * * 10/2187 * * ] ( first [ * * last Name ( un ) * * ] [ * * Hospital 5279 * * ] Rehab
Centers ) present [ * * hospital1 * * ] rehab respiratory
distress . start Rocephin [ * * 5 - 22 * * ] presume
pneumonia Rehab setting labored breathing . Patient
intubate [ * * hospital1 * * ] labored breathing , accessory muscle
use . per report , may fail attempt OSH
ED - open tracheostomy prior intubation .
.
OSH , patient receive , levoquin 750 mg @ 03:25 , Vancomycin 1 g
@ 5:09 pneumonia . order 4L NS receive
least 2.5L. CXR CT Chest appear show fluid
overload . Patient difficult maintain sedation ; blood
pressure drop propofol , patient briefly dopamine
sedation switch verse bolus prn ,
tolerate well . Trach site serosanguinous fluid
leakage , cover guaze tegaderm . respiratory
therapist ED confirm air leakage
ventilator . Patient transfered [ * * Hospital1 18 * * ]
management .
.
ED , initial VS follow : 99.9 ( rectal temp ) 101
174/100 22 98 % ventilator 100%fio2 . give 1amp
D50 blood sugar 69 . also receive 250cc IVF
2.5 mg bolus IV verse sedation ventilate . EKG
show sinus tach rate 103 . CXR show fluid overload
possible consolidation , CTA chest do
characterize ? consolidation rule PE . CTA show
sign PE confirm RUL RML pneumonia , well
fluid fill esophagus , suggest aspiration . CT also show
moderate left small right effusion , pulmonary edema .
vital ED prior transfer ICU follow : 99.8F hr
91 BP 92/53 rr 16 o2sat100 % cpap FIO2 60 % , PS 10 , PEEP 5 .
.
arrival unit , patient mechanically ventilate
appear comfortable . accompany sister
able corroborate story . note , patient
non - verbal baseline make sign , eat
icecream [ * * last Name ( un ) * * ] tea mouth ( pleasure ) otherwise
feed tube feed .
.
Past Medical History :
- Downs Syndrome
- MRSA Pneumonia complicate tracheostomy [ * * 10/2187 * * ]
- reverse [ * * 2188 - 5 - 13 * * ]
- C Diff Colitis - [ * * 2188 * * ]
- Pseudomonas Colitis - [ * * 2188 * * ] - dx colonoscopy , tx w cipro
g - tube
- Adrenal Insufficiency
- Seizure history , per sister [ * * name2 ( NI ) 89173 * * ]
hospitalization [ * * 11 - 3 * * ] - keppra
- Hx transaminitis - presume secondary antiepileptic
- Hx HBV
- Membranoproliferative Glomerulonephritis
Social History :
live Group Home , spend significant amount time
Rehab since [ * * 10/2187 * * ] present [ * * first Name4 ( NamePattern1 ) 5279 * * ] [ * * last Name ( NamePattern1 ) * * ] . [ * * last Name ( NamePattern1 ) 6961 * * ]
guardian , sister [ * * Name ( NI ) * * ] also involved
care finance .
Family history :
NC
Physical Exam :
admission exam :
GEN : comfortable appear , open eye command
HEENT : ett place .
neck : Tegaderm place anterior neck ; difficult assess
opening skin . drainage erythema .
CV : RRR , murmur
lung : Rhonchi anteriorly R > l , CTAB laterally side
ABD : soft , non - tender distend . central g - tube cover
gauze tube feed drain around opening . ostomy
erythematous , raw . erythema surround skin .
EXT : LE cachectic , LE edema .
DISCHARGE EXAM :
GEN : comfortable appear , open eye command ,
distress
HEENT / Neck : EOMI , trach place sputum surrounding , mild
erythema around site
CV : RRR , murmur
lung : Rhonchi anteriorly , CTAB laterally side
ABD : soft , non - tender distend . central g - tube cover
gauze . mildly erythematous around opening .
EXT : LE cachectic , LE edema .
pertinent result :
ADMISSION labs :
.
[ * * 2188 - 5 - 24 * * ] 11:50am pt-18.8 * PTT-31.4 INR(PT)-1.7 *
[ * * 2188 - 5 - 24 * * ] 11:50am urine RBC-28 * WBC-7 * BACTERIA - yeast - NONE
EPI-0 TRANS EPI-<1
[ * * 2188 - 5 - 24 * * ] 11:50am urine BLOOD - MOD NITRITE - NEG PROTEIN-30
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-6.0
LEUK - SM
[ * * 2188 - 5 - 24 * * ] 11:50AM WBC-11.7 * RBC-2.84 * HGB-10.5 * HCT-31.6 *
MCV-111 * MCH-37.1 * mchc-33.4 RDW-18.9 *
[ * * 2188 - 5 - 24 * * ] 11:50am GLUCOSE-69 * UREA N-54 * CREAT-1.0 sodium-136
POTASSIUM-5.0 chloride-107 total CO2 - 24 anion GAP-10
[ * * 2188 - 5 - 24 * * ] 12:00PM LACTATE-2.0
.
DISCHARGE LABS :
.
[ * * 2188 - 5 - 30 * * ] 03:56am blood wbc-8.1 RBC-2.32 * Hgb-8.9 * hct-26.7 *
MCV-115 * MCH-38.5 * mchc-33.5 RDW-17.4 * Plt ct-130 *
[ * * 2188 - 5 - 30 * * ] 03:56am blood Glucose-83 UreaN-29 * Creat-1.1 Na-135
K-3.7 Cl-108 HCO3 - 24 AnGap-7 *
[ * * 2188 - 5 - 30 * * ] 03:56am blood Calcium-7.3 * Phos-2.5 * Mg-1.5 *
[ * * 2188 - 5 - 30 * * ] 03:56am blood vanco-25.0 *
.
MICRO :
C. diff negative
Urine culture - growth
blood culture x2 - growth date
IMAGING :
CXR [ * * 2188 - 5 - 24 * * ] :
1 . endotracheal tube terminate carina .
2 . mild pulmonary interstitial edema .
3 . right upper zone opacity may reflect aspiration pneumonitis
develop
pneumonia .
CT - [ * * 2188 - 5 - 24 * * ] :
impression :
1 . rul RML pneumonia , possible due aspiration since
esophagus fluid fill dilate .
2 . PE .
3 . moderate left small right effusion , pulmonary
edema .
4 . mediastinal lymphadenopathy
5 . Acute leave 7th rib fracture .
G / GJ / GI TUBE check
finding : supine radiograph demonstrate jejunostomy tube
tip
junction distal duodenum proximal jejunum . contrast
see pass distally jejunum without evidence leak .
Bowel gas pattern normal without evidence leak . image
portion lung clear . surgical clip note
overlie base heart .
IMPRESSION : jejunostomy tube appropriate position normal
passage contrast without evidence leak .
Brief Hospital Course :
55 hx Downs Syndrome , MRSA pneumonia c / b respiratory
failure tracheostomy , / p tracheostomy reversal 10d prior
admission , transfer [ * * Hospital1 18 * * ] hypoxic respiratory failure
[ * * 2 - 27 * * ] RUL / RML aspiration PNA
.
# Aspiration PNA / respiratory distress : PE rule
potential cause respiratory distress . Imaging demonstrate
RUL / RML pneumonia secondary aspiration , well airway
narrowing site prior tracheostomy . likely secondary
aspiration , patient also note fluid fill
esophagus CT scan . Patient treat hospital
acquire community acquire pneumonia Vancomycin ,
Levoquin Cefepime ( 8 - day course ) . culture urine
blood OSH show growth . aspiration may
relate overflow g - tube site . Tube feed initially
hold , G tube study order show jejunostomy tube
appropriate position normal passage contrast without
evidence leak . patient steroid home adrenal
insufficiency , PCP prophylaxis home bactrim
daily start . Patient arrange transfer
[ * * Hospital Ward Name 517 * * ] ICU service extubation potential IP
intervention site airway narrowing . IP find 0.8 cm
focal area stenosis dynamic collapse 2nd tracheal
ring . granulation tissue debride IP replace
percutaneous trach exist stoma . Patient need
evaluation tracheal resection / reconstruction IP / p f / u
2 week . post - procedure CXR show multifocal PNA , unchanged
bilateral effusion , trach appropriate position . Patient
remain stable new trach place well prior
discharge . last day levaquin cefepime
[ * * 2188 - 5 - 31 * * ] .
.
# recent history colitis : report recent history
C.diff Pseudomembranous colitis . Patient several
episode lose stool . C. diff check negative .
.
# syndrome / anxiety : baseline , pt nonverbal . Pt
restart home dose ativan give evidence anxiety
aggitation w / group people intubate .
.
# Adrenal Insufficiency : history unclear patient currently
prednisone 20 daily - patient outpatient
endocrine evaluation . per [ * * Hospital 228 * * ] rehab facility steroid
start treat low sodium . Patient currently normal
blood pressure . Steroid dose taper 10 mg daily 1 week
outpatient follow electrolyte . Patient start
PCP prophylaxis , remain go
continue steroid long term . patient follow -
endocrinology work - possible renal
insufficiency . osh record fax endocrinology
department appointment make .
.
# Hx seizure disorder : reportedly first seizure [ * * 11 - 3 * * ] time
hospitalization MRSA pneumonia . continue home dose
Keppra .
.
# FEN : concern leak J tube site . Tube feed hold
concern leak feeding tube . Surgery consult
suture tube place clamp . dress place
tube site .
.
# Prophylaxis : SubQ heparin , Famotidine
.
# contact : [ * * Name ( NI ) 6961 * * ] = guardian , [ * * Name ( NI ) 449 * * ] [ * * Name ( NI ) * * ]
( [ * * 0 - 0- * * ] ) , Sister [ * * Name ( NI ) * * ] [ * * telephone / Fax ( 1 ) 89174 * * ] .
.
# Code Status : full code ( confirm family )
medication admission :
Prednisone 20 mg daily
Omeprazole 20 mg [ * * hospital1 * * ]
Keppra 500 mg [ * * hospital1 * * ] ( crush )
Ativan 0.25 - 0.5 mg via PEG Q8h PRN ( moderate severe
anxiety )
Duonebs prn wheezing
oxycodone
Zinc
Bacitracin ointment
Bowel Regimen prn
discharge disposition :
Extended Care
Facility :
[ * * Hospital * * ] Healthcare Center - [ * * Location ( un ) 1110 * * ]
discharge diagnosis :
primary diagnosis :
subglottic stenosis
Hosptial acquire pneumonia
.
secondary diagnosis :
? adrenal insufficiency
's syndrome
Seizure disorder
Discharge condition :
level consciousness : alert interactive .
Activity Status : Bedbound .
Mental Status : Confused - sometimes . ( baseline )
Discharge instruction :
pleasure participate care Mr. [ * * know lastname 89172 * * ] .
admit [ * * Hospital1 18 * * ] evaluation respiratory failure .
find narrowing trachea .
take procedure replace tracheostomy .
also treat pneumonia .
.
concern g tube work appropriately .
Surgery evaluate fix J tube .
.
start steroid outpatient facility
low sodium . decrease dose steroid start
Bactrim prevent type lung infection call PCP .
[ * * Name10 ( NameIs ) * * ] follow - endocrinology
evaluate need take steroid .
.
medication change :
start Cefepime 2gm Q24 one day
start Levofloxacin 750 mg daily one day
START Bactrim SS daily prophylaxis PCP
DECREASE Prednisone 10 mg daily
Followup Instructions :
department : Thoracic Multi [ * * hospital 4094 * * ] Clinic
: TUESDAY [ * * 2188 - 6 - 10 * * ] 2:30 pm
: [ * * first Name8 ( NamePattern2 ) * * ] [ * * Name8 ( MD ) * * ] , MD [ * * 0 - 0- * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 24 * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : Thoracic Multi [ * * hospital 4094 * * ] Clinic
: TUESDAY [ * * 2188 - 6 - 10 * * ] 3:00 pm
: [ * * Name6 ( MD ) 1532 * * ] [ * * Name8 ( MD ) 1533 * * ] , MD [ * * 0 - 0- * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 24 * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : MEDICAL SPECIALTIES - Endocrinology
: WEDNESDAY [ * * 2188 - 6 - 11 * * ] 3:15 pm
: MALA [ * * last Name ( namepattern4 ) 16956 * * ] , MD [ * * telephone / Fax ( 1 ) 1803 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : HEMATOLOGY / ONCOLOGY
: TUESDAY [ * * 2188 - 6 - 10 * * ] 2:30 pm
: [ * * first Name8 ( NamePattern2 ) * * ] [ * * Name8 ( MD ) * * ] , MD [ * * 0 - 0- * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 24 * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : HEMATOLOGY / ONCOLOGY
: TUESDAY [ * * 2188 - 6 - 10 * * ] 3:00 pm
: [ * * Name6 ( MD ) 1532 * * ] [ * * Name8 ( MD ) 1533 * * ] , MD [ * * 0 - 0- * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 24 * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : MEDICAL specialty
: WEDNESDAY [ * * 2188 - 6 - 11 * * ] 3:15 pm
: MALA [ * * last Name ( namepattern4 ) 16956 * * ] , MD [ * * telephone / Fax ( 1 ) 1803 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] garage
[ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(1 ) 292 * * ]
complete by:[**2188 - 5 - 30 * * ]
|
[
"5070"
] |
Admission Date : [ * * 2176 - 8 - 29 * * ] Discharge Date : [ * * 2176 - 9 - 6 * * ]
Date Birth : [ * * 2121 - 2 - 13 * * ] sex :
Service : MEDICINE
allergy :
Penicillins / Keflex
attending:[**first Name3 ( LF ) 1928 * * ]
Chief Complaint :
upper extremity weakness
Major Surgical Invasive Procedure :
C5 - C6 anterior cervical decompression fusion , C1 tumor
removal
history Present Illness :
55 - year - old man diabetes mellitus type 2 , hypertension ,
severe peripheral [ * * first Name3 ( LF ) 1106 * * ] disease / p r SFA stent angioplasty
L SFA stent placement , congenital pulmonic valve stenosis ,
CAD / p BMS stent , diastolic CHF , atrial fibrillation / p
ablation warfarin , stage 3 diabetic nephropathy , intradural
tumor compress spinal cord C1 / C2 , admit
[ * * 2176 - 8 - 29 * * ] neurosurgery anterior cervical decompression
c5/6 fusion ( [ * * 8 - 29 * * ] ) extradural tumor removal C1 intradural
tumor ( [ * * 8 - 30 * * ] ) .
patient post - operatively manage ICU
dexamethasone taper . develop small subdural hematoma
( [ * * 8 - 30 * * ] ) new neurologic symptom . aspirin heparin SC
restart . Clopidogrel , L SFA stent , schedule
restart POD#5 , [ * * 2176 - 9 - 4 * * ] , warfarin , atrial
fibrillation , restart [ * * 2176 - 9 - 9 * * ] .
Patient extubate [ * * 9 - 1 * * ] , come furosemide
drip dchf . [ * * Month / Day ( 4 ) * * ] follow patient mottled
right foot recent [ * * Month / Day ( 4 ) 1106 * * ] procedure .
Patient 's medical issue diabetes , HTN , CKD ( Cr 1.1 ) ,
atrial fibrillation ( hrs 70s-80s ) , CAD / p stent " chronic
hyponatremia " ( Na 138 ) stable . transfer request
ongoing management diastolic CHF .
evaluation SICU transfer , patient sleep
arousable , complain old back pain constipation .
vital sign stable O2 saturation 98 % 3l.
