TEXT
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| ICD9_CODE
list |
|---|---|
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"
] |
Admission Date : [ * * 2115 - 2 - 22 * * ] Discharge Date : [ * * 2115 - 3 - 19 * * ]
Date Birth : [ * * 2078 - 8 - 9 * * ] sex :
Service : MEDICINE
allergy :
Vicodin
attending:[**first Name3 ( LF ) 4891 * * ]
Chief Complaint :
post - cardiac arrest , asthma exacerbation
Major Surgical Invasive Procedure :
Intubation
Removal chest tube place outside hospital
R CVL placement
history Present Illness :
Mr. [ * * know lastname 3234 * * ] 36 year old gentleman PMH signifciant
dilate cardiomyopathy / p AICD , asthma , HTN admit
OSH dyspnea admit MICU PEA arrest
x2 . patient initially present LGH ED hypoxemic
respiratory distress . OSH , receive CTX ,
azithromycin , SC