Past Medical History :
( 1 ) type 2 diabetes mellitus , require insulin ,
complication year poor glycemic control :
-hypertension
-severe peripheral [ * * Month / Day ( 4 ) 1106 * * ] disease
-peripheral neuropathy
-pressure , venous stasis , neuropathic ulcer right
leave low extremity
-stage 3 diabetic nephropathy
-renal insufficiency ( baseline creatinine 1.5 1.7 )
( 2 ) atrial fibrillation status post ablation [ * * 2169 * * ] [ * * 2174 * * ] ,
coumadin
( 3 ) congenital pulmonic valve stenosis status post two childhood
surgery
-history RV failure
-history peripheral edema anasarca
( 4 ) chronic hyponatremia
( 5 ) chronic low back pain status post car accident
( 6 ) spinal cord meningioma compress spinal cord C1 / C2
( 7 ) COPD
( 8) Coronary artery disease status post stente [ * * 2169 * * ] ( bare
metal stent Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 7047 * * ] ( [ * * telephone / Fax ( 1 ) 8725 * * ] ) ) repeat
stente [ * * Hospital1 18 * * ] [ * * 2174 * * ] ( bare metal stent - see / c summary
[ * * 2175 - 2 - 7 * * ] )
( 9 ) mi [ * * 2161 * * ]
Social History :
patient married two adult son live
home . live [ * * Hospital1 1474 * * ] , . wife work 60 hour week ,
leave home day . bedbound
several year . visit nurse come week
change dressing low extremity ulcer . son
struggle alcoholism heroin abuse . young son
recently threaten suicide homicide ( patient 's
wife ) , source much stress home . use work
" bouncer " construction , enjoy ride
motorcycle . patient say try keep positive
attitude condition . say feel depressed ,
say interested therapy medication
depression . see primary care physician [ * * last Name ( namepattern4 ) * * ] 2
year travel ambulance PCP 's
office touch patient wife weekly .
-[**Name2 ( NI ) * * ] 2 pack per year smoke history " several year "
-He drink alcohol occasionally , never problem
alcoholism
-He deny recreational IV drug use
Family history :
heart disease unspecificed family member .
Physical Exam :
physical exam admission :
Gen : obese , deconditioned , pain movement extremity .
Extrem : B LE edema
Neuro :
mental status : awake alert , cooperative exam .
language : speech fluent good comprehension repetition .
name intact . dysarthria paraphasic error .
motor : patient severe bilateral wasting muscle hand .
UE 's : fi's:[**2 - 1 * * ] 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5 . RLE : [ * * 1 - 4 * * ] pf / df
0/5 LLE : IP3/5 PF / df 0/5
pertinent result :
[ * * 2176 - 8 - 29 * * ] 12:10PM GLUCOSE-94 UREA N-42 * creat-1.2 SODIUM-133
POTASSIUM-4.4 CHLORIDE-95 * TOTAL CO2 - 28 anion gap-14
[ * * 2176 - 8 - 29 * * ] 12:10PM estGFR - use
[ * * 2176 - 8 - 29 * * ] 12:10PM wbc-7.6 RBC-3.91 * HGB-9.7 * hct-30.5 * MCV-78 *
MCH-24.9 * MCHC-31.9 RDW-13.6
[ * * 2176 - 8 - 29 * * ] 12:10PM PLT count-206
IMAGING study :
# c - spine Xray [ * * 8 - 29 * * ] : single lateral view cervical spine
obtain portably , label # 1 . c1 c4/5
disc space visualize . C5 vertebral body faintly see
-- bony structure low obscure overlying
soft tissue . however , surgical marker see overlie
anterior aspect C4 - 5 C5 - 6 disc space ,
anterior approach . support tubing temperature proble note .
# c - spine CT [ * * 2176 - 8 - 29 * * ] :
1 . new interval C5 - C6 anterior fusion intervertebral disc
spacer ,
immediate hardware complication . post - surgical change
soft tissue
subcutaneous emphysema mostly right submandibular
region .
2 . Mass C1 level associated cord compression consistent
know
meningioma well describe recent MRI .
3 . soft tissue thicken right lung apex , fully
characterize current CT . comparison CT neck
[ * * 2176 - 8 - 9 * * ] , increase size . CT chest
recommend evaluate , clinically warrant .
# head CT [ * * 2176 - 8 - 30 * * ] :
1 . new interval leave frontal subdural hyperdense extra - axial
fluid collection new interval subdural subfalcine
extra - axial hyperdense fluid collection , indicate subdural
hemorrhage , likely post - surgical clinical correlation
recommend .
2 . pneumocephalus distribution basilar cistern ,
mostly
leave sylvian fissure , bifrontally falx , likely
post - surgical , additionally posterior fossa near
site occipital craniotomy .
3 . post - surgical change left craniotomy occipital
bone
laminectomy C1 subcutaneous emphysema hyperdense
product , likely post - surgical .
4 . soft tissue hyperdensity posterior parietal , occipital
soft tissue region , could small post - surgical hematoma .
.
# c - spine MRI [ * * 2176 - 8 - 31 * * ] : status post resection C1 extradural
tumor , likely meningioma expectorated postoperative
change . large intraspinal hematoma see . remain
persistent narrowing spinal canal C1 level
indentation posterior aspect spinal cord .
continue followup recommend . mild spinal cord atrophy could
secondary chronic myelomalacia .
.
# LE arterial Duplex [ * * 2176 - 9 - 3 * * ] : peak systolic velocity
involve native right common femoral artery 104 cm / sec .
velocity within superficial femoral artery range 85
234 cm / sec within popliteal artery right ,
25 cm / sec . left , peak systolic velocity within
common femoral artery 132 cm / sec , SFA , velocity range
146 - 75 cm / sec within popliteal artery 85 cm / sec .
IMPRESSION : finding state indicate widely
patent common
femoral , superficial femoral popliteal artery bilaterally .
.
PATHOLOGY :
# c1 tumor [ * * 2176 - 8 - 30 * * ] : cervical medullary junction tumor :
Meningioma , psammomatous subtype ( Grade ) . tumor
compose meningothelial cell numerous psammoma body
collagen deposition typical feature mitotic
activity .
Brief Hospital Course :
55 - year - old man diabetes mellitus type 2 , severe peripheral
[ * * Month / Day / Year 1106 * * ] disease , CAD , diastolic CHF , atrial fibrillation ,
present plan anterior cervical decompression C5 - 6
removal C1 meningioma .
# cervical myelopathy meningioma : Patient underwent anterior
cervical decompression c5/6 fusion [ * * 2176 - 8 - 29 * * ] removal
C1 meningioma [ * * 2176 - 8 - 30 * * ] .
patient post - operatively manage ICU
dexamethasone taper . develop small subdural hematoma
[ * * 2176 - 8 - 30 * * ] new neurologic symptom . per neurosurgery
recommendation , aspirin heparin SC restart .
Clopidogrel , recent left SFA stent , restart POD#5 ,
[ * * 2176 - 9 - 4 * * ] , warfarin , atrial fibrillation ,
restart [ * * 2176 - 9 - 9 * * ] . note , concern
develop LE weakness procedure ,
- evaluation neurosurgery team feel
strength leg baseline
change . continue work PT
hospitalization .
# diastolic heart failure : patient experience acute
exacerbation diastolic heart failure likely secondary
significant fluid administration surgery . place
furosemide gtt SICU , transition
home dose lasix floor . discharge slightly
admission weight 115 kg O2 sat mid 90 's
room air .
# Peripheral [ * * Date Range * * ] disease . patient recently underwent
bilateral SFA angioplasty leave SFA stente .
preparation neurosurgery , plavix hold
pre - procedure subsequently - start [ * * 2176 - 9 - 4 * * ] .
undergo bilateral arterial ultrasound [ * * 2176 - 9 - 3 * * ]
demonstrate patent SFA femoral artery .
# atrial fibrillation : patient atrial
fibrillation hospitalization . give need
neurosurgery coumadin hold . schedule
restart 10 day post - procedure ( [ * * 2176 - 9 - 9 * * ] ) . well
rate control time discharge .
# DM II . patient 's insulin regimin adjust 50 unit
insulin glargine nightly humalog insulin slide scale
achieve good control blood sugar ( FSBS 100 - 180 ) .
# pressure ulcer . patient 2x2 cm right heel full
thickness ulcer without odor drainage . right
dorsum small 1x1 cm partial thickness ulcer . wound care nursing
consult obtain . pressure ulcer care perform
repositioning , skin cleansing conditioner application ,
cover ABD kerlex .
# cope . pt express staff member mood
poor cope well surgery . never
express suicidal ideation . express
extremely frustrated hospitalization inability
walk function independently . discuss possibility
talk psychiatrist hospital , decline .
feel feeling persist would pursue
psychiatric care . number psychiatric service
provide discharge .
# Chronic pain syndrome : patient continue home
regiman dilaudid 4 mg PO Q3H : prn
# chronic hyponatremia . patient history chronic
hyponatremia although sodium remain 130 - 140
admission .
medication admission :
1 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID :
PRN need constipation .
2 . furosemide 10 mg / mL Solution Sig : Sixty ( 60 ) mg Injection [ * * hospital1 * * ]
( 2 time day ): hold sbp<100 .
3 . Ascorbic Acid 500 mg Tablet Sig : one ( 1 ) Tablet po twice
day .
4 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
5 . Metoprolol Tartrate 25 mg Tablet Sig : one ( 1 ) Tablet PO BID
( 2 time day ): hold sbp<100 HR<60 .
6 . trazodone 50 mg Tablet Sig : one ( 1 ) Tablet PO HS ( bedtime )
need insomnia .
7 . Acetaminophen 325 mg Tablet Sig : 1 - 2 tablet po Q6H ( every 6
hour ) need fever .
8 . Petrolatum Ointment Sig : one ( 1 ) Appl Topical DAILY
( Daily ): please apply leg wound per wound care order . thank
!
.
9 . Methocarbamol 500 mg Tablet Sig : two ( 2 ) Tablet PO QID ( 4
time day ) .
10 . albuterol Sulfate 90 mcg / actuation HFA Aerosol Inhaler Sig :
two ( 2 ) Puff Inhalation q6H : PRN need shortness
breath wheezing .
11 . hydromorphone 4 mg Tablet Sig : one ( 1 ) Tablet PO Q3H ( every
3 hour ) need pain : hold rr<12 sedation .
12 . Simvastatin 10 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
13 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
14 . hydroxyzine HCl 25 mg Tablet Sig : one ( 1 ) Tablet PO q6H : PRN
need itching .
15 . Polyethylene Glycol 3350 17 gram / dose Powder Sig : seventeen
( 17 ) g po BID : PRN need constipation .
16 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need
constipation : hold diarrhea .
17 . Clonazepam 0.5 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need anxiety .
18 . Menthol - Cetylpyridinium 3 mg Lozenge Sig : one ( 1 ) Lozenge
mucous membrane PRN ( need ) need dry mouth , sore
throat .
19 . Ketoconazole 2 % Cream Sig : one ( 1 ) Appl Topical [ * * hospital1 * * ] ( 2
time day ): please apply upper forehead scalp
seborrheic dermatitis ( day 1 = [ * * 2176 - 8 - 11 * * ] ) . also , please apply
wound leave shin overlie fungal infection(day 1 =
[ * * 2176 - 8 - 15 * * ] ) . thank !
.
20 . Glycerin ( Adult ) Suppository Sig : one ( 1 ) Suppository
Rectal PRN ( need ) need constipation .
21 . Hydrocodone - Acetaminophen 5 - 500 mg Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) need headache : hold
somnolence .
22 . Heparin drip
Heparin IV Sliding Scale ( please see include scale ):
diagnosis : DVT / - fib ,
Patient Weight : 114.76 kg ,
Initial Bolus : 0 unit ivp ,
Initial Infusion Rate : 1450 unit / hr ,
Target PTT : 60 - 100 second ,
.
PTT < 40 : 4600 unit Bolus increase infusion rate 450
unit / hr ,
PTT 40 - 59 : 2300 unit Bolus increase infusion rate 250
unit / hr ,
PTT 60 - 100 * : ,
PTT 101 - 120 : reduce infusion rate 250 unit / hr ,
PTT > 120 : hold 60 min reduce infusion rate 450
unit / hr ,
23 . insulin slide scale
glargine 46 unit bedtime ;
humalog slide scale per include slide scale .
Discharge medication :
1 . hydroxyzine HCl 25 mg / mL Solution Sig : one ( 1 ) Intramuscular
Q6H ( every 6 hour ) need pruritis .
2 . Clonazepam 0.5 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
3 . furosemide 40 mg Tablet Sig : 2.5 tablets po BID ( 2 time
day ) .
4 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
5 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need constipation .
6 . famotidine 20 mg Tablet Sig : one ( 1 ) Tablet po Q12H ( every 12
hour ) .
7 . Metoprolol Tartrate 50 mg Tablet Sig : one ( 1 ) Tablet PO BID
( 2 time day ) .
8 . ascorbic Acid 500 mg Tablet Sig : one ( 1 ) Tablet po twice
day .
9 . Methocarbamol 500 mg Tablet Sig : 1.5 tablet po Q4H ( every 4
hour ) .
10 . albuterol Sulfate 90 mcg / actuation HFA Aerosol Inhaler Sig :
[ * * 12 - 1 * * ] Inhalation every 4 - 6 hour need shortness
breath wheezing .
11 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID
( 2 time day ) .
12 . dilaudid 4 mg Tablet Sig : one ( 1 ) Tablet PO Q3hr : prn .
13 . simvistatin 10 mg Qday
14 . Petrolatum Ointment Sig : one ( 1 ) Appl Topical DAILY
( Daily ) .
15 . Ketoconazole 2 % Cream Sig : one ( 1 ) Appl Topical [ * * hospital1 * * ] ( 2
time day ) .
16 . outpatient lab Work
Chem 10 monitor electrolyte creatinine take
lasix
17 . turn reposition back prn limit sit time 1hour
time use pressure redistribution cushion . cleanse skin
wound cleanser NS pat dry nad apply aquafor
gluteal leg foot daily
18 . heel lateral foot ulcer apply thin layer duoderm
wound gel , cover dorsum lateral wound adaptic heel
gauze follow ABD pad , wrap iwth kerlix change
daily
19 . headr occiput frequent repositioning
20 . please remove suture posterior neck tuesday [ * * 9 - 10 * * ] [ * * 2175 * * ]
21 . please start warfarin [ * * 2176 - 9 - 9 * * ] ( post op day 10 )
monitor INR prn
22 . check weight Qday
Discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 105 * * ] Northeast - [ * * Location ( un ) 701 * * ]
discharge diagnosis :
cervical myelopathy
C1 tumor cervical myelopathy
Acute chronic diastolic heart failure
discharge condition :
stable , afebrile
Discharge instruction :
admit [ * * Hospital1 18 * * ] [ * * 2176 - 8 - 29 * * ] worsen upper
extremity weakness due spinal tumor . undergo
operation remove tumor . also undergo operation
decrease pressure spinal cord neck .
need staple surgical site
[ * * 2176 - 9 - 10 * * ] , rehab facility .
appointment make follow Dr. [ * * last Name ( STitle ) * * ] 6
week .
please return Emergency department fever , chill ,
difficulty breathing , worsen upper extremity weakness ,
worsen symptom .
Followup Instructions :
1 . [ * * last Name ( STitle ) * * ] LAB
[ * * Hospital1 18 * * ] [ * * Hospital Unit Name * * ] , [ * * Location ( un ) * * ]
[ * * Location ( un ) * * ] surgery
phone:[**telephone / fax ( 1 ) 1237 * * ]
Date / Time:[**2176 - 9 - 26 * * ] 3:15
2 [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern4 ) 3469 * * ] , MD
LM [ * * Hospital Unit Name * * ] , [ * * Location ( un ) * * ]
[ * * Location ( un ) * * ] surgery
phone:[**telephone / fax ( 1 ) 2625 * * ]
Date / Time:[**2176 - 9 - 26 * * ] 4:15
3 . Dr. [ * * last Name ( STitle ) 47032 * * ] [ * * Name ( STitle ) * * ]
address : [ * * Doctor First Name * * ] [ * * Hospital Unit Name * * ] [ * * Location ( un ) 470 * * ] [ * * Hospital Unit Name * * ]
phone : [ * * telephone / Fax ( 1 ) * * ]
appointment : [ * * 2176 - 10 - 8 * * ] 1:15pm
4 . Psychiatry Clinic
[ * * Hospital1 18 * * ] Psychiatry Clinic
please call bottom number schedule appointment
mood sad take pleasure life :
[ * * telephone / Fax ( 1 ) * * ]
|
[
"2761",
"5119",
"4280",
"3572",
"496",
"412"
] |
Admission Date : [ * * 2138 - 6 - 9 * * ] Discharge Date : [ * * 2138 - 6 - 12 * * ]
Date Birth : [ * * 2111 - 2 - 28 * * ] sex :
Service : Cardiothoracic Surgery
PREOPERATIVE DIAGNOSIS :
1 . Bicuspid aortic valve .
2 . dilate aorta .
3 . Aortic insufficiency .
history PRESENT ILLNESS : patient heart
murmur since childhood find bicuspid aortic
valve echocardiogram , recently increase
size ascending aorta . otherwise , patient deny
medical problem . [ * * Name ( NI ) * * ] surgery [ * * 2124 * * ]
undescended testicle .
SOCIAL history : deny smoking history . occasional
alcohol , maybe per week .
FAMILY history : Noncontributory .
medication admission : prophylactic antibiotic .
allergy : know drug allergy .
LABORATORY ADMISSION : preoperative vital sign
heart rate 78 , blood pressure 102/68 , respiratory rate
18 . healthy , 27 - year - old male . lung
clear . Heart 3/6 systolic ejection murmur . otherwise ,
examination within normal limit .
HOSPITAL COURSE : , [ * * 2138 - 6 - 9 * * ] , patient
underwent homograft aortic root replacement , resection ,
graft proximal aortic arch . undergo general
anesthesia . intraoperative complication .
postoperatively , patient transfer recovery
room nitroglycerin drip normal sinus rhythm .
transfer recovery room Intensive Care
Unit , postoperative day one transfer
floor , continue uncomplicated postoperative
course .
patient experience tachycardia heart rate
around 117 . tachycardia patient 's beta
blocker increase , respond . beta
blocker increase 75 mg p.o . b.i.d . Potassium
replete . patient diurese 4 liter per day .
patient good pain control . ambulate
around hall without difficulty .
condition discharge : Stable .
DISCHARGE STATUS : discharge home prescription .
service need .
medication DISCHARGE :
1 . Lopressor 75 mg p.o . b.i.d .
2 . [ * * first name5 ( NamePattern1 ) 233 * * ] [ * * last Name ( NamePattern1 ) 1002 * * ] 40 meq p.o . q.d . times five day .
3 . iron sulfate 325 mg p.o . t.i.d .
4 . Percocet 5 one two tablet p.o . q.6h . p.r.n .
5 . Aspirin 81 mg p.o . q.d .
[ * * Doctor Last Name 412 * * ] [ * * last Name ( Prefixes ) 413 * * ] , M.D. [ * * MD Number(1 ) 414 * * ]
dictate by:[**last Name ( NamePattern1 ) 8344 * * ]
medquist36
: [ * * 2138 - 6 - 12 * * ] 23:01
: [ * * 2138 - 6 - 13 * * ] 18:17
JOB # : [ * * Job number 13750 * * ]
|
[
"4241"
] |
Admission Date : [ * * 2142 - 11 - 30 * * ] Discharge Date : [ * * 2142 - 12 - 10 * * ]
Date Birth : [ * * 2084 - 5 - 2 * * ] sex :
Service : MEDICINE
allergy :
Percocet / Bactrim Ds / Lisinopril
attending:[**first Name3 ( LF ) 898 * * ]
Chief Complaint :
hypotension
Major Surgical Invasive Procedure :
none
history Present Illness :
Mr. [ * * know lastname 25925 * * ] 58 yo w/ multiple sclerosis seizure
disorder present OSH delusion ams x 2 day .
OSH , note Na 124 . history
hyponatremia ; Na 117 [ * * 2 - 27 * * ]
mid 130s since . see nephrology . OSH ,
approx 45sec generalize tonic clonic seizure , receive 1 mg
Ativan , transfer ED [ * * Hospital1 18 * * ] . also
history seizure especially setting infection
hyponatremia . unclear seizure without
incite event . currently wean Keppra
Gabapentin start Tegretol . er , VS
: 97.5 ; 189/105 ; 78 ; 16 ; 95 % 3l. give 2L NS .
give ams setting infection
know chronic uti [ * * 12 - 24 * * ] indwelling suprapubic catheter
neurogenic bladder , blood urine culture obtain
well CXR . urine culture [ * * 11 - 28 * * ] grow
pseudomona CXR show possible infiltrate
treat vancomycin cefepime . head CT negative .
Past Medical history :
MS - since [ * * 2119 * * ] , progressive , quadriplegic , neurogenic bladder
suprapubic catheter , restrictive PFT 's
history Aspiration PNAs
Esophageal Ulcer - [ * * 12 - 24 * * ] nsaid , [ * * 2139 * * ] , small bowel bx negative
recurrent uti
CHF ( EF > 65 % moderate LVH ' [ * * 39 * * ] )
HTN
legally blind
Social History :
marry 32 year live wife home .
three child three grandchild . professor [ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) 25949 * * ] engineering [ * * University / College 25932 * * ] ,
retire disability [ * * 2128 * * ] spring semester due
MS . [ * * Name13 ( STitle ) * * ] wheelchair - bind . deny tobacco , alcohol ,
recreational drug use . personal care assistant .
Family history :
Father CAD CVA . Mother [ * * Name ( NI ) 2481 * * ] disease . Brother
diabete .
Physical Exam :
general : Alert , oriented , acute distress
HEENT : Sclera anicteric , MMM , oropharynx clear
Neck : supple , JVP elevate , LAD
lung : clear auscultation bilaterally , wheeze , rale ,
ronchi
CV : regular rate rhythm , normal S1 + S2 , murmur , rub ,
gallop
Abdomen : soft , non - tender , non - distended , bowel sound present ,
rebound tenderness guarding , organomegaly
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
pertinent result :
[ * * 2142 - 11 - 29 * * ] 10:47PM BLOOD wbc-6.4 rbc-3.99 * # hgb-11.8 * # hct-33.1 *
MCV-83 # MCH-29.7 MCHC-35.7 * RDW-15.0 Plt ct-235 #
[ * * 2142 - 12 - 10 * * ] 05:50AM blood wbc-8.8 RBC-3.54 * Hgb-10.8 * Hct-31.0 *
MCV-88 MCH-30.5 mchc-34.7 RDW-15.3 Plt ct-424
[ * * 2142 - 12 - 7 * * ] 05:50AM blood PT-13.6 * PTT-34.1 INR(PT)-1.2 *
[ * * 2142 - 11 - 29 * * ] 10:47PM blood Glucose-102 UreaN-11 Creat-0.6 Na-126 *
K-4.5 Cl-88 * HCO3 - 29 angap-14
[ * * 2142 - 11 - 30 * * ] 06:58AM blood Glucose-89 UreaN-11 Creat-0.7 na-125 *
K-4.6 Cl-90 * HCO3 - 28 AnGap-12
[ * * 2142 - 11 - 30 * * ] 12:40pm blood na-128 *
[ * * 2142 - 11 - 30 * * ] 09:45PM blood na-127 *
[ * * 2142 - 12 - 1 * * ] 07:40AM blood Glucose-79 UreaN-11 Creat-0.7 Na-131 *
K-4.0 Cl-93 * HCO3 - 29 angap-13
[ * * 2142 - 12 - 1 * * ] 03:00pm blood glucose-101 UreaN-16 Creat-0.8 Na-131 *
K-4.5 cl-94 * HCO3 - 30 AnGap-12
[ * * 2142 - 12 - 2 * * ] 05:45am blood Glucose-81 urean-15 creat-0.7 Na-133
K-4.6 cl-95 * HCO3 - 28 angap-15
[ * * 2142 - 12 - 2 * * ] 04:10PM blood Glucose-98 urean-15 Creat-1.0 Na-131 *
K-4.9 Cl-93 * HCO3 - 27 AnGap-16
[ * * 2142 - 12 - 3 * * ] 06:20AM blood glucose-121 * UreaN-21 * creat-1.2 Na-131 *
K-4.3 Cl-93 * HCO3 - 28 angap-14
[ * * 2142 - 12 - 3 * * ] 05:40PM blood Glucose-115 * UreaN-25 * Creat-1.3 * Na-134
K-4.4 Cl-96 HCO3 - 27 angap-15
[ * * 2142 - 12 - 4 * * ] 07:18AM blood glucose-101 urean-23 * Creat-0.8 Na-135
K-4.0 Cl-98 HCO3 - 27 angap-14
[ * * 2142 - 12 - 5 * * ] 05:30AM blood Glucose-83 UreaN-21 * Creat-0.7 Na-135
K-3.9 Cl-96 HCO3 - 26 AnGap-17
[ * * 2142 - 12 - 6 * * ] 05:30AM blood Glucose-96 UreaN-19 Creat-0.8 na-134
K-4.2 Cl-97 HCO3 - 28 angap-13
[ * * 2142 - 12 - 7 * * ] 05:50am blood Glucose-102 UreaN-21 * Creat-0.8 na-137
K-4.2 Cl-97 HCO3 - 26 angap-18
[ * * 2142 - 12 - 8 * * ] 07:00AM blood Glucose-89 urean-15 Creat-0.9 Na-136
K-3.9 Cl-99 HCO3 - 27 angap-14
[ * * 2142 - 12 - 9 * * ] 06:30AM blood Glucose-96 UreaN-14 Creat-0.9 Na-140
K-4.0 cl-101 HCO3 - 28 angap-15
[ * * 2142 - 12 - 10 * * ] 05:50am blood Glucose-99 UreaN-18 Creat-1.0 Na-140
K-4.5 Cl-102 HCO3 - 26 AnGap-17
[ * * 2142 - 11 - 29 * * ] 10:47PM blood Osmolal-260 *
[ * * 2142 - 11 - 30 * * ] 12:40pm blood osmolal-264 *
[ * * 2142 - 12 - 8 * * ] 07:00AM blood alt-23 AST-16 LD(LDH)-213 AlkPhos-87
totbili-0.2
[ * * 2142 - 12 - 10 * * ] 05:50AM blood Calcium-9.3 Phos-2.8 Mg-2.4
u / [ * * 11 - 28 * * ] : nit + , LE + , WBC 55 , RBC 6 , Epi 1 , bact
u / [ * * 11 - 29 * * ] : sm bld , 100 prot / gluc ; WBC [ * * 1 - 24 * * ] , RBC [ * * 1 - 24 * * ] , Epi [ * * 1 - 24 * * ] , bact
mod
u / [ * * 12 - 2 * * ] : sm LE , WBC 10 , RBC 2 , Epi 1 , bact none
u / [ * * 12 - 5 * * ] : 30 prot , 10 ket , lg LE ; WBC 99 , RBC 11 , Epi 1 , bact
u / [ * * 12 - 6 * * ] : 30 prot , mod LE ; WBC 22 , RBC 8 , Epi 3 , bact none
u / [ * * 12 - 8 * * ] : neg leuk
CULTURES :
BCx [ * * 11 - 29 * * ] x2 : neg
BCx [ * * 12 - 2 * * ] x2 : neg
UCx [ * * 11 - 28 * * ] : pseudomona AERUGINOSA . > 100,000 ORGANISMS / ML
UCx [ * * 11 - 29 * * ] pseudomona
UCx [ * * 12 - 2 * * ] yeast
Ucx [ * * 12 - 5 * * ] neg
Ucx [ * * 12 - 6 * * ] yeast
Ucx [ * * 12 - 8 * * ] neg
c.diff neg x 2
- CXR [ * * 12 - 2 * * ] : patchy opacity left base note ,
significance setting low inspiratory volume
uncertain .
- CTA [ * * 12 - 2 * * ] : pe . scatter patchy ground - glass opacity
may represent expiratory state air trapping .
- Renal u / [ * * 12 - 2 * * ] : evidence abscess , hydronephrosis
mass
- abd xray [ * * 12 - 3 * * ] : non - specific bowel gas pattern , stool
throughout colon , free air
- abd xray [ * * 12 - 4 * * ] : Stool- air - fill loop large
small bowel consistent ileus .
- Liver u / [ * * 12 - 5 * * ] : hypoechoic right hepatic mass , measure
4.2 cm size
- CT abd : prelim read : arterially enhance liver lesion
fully characterize , may represent adenoma , FNH , less
likely HCC .
Brief Hospital Course :
58 yo male w/ progressive multiple sclerosis admit
ams seizure 45 GTC OSH respond
1 mg Ativan . negative head CT find
Na level 126 . hyponatremic past
often cause change mental status . ed ,
treat 2L NS concern hypovolemic
hyponatremia . time , urine osm 423 serum osm
263 . also CXR prelim concern
pneumonia cause ADH like effect ( final read
neagtive ) . Neurology consult ams seizure
feel hyponatremia likely relate recent
initiation carbamezapine sensory illusion .
Carbamezapine know ADH like effect cause
hyponatremia . follow discontinuation carbamezapine along
fluid restriction , Na increase . several day ,
pt appear slightly dehydrate fluid restriction
lift . time discharge , serum Na 140 .
.
past , seizure instigate underlying
infection . however , upon admission afebrile
leukocystosis . likely source either
pneumonia UTI . suprapubic catheter [ * * 12 - 24 * * ] neurogenic
bladder day prior admission , urine sample
grow pseudomona , bacteria past .
also several pneumonia past , likely [ * * 12 - 24 * * ]
frequent aspiration first CXR concern lung
infiltrate . treat one dose vancomycin
cefepime pneumonia . ultimately , repeat CXR CTA
negative pneumonia .
.
pseudomonal bacteriuria , start
ciprofloxacin . urine culture draw prior abx inititian also
grow pseudomona . afebrile
leukocytosis think may actually
colonization oppose infection . however ,
treat full course cipro complicated UTI .
catheter change culture remain negative .
.
admission , pt afebrile hypertensive 180 - 200 .
however , shortly arrive floor , episode
hypotension 70 's systolic . time
mentate well , complaint , deny chest
pain , headache , visual change . ivf give , however
hypotension initially respond , however come
eventually prior get ICU . labile blood
pressure likely secondary patient 's autonomic
dysfunction secondary SPMS . consideration
infection possible sepsis , however patient continue
afebrile . blood urine culture negative .
monitor ICU 24 hour stable swing BP
asymptomatic consistent autonomic dysfunction .
change clonidine dose 0.2 mg [ * * hospital1 * * ] 0.1 mg TID .
maintain blood pressure medication home dose .
.
next day , transfer MICU return
floor . shortly arrival , develop fever .
blood urine culture send negative .
Pneumonia rule UTI treat
medication appropriate per sensitivity .
CTA negative PE . however , start
meropenem treat 2 day . still slightly
febrile meropenem discontinue concern drug
fever . defervesce without treatment .
.
however , mental status continue fluctuate despite
afebrile , obvious source infection , eunatremic .
occasionally aggressive would say
murder kidnap . Neurology reconsulte
feel symptom relate keppra
think subclinical seizure . continue
repetitive shake move head conscious
able speak episode . also , despite
Keppra , continue sensory illusion , mostly center
around feeling bowel movement ( actually
) .
.
work source infection source AMS ,
CTA reveal liver lesion .
ultrasound multiphase liver CT describe
lesion MRI [ * * 12 - 24 * * ] implanted baclofen
pump . Mr [ * * know lastname 25925 * * ] family decide biopsy lesion
time rule completely malignancy ,
although unlikely . work also KUB
concern ileus continue bm keep
regular diet .
.
prior discharge , mental status completely
return baseline alert orient x 3
long aggressive towards staff . definite etiology
elucidated hypothesize could result
progression establish disease .
medication admission :
BACLOFEN 2,000 mcg / mL Kit -pump
BRIMONIDINE Dosage uncertain
CARVEDILOL - 25 mg Tablet [ * * hospital1 * * ]
CARBAMEZAPINE - 100 mg [ * * hospital1 * * ]
CLONIDINE - 0.2 mg Tablet [ * * hospital1 * * ]
CLOTRIMAZOLE - BETAMETHASONE - 1 % -0.05 % Cream tid
FENTANYL - 12 mcg / hour patch 72 hr
FUROSEMIDE - 40 mg Tablet qd
IPRATROPIUM - ALBUTEROL prn
LACTULOSE prn
MINOCYCLINE - 100 mg Tablet [ * * hospital1 * * ]
MODAFINIL [ provigil ] 50 [ * * hospital1 * * ]
OMEPRAZOLE 20 [ * * hospital1 * * ]
OXYBUTYNIN CHLORIDE - 15 mg qhs
SIMVASTATIN - 40 mg qd
TRAVOPROST1 drop l eye day
ACETAMINOPHEN prn
ASCORBIC ACID 500 [ * * hospital1 * * ]
BISACODYL hs
CALCIUM 500 mg Tid
CRANBERRY 475 mg Capsule [ * * hospital1 * * ]
ERGOCALCIFEROL ( VITAMIN D2)400 [ * * hospital1 * * ]
MINERAL OIL prn
omega-3 FATTY ACIDS [ * * hospital1 * * ]
PSYLLIUM [ METAMUCIL ] prn
senna - 8.6 mg Tablet prn
Discharge medication :
1 . Carvedilol 12.5 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
2 . fentanyl 12 mcg / hr Patch 72 hr Sig : one ( 1 ) patch 72 hr
Transdermal Q72H ( every 72 hour ) .
3 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
4 . Lactulose 10 gram/15 ml Syrup Sig : thirty ( 30 ) ML PO Q8H
( every 8 hour ) need .
5 . Acetaminophen 325 mg Tablet Sig : 1 - 2 tablet po Q6H ( every 6
hour ) need .
6 . Oxybutynin Chloride 5 mg Tablet Sig : three ( 3 ) Tablet po QHS
( day ( bedtime ) ) .
7 . Ascorbic Acid 500 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2
time day ) .
8 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) need .
9 . Senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need .
10 . calcium Carbonate 500 mg Tablet , Chewable Sig : one ( 1 )
Tablet , Chewable PO TID ( 3 time day ) .
11 . omeprazole 20 mg Capsule , Delayed Release(E.C. ) Sig : one ( 1 )
Capsule , Delayed Release(E.C. ) PO BID ( 2 time day ) .
12 . Simvastatin 10 mg Tablet Sig : four ( 4 ) Tablet PO DAILY
( Daily ) .
13 . brimonidine 0.15 % drop Sig : one ( 1 ) Drop Ophthalmic [ * * hospital1 * * ] ( 2
time day ) .
14 . Modafinil 100 mg Tablet Sig : 0.5 Tablet po BID ( 2 time
day ) .
15 . Ciprofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet po Q12H
( every 12 hour ) 6 day : [ * * 2142 - 12 - 13 * * ] .
16 . clonidine 0.1 mg Tablet Sig : one ( 1 ) Tablet PO TID ( 3 time
day ) .
17 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need .
18 . Levetiracetam 250 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2
time day ) .
19 . combivent 18 - 103 mcg / Actuation Aerosol Sig : one ( 1 ) inh
Inhalation twice day need .
20 . travatan z 0.004 % drop Sig : one ( 1 ) ophthalmic
day : left eye .
21 . cranberry 475 mg Capsule Sig : one ( 1 ) Capsule po twice
day .
22 . omega-3 Fatty Acids Capsule Sig : one ( 1 ) Capsule po
twice day .
23 . ergocalciferol ( Vitamin D2 ) 400 unit Tablet Sig : one ( 1 )
Tablet PO twice day .
patient allergy list ACE Inhibitors ,
therefore discharge ACE Inhibitor .
communicate PCP .
discharge Disposition :
Home Service
Facility :
[ * * Hospital * * ] Home Health Care
discharge Diagnosis :
1 . Multiple Sclerosis
2 . Urinary Tract Infection , complicated
3 . Hyponatremia
.
secondary :
1 . Chronic Diastolic CHF
discharge condition :
stable vital sign .
Discharge instruction :
admit altered mental status find
low sodium urinary tract infection . start
antibiotic urinary tract infection ( cipro ) complete
2 week course . sodium correct adjust
medication reduce water intake .
.
find abnormality liver .
CT scan result pende final interpretation .
provide phone number schedule
appointment [ * * Hospital * * ] clinic . may necessary reimage
liver take biopsy lesion see CT scan .
.
medication change . switch tegratol
keppra . please review recent medication list
take medication , discard old medication
list .
.
please return hospital develop fever , chill ,
worsen symptom .
Followup Instructions :
1 . [ * * First Name8 ( NamePattern2 ) * * ] [ * * first Name8 ( NamePattern2 ) 1575 * * ] [ * * last Name ( NamePattern1 ) * * ] , MD phone:[**telephone / fax ( 1 ) 8645 * * ]
Date / Time:[**2143 - 1 - 8 * * ] 1:30
.
2 . [ * * First Name11 ( Name Pattern1 ) 1037 * * ] [ * * last Name ( namepattern4 ) 2335 * * ] , MD phone:[**telephone / fax ( 1 ) 457 * * ] Date / time:[**2143 - 1 - 15 * * ]
4:00
.
3 . [ * * Hospital * * ] CLINIC [ * * Hospital1 18 * * ] : ( [ * * telephone / Fax ( 1 ) 2233 * * ]
complete by:[**2142 - 12 - 13 * * ]
|
[
"5990",
"2761",
"5849",
"4280",
"2930",
"4019"
] |
Admission Date : [ * * 2109 - 8 - 17 * * ] Discharge Date : [ * * 2109 - 10 - 16 * * ]
Date Birth : [ * * 2054 - 10 - 24 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 759 * * ]
Chief Complaint :
B / l ankle fracture , / p fall
Major Surgical Invasive Procedure :
[ * * 8 - 18 * * ]
.
1 . closed reduction left pilon fracture .
2 . Application multi - planar external fixator leave low
extremity .
3 . Closed treatment calcaneus fracture mild amount
manipulation .
4 . external fixation right Pilon fracture
.
[ * * 8 - 30 * * ] adjustment external fixator r pilon fracture
.
[ * * 9 - 17 * * ] ORIF right intra - articular distal tib - fib fracture r
history Present Illness :
54 year old spanish speak male , US vacation ,
questionable pmh liver disease present
jumping?falle ? window . per daughter drink
alcohol son report feel someone
kill . lock second - story bedroom
later find daughter crawl outside .
initially see [ * * hospital3 * * ] find opiate
cocaine UA emergency department .
transport [ * * Hospital1 18 * * ] b / l ankle fracture . per family ,
pt confuse home . [ * * Name ( NI ) * * ] , pt aggitate
receive haldol ativan . later somnolent . EKG
demonstrate atrial flutter hrs 110 - 140 's , rate
control ED IV diltiazem .
Patient poor historian , information obtain
daughter
ROS : + b / l ankle pain , -CP , -SOB , -abdominal pain
Past Medical history :
" get yellow "
high ammonia
HTN
questionable anginal history
depression , family state see psychiatrist
Social History :
EtOH abuse , polysubstance abuse , one ppd mayn year
Urine positive cocaine opiate ED
marry
daughter involve care
Family history :
Noncontributory
Physical Exam :
vital : 96.7 140/90 76 16 99 % 2L NPO/1000
Physical Exam :
general : sleepy arousable , orient place person ,
able name month year forwards , backwards ,
orient current month / year
HEENT : icteric sclerae , dry MM , + c - collar
CVS : irregular rate , tachy , murmur / rub / gallop appreciate
Pulm : CTA b / l , wheeze , rale rhonchi
Abd : soft , NT , mild hepatosplenomegaly , + BS
Ext : b / l ankle splint , mild bruise b / l knee , -
asterixis
GU : + foley
pertinent result :
CT C - Spine : negative fracture
Left tib / fib : Comminuted fracture calcaneus . dense sliver
bone along medial aspect proximal fibula , see
single view . could represent additional
calcification intraosseous ligament , small cortical
fracture fragment , foreign body .
right tib / fib : Comminuted , intraarticular , impact ,
displace fracture distal tibia well fracture
distal fibula detail .
.
CT bilat LE
1 . Comminuted intra - articular distal right tibial fracture .
2 . comminuted distal right fibular fracture displacement .
3 . Comminuted leave calcaneal fracture .
.
RUQ U / :
finding : liver coarse echotexture without evidence
focal lesion . gallbladder distend due nonfaste
stage . evidence gallstone . evidence intra-
extra - hepatic biliary ductal dilatation common duct
measure 3 mm . pancrea well visualize due bowel
gas . evidence free fluid . main portal vein
patent antegrade flow .
impression : evidence cholecystitis .
.
head CT ( [ * * 8 - 21 * * ] )
impression : evidence acute intracranial pathology ,
include sign intracranial hemorrhage .
.
CXR ( [ * * 8 - 21 * * ] )
previous study comparison . low lung volume . heart size
difficult evaluate semi - upright AP film .
could LVH evidence CHF lung
clear . questionable slight impression right margin
tracheal air column well evaluate standard PA
lateral chest film condition permit .
.
Chest CT ( [ * * 8 - 23 * * ] ):
1 . juxtatracheal mass leave upper lobe lesion question
chest radiograph report .
2 . three foci ground glass , right upper lobe , detectable
routine radiograph , nonspecific finding . six- month CT
follow recommend look change ,
bronchoalveolar cell carcinoma , though unlikely ,
exclude .
3 . borderline size mediastinal hilar lymph node
check followup CT .
4 . mild atherosclerotic coronary artery calcification .
Chest CTA ( [ * * 8 - 24 * * ] ):
1 . pulmonary embolism .
2 . relatively unchanged appearance multiple ill - define
opacity tiny nodule right upper lobe . follow -
state examination 1 day prior recommend .
3 . new foci opacification present lung basis compare
examination one day prior likely relate aspiration .
Layering debris present within right main stem bronchus
suggestive aspiration well . clinical correlation
recommend .
4 . recommend advance NG tube least 4 - 5 cm . current
position elevate risk aspiration .
.
CT RLE contrast ( [ * * 8 - 24 * * ] ):
impression : comminuted distal tibial fibular fracture
intra- articular involvement tibial plafond lateral
displacement talus respect tibia . posterior
displacement distal fibular fragment .
.
CT LLE without contrast ( [ * * 8 - 24 * * ] )
Comminuted leave calcaneal fracture .
Lentiform area fluid attenuation skin
posterolateral aspect left foot . significance
latter finding uncertain , may due skin blister
possibly dress material within cast . clinical correlation
request .
.
CXR ( [ * * 8 - 26 * * ] )
1 . NG tube could advanced several centimeter standard
positioning , describe prior exam .
2 . new perihilar opacity , likely due acute aspiration
superior segment .
.
head CT ( [ * * 9 - 3 * * ] )
impression : evidence hemorrhage CT evidence
acute infarct .
.
CT abd / pelvis ( [ * * 9 - 22 * * ] ):
impression : CT evidence pyelonephritis abscess within
abdomen / pelvis .
.
CT LLE without contrast ( [ * * 9 - 26 * * ] )
1 . markedly comminute fracture calcaneus wide
distraction dispersal fracture fragment .
2 . non - displace fracture sustentaculum tali
middle facet talus .
3 . fracture identify medial malleolus .
4 . non - displace fracture anterior aspect
inferior aspect lateral malleolus .
5 . non - displace fracture cuboid .
6 . fracture identify navicular .
7 . fracture identify within remainder mid
foot forefoot .
8 . lateral subluxation peroneal tendon respect
fibula .
9 . probable tear anterior talofibular ligament .
.
Echo ( [ * * 9 - 26 * * ] ):
left atrium mildly dilate . leave ventricular wall
thickness , cavity
size regional / global systolic function normal ( LVEF
> 55 % ) transmitral
tissue Doppler imaging suggest normal diastolic function ,
normal
leave ventricular filling pressure ( pcwp<12mmhg ) . right
ventricular chamber
size free wall motion normal . aortic valve leaflet
( 3 ) appear
structurally normal good leaflet excursion aortic
regurgitation .
mitral valve appear structurally normal trivial mitral
regurgitation . mitral valve prolapse . estimate
pulmonary
artery systolic pressure normal . pericardial
effusion .
IMPRESSION : normal global regional biventricular systolic
function .
Brief Hospital course :
course hospitalization , pt put CIWA scale
EtOH withdrawal give thiamine , folate multivitamin ,
AFib RVR initially treat metoprolol ,
diltiazem , high ammonia level treat lactulose .
b / l ankle fracture follow orthopedic .
patient severely agitate one occassion
hospitalization , require three code puple
call well require restraint protection
patient staff .
patient originally send floor MICU
delirium unknown cause severe agititation . require
increase amount sedation return floor
NG tube place . return floor ,
patient require less sedation , take
benzodiazipine intermittently need restraint .
patient remain somnolent delerious . pull
NG tube . also febrile rhoncorous floor .
initially treat vancomycin flagyl ,
change azithro / ceftriaxone / flagyl . schedule
return revision right external fixation .
preop hold , find hypoxic send
MICU .
MICU COURSE : morning [ * * 8 - 28 * * ] , patient schedule return
revision externally fixate RLE . upon transport PACU ,
patient become somnolent report " agonal
breathing " . O2 sat 83 % 2lnc NRB apply O2 sat
100 % . BP 90s/60s , hr 80 , RR 17 - 19 . abg draw : 7.38/58/90 .
stay MICU , patient cough large amount thick
sputum improved respiratory status . Surgery postpone
patient transfer MICU monitoring . MICU ,
respiratory status remain stable Sp02 high 90
room air . Pt hemodynamically stable chronic - flutter .
call floor [ * * 8 - 29**]- intensive care need
identify .
MICU , patient start Zosyn restart
Vancomycin wiht marked improvement respiratory status .
within day return floor , Vancomycin
zosyn stop CXR show resolution questionable
aspiration pneumonia - feel likely
pneuomonitis resolve .
.
MICU , patient 's delirium start improve ,
worsen return removal external
fixation . develop fever 102F post - operatively
likely worsen delirium . source fever unclear - note
patient recently develop VRE urine infectious
disease feel active infection . receive
three day antibiotic ( daptomycin linezolid ) .
stop become afebrile delirium begin
lift .
.
# Aggitation mostly control haldol . Zyprexa
try two week seem help acute
aggitation . QTc monitor patient
antipsychotic stable approximately 420 - 440msec .
overall etiology delirium remain unclear
think multifactorial due part chronic alcohol use ,
hepatic encephalopathy , benzodiazepine use , post - operative
delririum . although spanish - speak 1:1 sitter
interpreter employ much possible , language also
likely contribute persistance delirium . Delirium
completely resolve patient restraint sitter free .
haldol stop . past period etoh
withdrawal . recommend patient follow
alcohol abuse counseling .
.
# afib / flutter
febrile , afib / flutter complicate frequent
episode rapid ventricular rate . control IV
metoprolol need also increase po metoprolol
diltiazem . treat fever tylenol also seem help .
briefly put therapeutic lovenox atrial fibrillation ,
stop feel eligible CHADS
criterion also high fall risk . Patient
transition beta blocker place Diltiazem 120 mg
daily .
.
# urinary retention
patient fail several voiding trial . also pull
foley several occasion , cause hematuria . Intermittent
straight catheterization try reduce infection risk
long - term indwelling foley . however give delirium
aggitation untenable . resolve reduction
haldol . patient able void freely . history
VRE urine culture , sign infection , dyruria ,
increase urinary frequency . evidence base
literature clinical indication treat
asymptomatic bacteuria time .
.
# fracture
patient follow orthopedic admission . L ankle
fracture treat casting , however repeat plain film
CT scan 4 - 6 week post - op show fracture
initially visualize . orthopedic feel casting still
appropriate indication surgery . r
pilon fracture manage initially external fixation system
skin breakdown make internal fixation difficult .
one month hospitalization ex - fix removed tibial
fibular plate place . remain non - weight bearing
total one month hospital discharge . patient
complete necessary course lovenox . follow
appointment schedule orthopaedic surgeon Dr. [ * * last Name ( STitle ) * * ]
[ * * 11 - 28 * * ] 1030am , [ * * hospital3 * * ] [ * * Hospital Ward Name * * ] , [ * * Location ( un ) 1385 * * ] [ * * Hospital Ward Name 23 * * ] building .
.
transfer [ * * Hospital * * ] Rehab Hospital .
medication admission :
Diltiazem 180 mg one daily
Discharge medication :
1 . aspirin 81 mg Tablet , Chewable Sig : one ( 1 ) Tablet , Chewable
po DAILY ( Daily ) .
disp:*30 Tablet , Chewable(s ) * Refills:*0 *
2 . Folic Acid 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*1 *
3 . thiamine HCl 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*1 *
4 . calcium Carbonate 500 mg Tablet , Chewable Sig : one ( 1 )
Tablet , Chewable PO QID ( 4 time day ) need .
Disp:*30 Tablet , Chewable(s ) * Refills:*0 *
5 . diltiazem HCl 120 mg Capsule , Sustained Release Sig : one ( 1 )
Capsule , Sustained Release po DAILY ( Daily ) .
disp:*30 Capsule , sustained release(s ) * Refills:*1 *
6 . trazodone 50 mg Tablet Sig : 0.5 Tablet PO HS ( bedtime )
need .
disp:*15 Tablet(s ) * Refills:*0 *
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 2222 * * ] - [ * * Location ( un ) 538 * * ]
discharge diagnosis :
Primary :
1 ) Bilateral Lower Extremity fracture
a. Closed leave tibial plafond fracture / pilon fracture .
b. Dislocation leave tibiotalar joint .
c. right calcaneus fracture , intra - articular
2 ) persistent agitated delirium ? ? ? ? ? ? resolve
3 ) Aspiration Pneumonitis - resolve
4 ) alcoholism ? ? ? ? ? ? continuous
5 ) Delirium Tremens
6 ) Polysubstance Abuse ( cocaine , opiate , alcohol )
7 ) Atrial Fibrillation / Atrial Flutter
8) abnormal CT chest ? ? ? ? ? ? follow - ( [ * * 2111 - 1 - 5 * * ] ) recommend
9 ) Liver Failure ? ? ? ? ? ? presume secondary alcoholism ( evidence
HBV HCV infection )
a. Thrombocytopenia presume secondary thrombopoitin
deficiency . evidence splenomegaly imaging .
10 ) elevate AFP level ? ? ? ? ? ? etiology yet undetermined
secondary :
1 ) Hypertension
2 ) urinary retention ? ? ? ? ? ? resolve
3 ) Bactiuria ? ? ? ? ? ? asymptomatic , colonize Vancomycin resistant
enterococcus
Contact information :
[ * * first Name8 ( NamePattern2 ) * * ] [ * * know lastname 1794 * * ] ( daughter ): [ * * telephone / Fax ( 1 ) 74301 * * ]
[ * * Female First Name ( un ) 74302 * * ] & [ * * first Name9 ( NamePattern2 ) 74303 * * ] [ * * know lastname 1794**](son ) cell [ * * telephone / Fax ( 1 ) 74304 * * ]
follow - :
1 ) Repeat CT scan chest [ * * 2111 - 1 - 5 * * ] f / u 3 foci
ground glass rul well borderline mediastinal
hilar lymphadenopathy
2 ) Assess etiology elevated alpha - fetoprotein
3 ) evaluate etiology pancyctopenia ? ? ? ? ? ? consider bone
marrow aspirate well HIV testing
discharge condition :
stable , Non - weight bearing leg one month start
[ * * 10 - 15 * * ]
Discharge instruction :
transfer [ * * Hospital1 18 * * ] emergency room large fall .
find bilateral ankle fracture . CT
scan head show acute bleed .
come emergency room heart rate fast ,
give medication help slow .
.
[ * * 8 - 18 * * ] operation left leg heel
ankle fracture , several pin place left
leg . left leg cast .
.
[ * * 8 - 30 * * ] operation r tibula fibula fracture
stabilize leg externally .
.
[ * * 9 - 17 * * ] operation right tibula
fibula screw place help leg heal .
.
hospital stay . confused place
many psychiatric medication , become agitated
time , restrain time . resolve
long psychiatric medication .
.
hospital develop breathing problem . [ * * Name ( NI ) * * ]
spend time intensive care unit ,
worry might pneumonia , start
antibiotic , breathing problem improve ,
chest xray improve . think
pneumonia antibiotic normal .
.
also find bacteria urine call
VRE , , burning urination .
infectious disease doctor think bacteria
treat .
.
transfer rehab facility . important
rehab facility , follow get
counseling problem alcohol abuse .
.
follow appointment schedule orthopaedic
new primary care physician . [ * * Name10 ( NameIs ) * * ] important
follow appointment .
.
also important put weight leg
next month . please return hospital emergency
room condition worsen way .
abnormal chest x - ray / CT scan
repeat [ * * 2111 - 1 - 5 * * ] make sure not lung
cancer .
blood count low stable
hospitalization . see Hematologist ( Blood Doctor )
consider test HIV .
elevation marker blood call AFP ( alpha
fetoprotein ) . significance know . may
relate underlying liver disease
evaluate specialist .
absolutely refrain use alcohol ,
cocaine illicit drug explicitly prescribe
physician .
Ten??????as una exploraci??????n anormal [ * * Doctor First Name * * ] pecho x - ray / CT [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] [ * * last Name ( un ) 7214 * * ]
esto
repetido en diciembre de [ * * 2110 * * ] para cerciorarse de ? ? ? ? ? ? [ * * last Name ( un ) 7214 * * ]
pulm??????n
c??????ncer .
Tus cuentas de sangre [ * * Doctor First Name * * ] [ * * first Name9 ( NamePattern2 ) 74305 * * ] [ * * last Name ( un ) * * ] [ * * first Name9 ( NamePattern2 ) 74306 * * ] [ * * last Name ( un ) 33761 * * ] tu
hospitalizaci??????[**initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 7213 * * ] [ * * last Name ( un ) * * ] un hemat??????logo ( el doctor [ * * last Name ( Titles ) * * ]
[ * * last Name ( Prefixes ) 74307 * * ] )
sobre esto considerar el probar para el VIH .
Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
( alfa
fetoprotein ) . [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) 74308**]??????n de esto es saber . puede ser
relacionado con tu enfermedad [ * * Doctor First Name * * ] higado [ * * first Name9 ( NamePattern2 ) 74309 * * ] [ * * last Name ( un ) * * ] debe
ser m??????s futuro
evaluado por un especialista .
[ * * last Name ( un ) 7213 * * ] refrenarse absolutamente [ * * Doctor First Name * * ] uso adicional [ * * Doctor First Name * * ] alcohol , de
[ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] ? ? ? ? ? ? na de cualquier droga il??????cita prescrito
expl??????citamente ti por un m??????dico .
Followup Instructions :
Ten??????as una exploraci??????n anormal [ * * Doctor First Name * * ] pecho x - ray / CT [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] [ * * last Name ( un ) 7214 * * ]
esto
repetido en diciembre de [ * * 2110 * * ] para cerciorarse de ? ? ? ? ? ? [ * * last Name ( un ) 7214 * * ]
pulm??????n
c??????ncer .
Tus cuentas de sangre [ * * Doctor First Name * * ] [ * * first Name9 ( NamePattern2 ) 74305 * * ] [ * * last Name ( un ) * * ] [ * * first Name9 ( NamePattern2 ) 74306 * * ] [ * * last Name ( un ) 33761 * * ] tu
hospitalizaci??????[**initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 7213 * * ] [ * * last Name ( un ) * * ] un hemat??????logo ( el doctor [ * * last Name ( Titles ) * * ]
[ * * last Name ( Prefixes ) 74307 * * ] )
sobre esto considerar el probar para el VIH .
Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP
( alfa
fetoprotein ) . [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) 74308**]??????n de esto es saber . puede ser
relacionado con tu enfermedad [ * * Doctor First Name * * ] higado [ * * first Name9 ( NamePattern2 ) 74309 * * ] [ * * last Name ( un ) * * ] debe
ser m??????s futuro
evaluado por un especialista .
[ * * last Name ( un ) 7213 * * ] refrenarse absolutamente [ * * Doctor First Name * * ] uso adicional [ * * Doctor First Name * * ] alcohol , de
[ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] ? ? ? ? ? ? na de cualquier droga il??????cita prescrito
expl??????citamente ti por un m??????dico .
please follow Dr. [ * * last Name ( STitle ) * * ] orthopedic surgery
appointment schedule [ * * 2112 - 11 - 28**]:30 , [ * * Location ( un ) 1385 * * ] [ * * Hospital Ward Name 23 * * ] build [ * * Hospital Ward Name * * ] [ * * hospital1 771 * * ] . please call [ * * telephone / Fax ( 1 ) 9769 * * ] would like
change appointment .
please follow new primary care physician [ * * last Name ( namepattern4 ) * * ] .
[ * * last Name ( STitle ) 15259 * * ] [ * * 2109 - 11 - 19 * * ] 3 pm [ * * Hospital Ward Name 23 * * ] Center
[ * * Location ( un ) * * ] [ * * Hospital Ward Name 516 * * ] [ * * Hospital1 1170 * * ] .
abnormal chest x - ray / CT scan
repeat [ * * 2111 - 1 - 5 * * ] make sure not lung
cancer .
blood count low stable
hospitalization . see Hematologist ( Blood Doctor )
consider test HIV .
elevation marker blood call AFP ( alpha
fetoprotein ) . significance know . may
relate underlying liver disease
evaluate specialist .
|
[
"4019",
"2875",
"5990",
"5070",
"5180"
] |
Admission Date : [ * * 2170 - 9 - 19 * * ] Discharge Date : [ * * 2170 - 9 - 25 * * ]
Date Birth : [ * * 2099 - 5 - 27 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 165 * * ]
Chief Complaint :
Dyspnea exertion fatigue
Major Surgical Invasive Procedure :
[ * * 2170 - 9 - 19 * * ] coronary artery bypass graft x 4 ( leave internal mammary
artery diagonal , saphenous vein graft left anterior
descending , saphenous vein graft obtuse marginal , saphenous
vein graft posterior descend artery )
history Present Illness :
71 year old male present PCP [ * * Name Initial ( PRE ) * * ] routine visit
complaint recent onset fatigue , dyspnea exertion ,
exertional throat discomfort leave arm . deny rest
pain report discomfort dyspnea occur minimal
activity shower . find hypertensive
start Atenolol 25 mg daily . ekg normal
send nuclear stress test . undergo nuclear
stress test [ * * 2170 - 8 - 1 * * ] reveal inferolateral ischemia
moderate inferior , inferolateral , posterolateral perfusion
abnormality . refereed cardiac catheterization .
refer cardiac surgery revascularization .
Past Medical history :
hypertension
Right rotator cuff tear
Compound fracture left arm / plate child
Benign colon polyp
Arthritis
/ p right rotator cuff repair
/ p repair leave arm fracture , plate
Social History :
race : caucasian
last Dental Exam:"a long time ago " , recall
live : Wife
Contact:[**Name ( NI ) * * ] ( wife ) phone # [ * * telephone / Fax ( 3 ) 74913 * * ]
Occupation : self employ painter
cigarette : Smoked [ x ]
Tobacco use : deny
ETOH : stop drink [ * * 12 - 20 * * ]
Illicit drug use : deny
family history :
premature coronary artery disease
Physical Exam :
pulse : 56 Resp:13 O2 sat:97 / RA
B / p Right:173/82 left:164/76
Height:5'9 " Weight:200 lbs
General : NAD , WG , WN
skin : Dry [ x ] intact [ x ]
HEENT : PERRLA [ x ] EOMI [ x ]
Neck : Supple [ x ] full rom [ x ]
chest : lung clear bilaterally [ x ]
heart : rrr [ x ] Irregular [ ] Murmur [ ] grade _ _ _ _ _ _
abdoman : Soft [ x ] non - distended [ x ] non - tender [ x ] bowel sound
+ [ x ]
extremity : Warm [ x ] , well - perfuse [ x ] Edema [ ] none _
varicosity : None [ x ]
Neuro : grossly intact [ x ]
pulse :
Femoral Right : 2 + leave : 2 +
dp right : 1 + leave : 1 +
PT [ * * Name ( NI ) 167 * * ] : 1 + leave : 1 +
Radial Right : 2 + leave : 2 +
Carotid Bruit right : leave :
bruit
pertinent result :
[ * * 2170 - 9 - 25 * * ] 06:35AM blood wbc-10.9 RBC-2.94 * Hgb-9.3 * Hct-26.3 *
MCV-89 MCH-31.6 mchc-35.3 * RDW-13.5 Plt ct-261
[ * * 2170 - 9 - 24 * * ] 06:20AM blood WBC-13.4 * RBC-3.27 * Hgb-10.1 * Hct-28.7 *
MCV-88 MCH-31.0 mchc-35.3 * RDW-14.2 Plt ct-197
[ * * 2170 - 9 - 25 * * ] 06:35AM blood Na-139 K-4.0 Cl-99
[ * * 2170 - 9 - 24 * * ] 06:20AM blood Glucose-118 * UreaN-26 * Creat-0.9 Na-139
K-4.0 Cl-98 HCO3 - 31 angap-14
[ * * 2170 - 9 - 23 * * ] 05:00am blood urean-25 * Creat-0.9 na-137 K-4.3 Cl-99
Brief Hospital course :
Mr. [ * * know lastname * * ] day admit [ * * 9 - 19 * * ] bring
operating room undergo Coronary artery bypass graft
x4 ( leave internal mammary artery diagonal saphenous
vein graft left anterior descending , obtuse marginal ,
posterior descend artery ) Dr.[**First Name ( STitle ) * * ] .
CARDIOPULMONARY BYPASS TIME:104 minute . cross - CLAMP TIME:93
minute . please see operative report surgical
detail . follow surgery transfer CVICU
intubate sedate critical stable condition . later
day wean sedation , awake neurologically
intact extubate without incident . wean pressor
support beta blocker / Statin / Aspirin diuresis
initiate . chest tube epicardial pacing wire remove
per protocol . pod#1 transfer step - unit
monitoring . Physical Therapy consult
evaluation strength mobility . postoperative
course develop atrial fibrillation treat
beta blocker amiodarone . anticoagulation initiate
Coumadin . develop phlebitis IV Amio place
course Keflex x 7 day . slowly improve .
pulmonary status wax wane strong productive cough
wheezing , improve time discharge .
continue nebulizer treatment . CXR show small bilateral
pleural effusion atelectasis , infiltrate density .
pulmonary status slowly improve day discharge .
POD 4 develop tender erythematous right knee
treat colchicine presume gout . improve
time discharge colchicine discontinue .
POD 6 afebrile , ambulate assistance , tolerate
full po diet wound heal well . POD 6
discharge Lifecare Center [ * * location 15289 * * ] stable
condition . follow appointment advise .
medication admission :
ATENOLOL 25 mg Daily
ASPIRIN 325 mg daily
FISH OIL - DHA - EPA 1,200 mg-144 mg-216 mg Daily
MV - FA - CA - FE - MIN - LYCOPEN - lutein [ THRU z high POTENCY ] 400
mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily
NAPROXEN SODIUM [ ALEVE]PRN
Discharge medication :
1 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
2 . ranitidine HCl 150 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2
time day ) .
3 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
4 . bisacodyl 10 mg Suppository Sig : one ( 1 ) Suppository Rectal
DAILY ( Daily ) need constipation .
5 . acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet po Q4H ( every
4 hour ) need pain / temp .
6 . hydromorphone 2 mg Tablet Sig : 1 - 2 tablet po every six ( 6 )
hour need pain .
7 . amiodarone 200 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ): x 1 week 200 [ * * hospital1 * * ] x 1 week 200 mg daily
direct caridologist .
8 . metoprolol tartrate 50 mg Tablet Sig : 1.5 tablet po TID ( 3
time day ) .
9 . magnesium hydroxide 400 mg/5 ml Suspension Sig : thirty ( 30 )
ML po HS ( bedtime ) need constipation .
10 . simvastatin 20 mg Tablet Sig : one ( 1 ) Tablet po day .
11 . albuterol sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) Inhalation Q6H ( every 6 hour ) .
12 . ipratropium bromide 0.02 % solution Sig : one ( 1 ) Inhalation
Q6H ( every 6 hour ) .
13 . guaifenesin 100 mg/5 mL Syrup Sig : 5 - 10 ml po Q6H ( every 6
hour ) need cough .
14 . cephalexin 500 mg Capsule Sig : one ( 1 ) Capsule PO Q6H ( every
6 hour ) 7 day : right arm phlebitis .
15 . Lasix 40 mg Tablet Sig : one ( 1 ) Tablet po day 14
day .
16 . potassium chloride 20 meq Tablet , ER Particles / Crystals Sig :
one ( 1 ) Tablet , ER Particles / Crystals PO day 14 day .
17 . warfarin 2 mg Tablet Sig : two ( 2 ) Tablet po ( ):
give 4 mg [ * * 9 - 26 * * ] direct INR goal 2.0 - 2.5
fib .
discharge Disposition :
Extended Care
Facility :
Life Care Center [ * * location 15289 * * ]
discharge diagnosis :
Coronary artery disease / p coronary artery bypass graft x 4
past medical history :
hypertension
Right rotator cuff tear
Compound fracture left arm / plate child
Benign colon polyp
Arthritis
/ p right rotator cuff repair
/ p repair leave arm fracture , plate
discharge condition :
alert orient x3 nonfocal
ambulate steady gait
incisional pain manage oral analgesia
incision :
Sternal - heal well , erythema drainage
Leg Right / left - heal well , erythema drainage .
Edema
discharge instruction :
please shower daily include wash incision gently mild
soap , bath swimming clear surgeon . look
incision daily redness drainage
please lotion , cream , powder , ointment incision
morning weigh evening
take temperature , write chart
drive approximately one month take
narcotic , discuss follow appointment
surgeon able drive
lifting 10 pound 10 week
please call question concern [ * * telephone / Fax ( 1 ) 170 * * ]
female : please wear bra reduce pull incision , avoid
rub low edge
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Followup Instructions :
schedule follow appointment
surgeon : Dr. [ * * First Name ( STitle ) * * ] [ * * 10 - 29 * * ] 1:15pm , # [ * * telephone / Fax ( 1 ) 170 * * ]
Cardiologist : Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 7047 * * ] [ * * 9 - 25 * * ] 2:00pm
please call schedule appointment
Primary Care Dr. [ * * last Name ( STitle ) * * ] . Nikolaos Michalacos [ * * 4 - 17 * * ] week
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Labs : PT / INR Coumadin ? ? ? ? ? ? indication atrial fibrillation
Patient give 4 mg Coumadin [ * * 2170 - 9 - 25 * * ]
Goal INR 2.0 - 2.5
first draw [ * * 2170 - 9 - 26 * * ]
please arrange follow PCP cardiologist prior
discharge rehab
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 173 * * ]
complete by:[**2170 - 9 - 25 * * ]
|
[
"4111",
"5119",
"5180",
"4019"
] |
Admission Date : [ * * 2191 - 7 - 13 * * ] Discharge Date : [ * * 2191 - 7 - 15 * * ]
Date Birth : [ * * 2191 - 7 - 13 * * ] sex :
Service : NEONATOLOGY
history : Baby [ * * Name ( NI ) * * ] [ * * know lastname 1661 * * ] bear 39 week gestation
32 - year - old gravida 1 , para 0 1 woman . mother 's
prenatal screen blood type positive , antibody
negative , rubella immune , RPR nonreactive , hepatitis surface
antigen negative , group B strep negative . infant
cry intubate meconium suction
cord . give brief period bag
mask ventilation good response . apgar 8 two
minute 9 five minute .
birth weight 3885 gram , birth length 20 [ * * 1 - 19 * * ]
inch , birth head circumference 34 cm .
transfer Newborn Intensive Care Unit four hour
age hypoglycemia . blood dextrose stick 36 .
PHYSICAL EXAMINATION : reveal vigorous , non - dysmorphic ,
term - appear infant . anterior fontanel open flat ,
cranial molding present , small caput posteriorly , palate
intact . respiration unlabore , lung sound clear equal .
Heart normal heart sound murmur . Femoral
brachial pulse +2 equal . soft abdomen masse .
normal external male genitalia testis descended .
symmetric tone reflexe .
HOSPITAL course system :
1 . Respiratory : infant remain room air
throughout Newborn Intensive Care Unit stay .
apnea , bradycardia desaturation .
2 . Cardiovascular : remain normotensive throughout
Newborn Intensive Care Unit stay .
cardiovascular issue .
3 . Fluids , electrolyte nutrition : infant require
supplemental intravenous fluid , wean
successfully 28 hour age , maintain euglycemia
feeding Enfamil 20 ad lib schedule , take
approximately one ounce every three four hour . last
blood glucose four hour mark 59 .
4 . Gastrointestinal : infant pass meconium .
5 . Sensory : hearing screening perform automate
auditory brain stem response , infant pass
ear [ * * 2191 - 7 - 15 * * ] .
6 . Psychosocial : parent involve
infant 's care Newborn Intensive Care Unit stay .
DISCHARGE STATUS : infant discharge
Newborn Nursery .
condition discharge : condition good time
discharge .
primary PEDIATRIC CARE : provide Dr. [ * * last Name ( STitle ) 43003 * * ]
[ * * Name ( STitle ) 17494 * * ] [ * * hospital3 * * ] Medical Center , telephone number
[ * * telephone / Fax ( 1 ) 17663 * * ] .
CARE recommendation :
1 . feeding : Enfamil 20 ad lib schedule .
2 . medication : infant discharge medication .
3 . state screening draw yet .
4 . infant yet receive hepatitis B vaccine .
discharge DIAGNOSIS :
1 . resolve hypoglycemia
2 . Term male infant
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) 38353 * * ] , M.D. [ * * MD Number(1 ) 38354 * * ]
dictate by:[**last Name ( NamePattern1 ) 37333 * * ]
medquist36
: [ * * 2191 - 7 - 15 * * ] 01:36
: [ * * 2191 - 7 - 15 * * ] 02:18
JOB # : [ * * Job number 43004 * * ]
|
[
"V053"
] |
Admission Date : [ * * 2142 - 12 - 23 * * ] Discharge Date : [ * * 2142 - 12 - 30 * * ]
Date Birth : [ * * 2070 - 6 - 15 * * ] sex : F
Service : SURGERY
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 371 * * ]
Chief Complaint :
right upper quadrant pain
Major Surgical Invasive Procedure :
[ * * 2142 - 12 - 23 * * ] : ERCP sphincterotomy stent placement
[ * * 2142 - 12 - 28 * * ] : cholecystectomy
history Present Illness :
72 year - old female history mild mental
retardation , present RUQ start . Pt
back pain . Pt go [ * * hospital1 * * ] find fever
102.9 elevated LFTs . RUQ u / concern stone
CBD . WBC 9.4 56 % band , tbili 8.7 , dbili 5.3
give levo / flagyl , tylenol , IVF transfered [ * * Hospital1 18 * * ]
presume cholangitis . orientate person
" hospital " . life home .
ed , VS arrival 97.3 82 132/74 20 96 % 2L NC . Pt
give IVF , unasyn , zofran , morphine . Labs show WBC
31 , lactate 3.2 , bili 7.7 elevated LFTs . ERCP
surgery consult . ERCP want pt [ * * Hospital Unit Name 153 * * ] ERCP tonight .
Surgery request u / CT abd contrast . CXR concern
LLL PNA , resp sx . RUQ u / prelim show : gallstone ,
evidence acute cholecystitis . Angiomyolipoma leave upper
pole , 1.5 cm . CT prelim show : intrahep bil dil . slight
enhancement normal caliber cbd , cbd raise
possibility cholangitis . pulmonary bronchiectasis . Pt
admit surgery [ * * Hospital Unit Name 153 * * ] . vs transfer 98 66 104/39 16
99 % 2lnc .
Pt go ERCP show pus bile duct
small stone cause obstruction . also stricture
1/3rd way CBD . Malignacy rule .
stent place need removal 3 week . Pt give
3 liter LR time arrive post procedure [ * * Hospital Unit Name 153 * * ]
include ER IVF .
Past Medical History :
-Mild mental retardation
-arthoscopy knee
-hysterectomy
-Low plt [ * * Hospital1 2025 * * ] [ * * 2129 * * ] , dx ITP
-cataract surgery
-right 3rd nerve palsy
-Esophageal web , food obstruction remove past
Social History :
live sister , brother - - law , mother . [ * * Name ( NI ) * * ] tobacco
etoh use . ambulate independently . enjoy watch tv
news today show .
Family history :
bleeding plt disorder
Physical Exam :
vital : 98.8 87 97/36 13 94%ra
GEN : well - appear , acute distress
HEENT : mild sclera ictericus , MMM , op Clear
neck : jvp 5 - 6 cm , bruit , cervical lymphadenopathy ,
trachea midline
COR : RRR , soft SEM Rt 2nd ICS , radial pulse +2
PULM : lung coarse crackle right bsea decrease bs
left base crackle
ABD : Soft , NT , ND , + BS , HSM , masse , neg Murphys
EXT : C / C / e , palpable cord
NEURO : alert , orient person time , " hospital " .
move ext , right third nerve palsy ( abduction rest
elevation past midline adduction ) pupil
asymetric offcenter contract ; CN otherwise grossly intact .
skin : mild jaundice
Pertinent result :
admission labs-
[ * * 2142 - 12 - 23 * * ] 04:54PM blood WBC-31.3 * RBC-5.04 Hgb-13.2 Hct-38.0
MCV-75 * MCH-26.1 * mchc-34.7 RDW-13.9 Plt Ct-162
[ * * 2142 - 12 - 23 * * ] 04:54PM blood Neuts-57 Bands-30 * Lymphs-6 * Monos-2
Eos-0 baso-0 Atyps-2 * Metas-3 * Myelos-0
[ * * 2142 - 12 - 23 * * ] 04:54PM blood PT-16.0 * PTT-27.9 INR(PT)-1.4 *
[ * * 2142 - 12 - 23 * * ] 04:54PM blood Glucose-106 * UreaN-18 Creat-0.8 Na-141
k-3.4 Cl-108 HCO3 - 20 * AnGap-16
[ * * 2142 - 12 - 23 * * ] 04:54PM blood alt-263 * AST-184 * AlkPhos-172 *
TotBili-7.7 *
[ * * 2142 - 12 - 23 * * ] 04:54PM blood Lipase-14
[ * * 2142 - 12 - 24 * * ] 12:08am blood calcium-7.7 * Phos-3.2 Mg-1.7
[ * * 2142 - 12 - 23 * * ] 05:08PM blood lactate-3.2 *
[ * * 2142 - 12 - 23 * * ] Liver US :
Gallstones , without gallbladder wall thickening
pericholecystic fluid suggest acute cholecystitis . biliary
dilation .
[ * * 2142 - 12 - 23 * * ] CT Abd / pelvis :
1 . intrahepatic biliary ductal dilatation , gallstone ,
gallbladder
normal appearance .
2 . slight mural hyperenhancement nondilated common
hepatic common bile duct - see cholangitis .
2 . Diverticula , evidence diverticulitis .
[ * * 2142 - 12 - 23 * * ] ERCP :
Esophageal web
periampullary diverticulum
successful biliary cannulation .
single stricture 6 mm long see middle
third common bile duct .
irregular appearance lining bile duct ,
likely secondary cholangitis .
sucessful sphincterotomy perform
small 4 mm stone extract . Pus see exit bile
duct .
successful plastic biliary stent placement
otherwise normal ercp third part duodenum
Possible Mirizzi 's versus tumor cause stricture .
[ * * 2142 - 12 - 26 * * ] CXR ;
1 . new small - - moderate right - side pleural effusion
parenchymal
opacity could probably explain compressive
atelectasis , although pneumonia additional differential
consideration .
2 . similar leave low lung opacity chronic
finding .
[ * * 2142 - 12 - 28 * * ] :
indication : cbd stricture unclear etiology . evaluate
pancreatic mass .
comparison : CT abdomen [ * * 2142 - 12 - 23 * * ] ERCP [ * * 12 - 23 * * ] , [ * * 2142 * * ] .
TECHNIQUE : multidetector helical scanning abdoman
perform prior
follow administration 200 cc IV Optiray
contrast .
Coronal , sagittal , volume - render MIP reformat
display .
CTA ABDOMEN : leave low lobe bronchiectasis small
bilateral
pleural effusion unchanged prior exam .
pneumobilia
common bile duct stent place traverse mid cbd stricture
see ERCP .
soft tissue surround cbd definitively
suggest biliary
malignancy . mild intrahepatic biliary ductal dilation .
8 - mm low - density lesion within segment V / VI liver
( 3A:43 ) ,
small characterize likely cyst .
intrahepatic lesion . portal vein patent . hepatic
arterial
anatomy conventional . pancreas enhance homogeneously
evidence pancreatic mass . superior mesenteric artery
vein
patent normal caliber course . prominent 12
mm portal
hilar lymph node ( 3B:110 ) , likely reactive . also
13 - mm precaval
node ( 3B:119 ) .
spleen , gallbladder , adrenal gland normal .
kidney enhance
excrete contrast symmetrically multiple subcentimeter
hypoattenuate
lesion small characterize likely cyst .
16 - mm
exophytic fat - contain left renal lesion consistent
angiomyolipoma ( 3a:66 ) . left extrarenal pelvis .
ascite .
mesenteric adenopathy . small bowel loop normal .
moderately extensive colonic diverticula .
bone mildly osteopenic degenerative
change , however ,
concern lytic sclerotic lesion .
IMPRESSION : mild biliary dilation stent within CBD ,
pancreatic biliary mass identify .
study report review staff radiologist .
DR . [ * * First Name ( STitle ) 18394 * * ] [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 18395 * * ]
DR . [ * * First Name ( STitle ) 8085 * * ] [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 8086 * * ]
approve : SAT [ * * 2142 - 12 - 29 * * ] 10:56 pm
Brief Hospital course :
72 year - old female present acute
cholangit transfer ERCP surgery evalaution .
# Acute Cholangitis : Pt elevate lft bili RUQ pain
fever 102.9 OSH . transfered ERCP
surgery eval . Pt appearance sepsis due WBC 9.4
56 % band OSH WBC 31.3 30 % band [ * * Hospital1 18 * * ] ER
fever . ERCP show stone obstruction drainage pus ,
stent place . Pt admit [ * * Hospital Unit Name 153 * * ] post procedure
remain NPO . lft start trend post ERCP . 2
hour post ERCP develop hypotension BP dropping
mid 90 70 . mentate make urine .
give IVF bolus LR bp improve 90 - 100 .
give IVF need maintain UO sbp>90 .
abd pain post procedre . continue tx unasyn .
[ * * 2142 - 12 - 23 * * ] osh blood cx grow GNR 2/4 bottle [ * * 2142 - 12 - 24 * * ]
9am . transferd sicu per request surgery
team .
# CBD stricture : ERCP pt find stricture
unclear cause . pancreatic protocol CTA ,
show mild biliary dilation stent within CBD ,
pancreatic biliary mass identify .
# cholelithiasis : follow ERCP sphincterotomy stone
extraction , pt clincally stabilize lft gradually
return [ * * Location 213 * * ] . point , take
operating room definitive management cholelithiasis .
Pt find acute suppurative cholecystitis
laproscopic cholecystectomy perform . recover
uneventfully procedure .
# atrial fibrillation : develop RAF 150 [ * * 2142 - 12 - 25 * * ]
give IV lopressor subsequently Diltiazem
conversion NSR . episode .
# Possibe PNA : clear resp sx hypoxia . CT Abd show
low lung field pulm bronchiectasis , may expalin
ER finding CXR . 3 liter oxygen requirment
likely IVF give setting sepsis .
follow transfer surgical floor continue make
good progress . remain free arrhythmias
gradually wean oxygen adequate saturation .
ambulate independently void without
difficulty . diet gradually advance regular well
tolerate .
medication admission :
Multivitamin
Discharge medication :
1 . Augmentin 500 - 125 mg Tablet Sig : one ( 1 ) Tablet PO three
time day 2 day .
Disp:*6 Tablet(s ) * Refills:*0 *
2 . metoprolol tartrate 25 mg Tablet Sig : 0.5 Tablet po BID ( 2
time day ) .
disp:*30 Tablet(s ) * Refills:*0 *
3 . multivitamin Tablet Sig : one ( 1 ) Tablet po day .
4 . oxycodone 5 mg Tablet Sig : one ( 1 ) Tablet po every 4 - 6 hour
need pain .
disp:*25 Tablet(s ) * Refills:*0 *
5 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po twice
day : take use oxycodone avoid constipation .
Disp:*60 Capsule(s ) * Refills:*2 *
discharge disposition :
home
discharge diagnosis :
cholangitis
choledocholithiasis
gram negative bacteremia
paroxsymal atrial fibrillation
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
* admit hospital abdominal pain due
stone bile duct . undergo ERCP stent
placement .
* surgery gallbladder remove .
* continue eat regular diet stay well
hydrated .
* take antibiotic prescribe .
* irregular heartbeat short time
ICU . normalize medication call lopressor .
continue Dr. [ * * last Name ( STitle ) 39288 * * ] evaluate thge
office .
* develop abdominal pain symptom
concern , please call doctor return
Emergency Room .
* need stent remove later . please call
number schedule appointment .
General Discharge instruction :
please resume regular home medication , unless specifically
advise take particular medication . please take
new medication prescribe .
please take prescribed analgesic medication need .
may drive heavy machinery take narcotic analgesic
medication . may also take acetaminophen ( tylenol )
direct , exceed 4000 mg one day .
please get plenty rest , continue walk several time per
day , drink adequate amount fluid . avoid strenuous
physical activity refrain heavy lifting great 10
lbs . , follow - surgeon , instruct
regard activity restriction . please also
follow - primary care physician .
Incision Care :
* please call surgeon go emergency department
increase pain , swelling , redness , drainage
incision site .
* avoid swimming bath clear surgeon .
* may shower wash incision mild soap warm
water . gently pat area dry .
* staple , remove follow -
appointment .
* steri - strip , fall .
please remove remain strip 7 - 10 day surgery .
Followup Instructions :
call Acute Care Clinic [ * * telephone / Fax ( 1 ) 600 * * ] follow
appointment [ * * 12 - 27 * * ] week .
call GI unit [ * * telephone / Fax ( 1 ) 1983 * * ] schedule appointment
repeat ERCP stent removal 3 week .
call Dr. [ * * last Name ( STitle ) 39288 * * ] follow appointment 2 week .
|
[
"0389",
"2875"
] |
Admission Date : [ * * 2185 - 4 - 17 * * ] Discharge Date : [ * * 2185 - 5 - 2 * * ]
Date Birth : [ * * 2185 - 4 - 17 * * ] sex : F
Service : neonatology
history : [ * * first Name4 ( NamePattern1 ) 14552 * * ] [ * * know lastname * * ] , twin # 2 , bear 34 - 2/7 week
gestation 40 - year - old gravida 3 , para 2 four woman
spontaneous vaginal delivery . mother 's prenatal
screen blood type O+ , antibody negative , rubella
immune , RPR nonreactive , hepatitis surface antigen negative ,
group B Strep unknown . pregnancy achieve
in-[**Last Name ( un ) 5153 * * ] fertilization result dichorionic - diamniotic
twin . mother receive betamethasone 23 week
gestation due cervical shortening . pregnancy also
complicated hypertension urinary tract infection x2
unknown organism , mother also chronic
smoker .
labor ensue spontaneous rupture membrane 12
hour delivery twin # 1 . twin emerge vigorous .
apgar eight one minute eight five minute .
birth weight 2,125 gram , birth length 44.5 cm ,
birth head circumference 31.5 cm . parameter
25 - 50th percentile gestational age .
ADMISSION PHYSICAL EXAM : reveal vigorous preterm infant .
anterior fontanel soft flat . suture proximate .
positive bilateral red reflex . mild subcostal - intercostal
retraction , positive grunting . Breath sound
equal . Heart regular , rate , rhythm , rhythm . pink
well perfuse . soft abdoman positive bowel sound ,
three vessel umbilical cord . normal preterm female
genitalia , femoral pulse +2 , nonfocal neurological
examination .
HOSPITAL COURSE systems :
respiratory : infant initially grunt flaring
retract resolve hour life .
occasional episode desaturation first two
day life , apnea , bradycardia ,
desaturation . examination , respiration
comfortable . always remain room air throughout
NICU stay .
Cardiovascular : infant remain normotensive
throughout nicu stay . cardiovascular issue .
Fluids , electrolyte , nutrition : time
discharge , weight 2,180 gram , length 45 cm ,
head circumference 31.5 cm .
Enteral feed begin day life # 1 advance
without difficulty full volume feed day life # 2 .
time discharge , eat adlib schedule
24 calorie / ounce breast milk Enfamil breast
feed mother present .
Gastrointestinal : one bilirubin draw day life
# 3 total 6.4 direct 0.3 . never require
phototherapy .
Hematology : time admission , hematocrit
46.8 . never receive blood product transfusion
nicu stay .
infectious disease : [ * * Doctor First Name 14552 * * ] start ampicillin
gentamicin time admission sepsis risk factor .
antibiotic discontinue 48 hour
blood culture negative , infant clinically
well .
Neurology : neurological issue .
Audiology : hearing screening perform automate
auditory brain stem response , infant pass
ear .
Psychosocial : parent involved infant 's
care throughout nicu stay .
infant discharge good condition home
parent .
primary PEDIATRIC CARE : provide Dr. [ * * first Name4 ( NamePattern1 ) 2048 * * ] [ * * last Name ( NamePattern1 ) * * ]
[ * * hospital1 1562 * * ] , telephone # [ * * telephone / Fax ( 1 ) 49156 * * ] .
CARE recommendation discharge :
1 . feeding : 24 calorie / ounce breast milk Enfamil
breast feed maintain consistent weight gain .
medication :
1 . iron sulfate ( 25 mg / ml elemental iron ) 0.2 cc po q day .
infant pass car seat oxygenation test .
State newborn screen send [ * * 4 - 21 * * ] [ * * 2185 - 5 - 1 * * ] .
infant yet receive immunization attempt
keep twin immunization schedule
twin yet reach 2 kg weight recommendation
first hepatitis B vaccine .
RECOMMENDED immunization :
1 . Synagis RSV prophylaxis consider [ * * Month ( ) 359 * * ]
[ * * Month ( ) 547 * * ] infant meet follow three
criterion : 1 ) bear less 32 week , 2 ) bear 32
35 week plan daycare RSV season ,
smoker household , preschool sibling , 3 )
chronic lung disease .
2 . influenza immunization consider annually
fall preterm infant chronic lung disease
reach six month age . age , family
caregiver consider immunization
influenza protect infant .
FOLLOW - appointment INFANT :
1 . [ * * hospital6 407 * * ] [ * * hospital3 * * ] , telephone
# 1-[**telephone / fax ( 1 ) 46331 * * ] .
2 . lactation consultant Learning Center [ * * hospital1 * * ] , telephone # [ * * telephone / Fax ( 1 ) 47507 * * ] .
discharge diagnosis :
1 . prematurity 34 - 2/7 week .
2 . twin # 2 .
3 . status post transitional respiratory distress .
4 . sepsis rule .
[ * * first Name8 ( NamePattern2 ) 36400 * * ] [ * * Name8 ( MD ) * * ] , M.D. [ * * MD Number(1 ) 37201 * * ]
dictate by:[**last Name ( NamePattern1 ) 37333 * * ]
medquist36
: [ * * 2185 - 5 - 2 * * ] 15:03
: [ * * 2185 - 5 - 2 * * ] 06:58
JOB # : [ * * Job number 49158 * * ]
|
[
"7742",
"V290"
] |
Admission Date : [ * * 2199 - 12 - 3 * * ] Discharge Date : [ * * 2199 - 12 - 19 * * ]
Date Birth : sex :
Service :
CHIEF COMPLAINT : Hypoxia
history PRESENT ILLNESS : 33 year old male
significant past medical history initially present
[ * * company 191 * * ] Outpatient Clinic [ * * 11 - 27 * * ] four day
high fever ( 103 degree F ) , nonproductive cough , malaise ,
diffuse myalgias , mild resting dyspnea , exposure ill
contact . [ * * 2199 - 11 - 27 * * ] vital sign office
temperature 99.5 , blood pressure 120/85 , heartrate 113
respiratory rate 20 , oxygen saturation 89 % room air .
Weight 238 lbs . nonspecific pulmonary examination
appreciate time . prescribe Levaquin 500 mg
p.o . q.d . discharge home . represent
outpatient [ * * Hospital 191 * * ] Clinic [ * * 2199 - 12 - 3 * * ] complain
persistent fever 102 degree f , weakness , bilious emesis ,
worsen dyspnea , nonproductive cough . vital sign
office temperature 97.3 , blood pressure 108/70 ,
respiratory rate 20 , heartrate 108 , oxygen saturation 70 %
room air . wheeze note examination .
give 1 gm Ceftriaxone send Emergency
Department receive normal saline 1 gm
Vancomycin . deny pleuritic chest pain . risk
factor human immunodeficiency virus . deny
history seizure disorder , alcohol use , recent somnolence ,
symptom gastroesophageal reflux disease .
transfer Intensive Care Unit arrival .
PAST MEDICAL history : significant past medical history
surgical history .
allergy : know drug allergy .
medication admission : Levofloxacin 500 mg p.o . q.d .
SOCIAL history : originally [ * * Male First Name ( un ) 1056 * * ] . bus driver ,
live wife daughter , alcohol , elicit drug
use . rare alcohol use .
FAMILY history : Father diabetes mellitus .
PHYSICAL EXAMINATION admission : General , moderately
obese , sit bed , accessory muscle use .
vital sign , temperature 99.0 , heartrate 92 , blood pressure
137/74 , respiratory rate 16 , oxygen saturation 100 % 100 %
nonrebreather .
Head , eye , ear , nose throat , pupil equal , round
reactive light , extraocular muscle intact , anicteric ,
oropharynx clear , fair dentition .
Neck , lymphadenopathy .
Chest , rhonchi , right great leave , crackle ,
wheeze . Normal e ratio , egophony , fremitus ,
dullness percussion .
Cardiac , regular rate rhythm , murmur , rub
gallop .
Abdomen , obese , normoactive bowel sound , nontender ,
nondistended , masse .
Neurological , cranial nerve II XII grossly intact .
alert oriented time three . Conversant appropriately .
Strength 5/5 extremity .
LABORATORY DATA : laboratory finding admission reveal
white blood cell count 8.4 , 73 % neutrophil , 0 band , 19
lymphocyte , 6 monocyte , hematocrit 43.8 , platelet 104 , MCV
83 , RDW 13.0 , sodium 137 , potassium 3.4 , chloride 92 ,
bicarbonate 29 , BUN 13 , creatinine 0.8 , glucose 129 .
arterial blood gas 100 % nonrebreather , PH 7.49 , carbon
dioxide 39 , oxygen 77 .
Imaging : [ * * 2199 - 11 - 27 * * ] , chest x - ray , normal , acute
cardiopulmonary process . Chest x - ray [ * * 2199 - 12 - 3 * * ] , (
admission ) , patchy right upper lobe , right middle lobe
infiltrate diffuse right great leave interstitial
pattern , normal mediastinum , effusion .
HOSPITAL COURSE : 33 year old male past medical
history originally admit Intensive Care Unit
hypoxia , bilateral pneumonia , receive Ceftriaxone
Azithromycin , Doxycycline add since
parakeet home ( also rat home ) . undergo
bronchoscopy compute tomographic angiography
thorax demonstrate right middle lobe right
low lobe pulmonary embolus question infarction .
subsequently heparinize . human immunodeficiency
virus test negative . receive Bactrim steroid
day stop human
immunodeficiency virus test come back negative .
hypercoagulability workup pende arrive
floor stable condition . arrival floor
clinically improve heparin drip , Ceftriaxone ,
Azithromycin , Doxycycline . study
obtain Intensive Care Unit include [ * * First Name8 ( NamePattern2 ) * * ] [ * * Doctor First Name * * ]
negative , ANCA negative , hepatitis
panel negative . LENIS demonstrate deep vein
thrombosis , thrombosis right lesser saphenous vein ,
echocardiogram obtain well [ * * 12 - 6 * * ] ,
demonstrate ejection fraction 50 % , mildly dilate
right ventricle mild tricuspid regurgitation . chest
computerized tomography scan mention [ * * 12 - 4 * * ] demonstrate multiple small pulmonary embolus
( right low lobe right middle lobe ) bilateral
atypical pneumonia . Workup organism say
pneumonia undertake . negative viral culture ,
negative Chlamydia , negative leptospirosis , negative C.
Psittaci negative mycoplasma . blood culture
negative well . maintain Azithromycin
complete 14 day course pneumonia . Doxycycline
withdraw . complete ten day course Ceftriaxone .
regard pulmonary embolus , remain hemodynamically
stable heparin drip throughout admission . repeat
computerized tomography scan thorax demonstrate
bilateral expand heterogenous soft tissue density within
rectus abdominis muscle ? hematoma , partial resolution
bilateral perihilar ground - glass opacity , leave SVC ,
however , pulmonary embolus . give discrepancy
[ * * 12 - 4 * * ] [ * * 12 - 11 * * ] , computerized tomography
scan , would difficult prove
pulmonary embolus [ * * 12 - 4 * * ] film . decision
anticoagulate three six month pursue
evaluation make . regard anticoagulation
workup , patient positive anticardiolipin IgM
( 46.9 ) . intermediate range value . IgG
anticardiolipin value 1.6 . patient normal ptt
admission . make diagnosis
anticardiolipin syndrome single value , finding
stand nonspecific , however , anticardiolipin panel
repeat six week . patient
subsequently continue anticoagulation pulmonary
embolus . heparin drip discontinue discharge
bridge Coumadin Lovenox . regard
rectus hematoma note computerized axial tomography scan ,
finding commonly see setting
anticoagulation . patient concurrently fever
maximally 101 degree F. concern perhaps
fever may attributable hematoma local
infection thereabout . start Clindamycin
conjunction infectious Disease Consult Service 's
recommendation . complete ten day course
Clindamycin .
finally , patient note drop
hematocrit anticoagulation . guaiac
negative . source bleed identify .
likely bleed abdominal hematoma attribute
drop hematocrit . patient also
intermittently hyponatremic stay , likely secondary
syndrome inappropriate antidiuretic hormone secondary
thoracic process ( namely bilateral pneumonia ,
pulmonary embolism ) admission .
discharge DIAGNOSIS :
1 . Bilobar pneumonia atypical fever
2 . Pulmonary embolus
3 . Rectus hematoma
4 . Anticardiolipin antibody igm positive
5 . Hyponatremia
6 . anemia
follow : patient follow primary
provider , [ * * last Name ( namepattern4 ) * * ] . [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] week follow discharge .
medication DISCHARGE : discharge Lovenox
bridge Coumadin . also discharge Clindamycin
complete ten day course .
[ * * Name6 ( MD ) 251 * * ] [ * * Name8 ( MD ) * * ] , M.D. [ * * MD Number(1 ) 1197 * * ]
Dictated By:[**Name8 ( MD ) 17844 * * ]
medquist36
: [ * * 2200 - 5 - 7 * * ] 17:14
: [ * * 2200 - 5 - 7 * * ] 19:08
JOB # : [ * * Job Number * * ]
|
[
"486",
"2761",
"2859"
] |
Admission Date : [ * * 2140 - 11 - 11 * * ] Discharge Date : [ * * 2140 - 11 - 24 * * ]
Service : cardiothoracic
history PRESENT ILLNESS : patient schedule
admission aortic aneurysm repair . 81 year old
woman history hypertension , recurrent
pericarditis pleuritis require percutaneous drainage
[ * * 2137 * * ] . echocardiogram [ * * 2137 - 12 - 13 * * ] , show normal left
ventricular function dilate aortic root 48 mm ,
mildly thicken aortic valve mild aortic regurgitation .
Follow - [ * * 2140 - 9 - 12 * * ] , echocardiogram show
ejection fraction 60 % dilate aortic root 55 mm ,
mild aortic sclerosis , mild aortic regurgitation ,
bilateral atrial enlargement . Cardiac catheterization do
[ * * 2140 - 10 - 26 * * ] , show ejection fraction 80 % normal
wall motion , severe aneurysmal dilatation ascending
aorta arch , recurrent dilatation descending
aorta dissection , 1 + aortic regurgitation , normal
coronary .
PAST MEDICAL history :
1 . Hypertension .
2 . Raynaud 's disease .
3 . Phlebitis .
4 . Osteoporosis .
5 . Tonsillectomy .
6 . spinal fusion .
7 . umbilical hernia repair .
8 . Appendectomy .
9 . Cholecystectomy .
10 . total abdominal hysterectomy .
medication admission :
1 . Metoprolol 100 mg twice day .
2 . hydrochlorothiazide 25 mg daily .
3 . Lisinopril 10 mg daily .
4 . Enteric Coated Aspirin 81 mg daily .
5 . Centrum Silver one daily .
6 . Calcium 600 daily .
7 . Nexium 40 mg daily .
allergy : state allergy Codeine cause bad
abdominal cramp adhesive tape cause rash .
SOCIAL history : patient live home husband .
[ * * Name ( NI ) 1139 * * ] one half pack per day time eighteen year , quit
forty - five year ago . Alcohol one drink per day , none time
past four week .
PHYSICAL EXAMINATION : time preadmission testing ,
heart rate 74 beat per minute , blood pressure 148/80 ,
respiratory rate 18 , oxygen saturation 96 % room air ,
height four foot eleven inch , weight 106 pound .
general , appear young state age acute
distress . skin - break rash . Head , eye , ear ,
nose throat - pupil equal , round , reactive
light accommodation . extraocular movement
intact . Pharynx clear . neck supple jugular
venous distention , bruit , carotid pulse 2 +
bilaterally . chest clear auscultation bilaterally .
heart regular rate rhythm , murmur , rub
gallop . abdoman soft , nontender , nondistended ,
positive bowel sound , hepatosplenomegaly , well heal
surgical scar . extremity without cyanosis , club
edema . leave upper extremity nodularity old
intravenous site near left wrist . varicosity
low extremity . neurologically , patient alert
orient time three , grossly intact . Pulses - femoral
indicate . Dorsalis pedi 1 + bilaterally . Posterior tibial
detect . Radial 2 + bilaterally . carotid bruit
bilaterally .
HOSPITAL COURSE : state previously , patient
direct admission operating room [ * * 2140 - 11 - 11 * * ] ,
time undergo supracoronary ascending aortic graft
resuspension aortic valve . please see
operative report full detail . patient tolerate
operation well transfer operating
room Cardiothoracic Intensive Care Unit . Circ arrest time
eleven minute . time transfer , patient
Milrinone 0.4 mcg / kg / minute , amiodarone 1 mg per
minute , Neo - Synephrine dose indicate Propofol , also
dose indicate . patient well immediate
postoperative period . anesthesia reverse .
wean ventilator . morning postoperative
day one , successfully extubate . postoperative
day number one , cardioactive medication begin
wean begin Amiodarone Milrinone .
postoperative day two , patient maintain
minimal amount Amiodarone , Milrinone Nipride .
postoperative day two , patient 's Milrinone
discontinue . amiodarone change p.o .
Nipride discontinue initiation beta blockade .
chest tube remove . maintain
Cardiothoracic Intensive Care Unit monitoring
hemodynamic pulmonary status . postoperative day
three , patient continue well . remain
hemodynamically stable . transfer
Cardiothoracic Intensive Care Unit [ * * Hospital Ward Name 121 * * ] two continue
postoperative care cardiac rehabilitation .
floor , note patient go sustain
atrial fibrillation heart rate 100 110 ,
hemodynamically tolerate well . see
electrophysiology service maintain p.o .
Lopressor well p.o . amiodarone continue
monitor floor . next two day , patient
atrial fibrillation . remain
hemodynamically stable throughout period .
postoperative day five , note patient
drop hematocrit guaiac positive stool .
see gastroenterology service . time ,
also transfer back Cardiothoracic Intensive Care
Unit close monitoring . patient undergo KUB
read normal . also stool send Clostridium
difficile negative . empirically start
Flagyl time . patient remain
Intensive Care Unit next several day monitor
gastrointestinal status make sure
guaiac positive stool . postoperative day seven ,
transfer floor continue postoperative
care . prior transfer Intensive Care Unit ,
note patient left upper extremity
swelling . undergo ultrasonography upper
extremity time rule thrombosis .
Ultrasound show right internal jugular cephalic
thrombus . follow transfer , vascular service
consult recommend oral anticoagulation
Coumadin , begin time . next
several day , exception intermittent atrial
fibrillation , patient uneventful hospital course .
see electrophysiology service give
episode atrial fibrillation , last episode last
great 24 hour . patient additionally begin
Heparin give duration episode atrial
fibrillation . patient schedule direct current
cardioversion , however , prior cardioversion , patient
spontaneously convert normal sinus rhythm .
postoperative day twelve , decide patient
remain rate control rhythm next 24 hour ,
would stable ready transfer
rehabilitation .
time dictation , patient 's physical
examination follow ; vital sign reveal temperature
98.2 , heart rate 71 , sinus rhythm , blood pressure 147/68 ,
respiratory rate 20 , oxygen saturation 98 % room air .
Weight preoperatively 50 kilogram transfer
rehabilitation 53 kilogram . laboratory datum [ * * 2140 - 11 - 23 * * ] ,
white blood cell count 11.7 , hematocrit 34.5 , platelet count
219,000 . Prothrombin time 15.0 , partial thromboplastin time
25.0 Heparin . INR 1.5 . Sodium 129 , potassium
4.8 , chloride 95 , CO2 29 , blood urea nitrogen 16 , creatinine
0.8 , glucose 183 . patient alert orient time
three , move extremity , follow command . Respiratory
reveal scatter rhonchi . Cardiac regular rate
rhythm murmur . sternum stable incision
Steri - strip open air , clean dry . abdoman
soft , nontender , nondistende positive bowel sound .
extremity warm well perfuse edema . right
upper arm minimal edema resolve
last several day .
medication DISCHARGE :
1 . Colace 100 mg p.o . twice day .
2 . amiodarone 200 mg p.o . three time day time one week
200 mg p.o . daily time one month .
3 . Metoprolol 100 mg twice day .
4 . Lasix 20 mg daily time ten day .
5 . Potassium Chloride 20 meq daily time ten day .
6 . Prilosec 40 mg p.o . daily .
7 . Heparin 600 unit per hour keep partial thromboplastin
time 40 60 INR therapeutic .
8 . warfarin maintain INR 2.0 2.5 .
patient receive 2 mg Coumadin two day prior discharge
Coumadin one day prior discharge 2 mg
Coumadin night discharge . check
INR morning dose Coumadin day transfer
rehabilitation center .
condition DISCHARGE : good .
discharge diagnosis :
1 . Status post supracoronary ascending aortic graft
resuspension aortic valve .
2 . Hypertension .
3 . Raynaud 's disease .
4 . Phlebitis .
5 . Osteoporosis .
6 . Status post tonsillectomy .
7 . Status post spinal fusion .
8 . Status post umbilical hernia repair .
9 . Status post inguinal hernia repair .
10 . status post appendectomy .
11 . status post cholecystectomy .
12 . status post total abdominal hysterectomy .
DISCHARGE STATUS : patient discharge [ * * Location 50742 * * ] .
fo[**last Name ( STitle ) * * ] p : follow - Dr. [ * * First Name ( STitle ) * * ] two
three week follow - Dr. [ * * last Name ( STitle ) 1159 * * ] one month
follow - Dr. [ * * last Name ( Prefixes ) * * ] one month .
[ * * Doctor Last Name 412 * * ] [ * * last Name ( Prefixes ) 413 * * ] , M.D. [ * * MD Number(1 ) 414 * * ]
Dictated By:[**Name8 ( MD ) 415 * * ]
medquist36
: [ * * 2140 - 11 - 23 * * ] 16:44
: [ * * 2140 - 11 - 23 * * ] 18:31
JOB # : [ * * Job Number 50743 * * ]
|
[
"4241",
"4019"
] |
Admission Date : [ * * 2164 - 4 - 23 * * ] Discharge Date : [ * * 2164 - 4 - 27 * * ]
Date Birth : [ * * 2096 - 1 - 7 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 1406 * * ]
Chief Complaint :
chest pain shortness breath
Major Surgical Invasive Procedure :
[ * * 2164 - 4 - 23 * * ] coronary artery bypass graft x3 left internal
mammary artery left anterior descend artery reverse
saphenous vein graft posterior descend artery
obtuse marginal artery .
history Present Illness :
68 year old male history mi 25 year ago .
treat medication since .
well year 3 week ago start
notice diaphoresis , shortness breath right side
chest discomfort occur exertion yard
work take trash . symptom resolve rest .
also one episode chest pain , diaphoresis back pain
occur rest large meal . episode last
little long episode prompt patient
contact Dr. [ * * last Name ( STitle ) 1270 * * ] . send stress echo
abnormal refer cardiac catheterization .
find three vessel disease refer
cardiac surgery revascularization .
Past Medical History :
diabete type II -diagnose [ * * 2160 * * ] ; control oral agent
hyperlipidemia
hypertension
MI [ * * 2138 * * ]
psoriasis
Social History :
race : caucasian
last Dental exam:[**1-/2164 * * ]
live : Wife
Contact:[**Name ( NI ) * * ] ( wife ) phone # [ * * telephone / Fax ( 1 ) 90854 * * ]
Occupation : retire FDA field investigator
consultant
cigarette : Smoked [ ] yes [ x ] Hx : smoke 2ppd 28 year
quit [ * * 2138 * * ]
Tobacco use : deny
ETOH : < 1 drink / week [ x ] [ * * 12 - 27 * * ] drink / week [ ] > 8 drink / week [ ]
Illicit drug use : deny
family history :
premature coronary artery disease- unknown - adopt
Physical Exam :
pulse:61 Resp:16 O2 sat:100 / RA
B / p Right:138/86 Left:135/74
Height:6'2 " Weight:230 lbs
General :
skin : Dry [ x ] intact [ x ]
HEENT : PERRLA [ x ] EOMI [ x ]
neck : Supple [ x ] full rom [ x ]
chest : lung clear bilaterally [ x ]
heart : rrr [ x ] Irregular [ ] Murmur [ ] grade _ _ _ _ _ _
abdoman : Soft [ x ] non - distended [ x ] non - tender [ x ] bowel sound
+ [ x ]
extremity : Warm [ x ] , well - perfuse [ x ] Edema [ x ] _ _ _ _ _
varicosity : ( L)LE superficial varicosities
Neuro : grossly intact [ x ]
pulse :
Femoral Right : leave :
dp Right:2 + Left:2 +
PT [ * * Name ( NI ) 167 * * ] : leave :
Radial right : leave :
Carotid Bruit -none appreciate , pulse Right:2 + Left:2 +
pertinent result :
[ * * 2164 - 4 - 23 * * ] echo : PRE - bypass : spontaneous echo contrast see
body left atrium leave atrial appendage . atrial
septal defect see 2D color Doppler . leave ventricular
wall thickness normal . left ventricular cavity size
top normal / borderline dilate . mild regional left
ventricular systolic dysfunction hypokinesis basal
distal inferoseptal anteroseptal wall . overall left
ventricular systolic function mildly depressed ( lvef= 50 - 55
% ) . right ventricular chamber size free wall motion
normal . simple atheroma aortic arch .
simple atheroma descending thoracic aorta . aortic
valve leaflet ( 3 ) appear structurally normal good leaflet
excursion aortic stenosis aortic regurgitation .
mitral valve leaflet mildly thicken . mild ( 1 + ) mitral
regurgitation see . pericardial effusion . Dr. [ * * last Name ( STitle ) * * ]
notify person result time surgery .
POST - BYPASS : patient sinus rhythm . patient
inotrope . biventricular function unchanged . mitral
regurgitation unchanged . aorta intact
post - decannulation .
[ * * 2164 - 4 - 27 * * ] 04:44AM blood WBC-11.7 * RBC-3.00 * Hgb-9.8 * hct-28.3 *
MCV-94 MCH-32.5 * MCHC-34.5 RDW-14.0 Plt ct-323
[ * * 2164 - 4 - 27 * * ] 04:44AM blood Plt ct-323
[ * * 2164 - 4 - 27 * * ] 04:44AM blood Glucose-121 * UreaN-22 * Creat-1.0 Na-139
K-3.8 Cl-102 HCO3 - 28 angap-13
[ * * 2164 - 4 - 27 * * ] 04:44AM blood mg-2.3
comparison : [ * * 2164 - 4 - 25 * * ] 10:45 a.m.
finding : note previously , similar - sized left
apical
pneumothorax . left chest tube remove
interim . leave
basilar atelectasis remain . cardiac silhouette
mediastinal contour
unchanged . median sternotomy wire unchanged .
IMPRESSION :
unchanged small leave apical pneumothorax , status post leave chest
tube removal .
Brief Hospital course :
Mr. [ * * know lastname * * ] 68 yr old male history MI develop
worsen chest pain , underwent cath reveal significnat
CAD . see cardiac surgery service accept
CABG . day admit [ * * 4 - 23 * * ] bring directly
operating room undergo coronary artery bypass
graft x 3 . please see operative note surgical detail .
follow surgery transfer CVICU invasive
monitoring stable condition . later day wean
sedation , awake neurologically intact extubate .
wean Neo overnight start beta - blocker POD#1 .
diurese towards preoperative weight . POD#1
transfer step unit monitoring .
continue progress well floor . Physical Therapy
consult evaluation strength mobility .
remainder postop course essentially uneventful .
clear discharge home vna service POD#4 .
follow - appt arrange .
medication admission :
ATENOLOL 50 mg Daily
lipitor 20 mg Daily
PLAVIX 75 mg Daily ( start [ * * 2164 - 4 - 14 * * ] ) , LD [ * * 4 - 17 * * ]
DILTIAZEM HCL 240 mg Daily
ENALAPRIL MALEATE take 10 mg qam , 5 mg qhs
HYDROCHLOROTHIAZIDE 25 mg Daily
METFORMIN 1,000 mg [ * * hospital1 * * ]
NITROGLYCERIN 0.4 mg Tablet PRN
Aspirin 325 mg Daily
Centrum Silver Multivitamin 1 tablet daily
Discharge medication :
1 . potassium chloride 10 meq Tablet Extended Release Sig : two
( 2 ) Tablet Extended Release po day 2 week .
Disp:*60 Tablet Extended release(s ) * Refills:*2 *
2 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
Disp:*60 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
3 . atorvastatin 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
Disp:*60 Tablet(s ) * Refills:*2 *
4 . tramadol 50 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need pain .
Disp:*40 Tablet(s ) * Refills:*0 *
5 . fluticasone 50 mcg / actuation Spray , Suspension Sig : two ( 2 )
Spray Nasal DAILY ( Daily ) .
Disp:*1 * Refills:*2 *
6 . metoprolol tartrate 50 mg Tablet Sig : one ( 1 ) Tablet PO TID
( 3 time day ) .
Disp:*90 Tablet(s ) * Refills:*2 *
7 . metformin 500 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
disp:*120 Tablet(s ) * Refills:*2 *
8 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
Disp:*60 Capsule(s ) * Refills:*2 *
9 . Lasix 40 mg Tablet Sig : one ( 1 ) Tablet po day 2
week .
Disp:*14 Tablet(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
[ * * Location ( un ) 86 * * ] VNA
Discharge Diagnosis :
Coronary artery disease / p Coronary artery bypass graft x 3
past medical history :
diabete type II -diagnose [ * * 2160 * * ] ; control oral agent
hyperlipidemia
hypertension
MI [ * * 2138 * * ]
psoriasis
discharge condition :
alert orient x3 nonfocal
ambulate steady gait
incisional pain manage oral analgesia
incision :
Sternal - heal well , erythema drainage
Leg Right / left - heal well , erythema drainage .
Edema
discharge instruction :
please shower daily include wash incision gently mild
soap , bath swimming clear surgeon . look
incision daily redness drainage
please lotion , cream , powder , ointment incision
morning weigh evening
take temperature , write chart
drive approximately one month take
narcotic , discuss follow appointment
surgeon able drive
lifting 10 pound 10 week
please call question concern [ * * telephone / Fax ( 1 ) 170 * * ]
female : please wear bra reduce pull incision , avoid
rub low edge
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
Followup Instructions :
schedule follow appointment
Wound Check : [ * * 2164 - 5 - 8 * * ] 10:00
surgeon : Dr. [ * * last Name ( STitle ) * * ] [ * * 2164 - 5 - 31 * * ] @ 1 pm
Cardiologist / PCP : [ * * last Name ( namepattern4 ) * * ] . [ * * last Name ( STitle ) 1270 * * ] [ * * telephone / Fax ( 1 ) 1144 * * ]
Date / time:[**2164 - 5 - 15 * * ] 10:30
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
complete by:[**2164 - 4 - 27 * * ]
|
[
"2724",
"4019",
"412"
] |
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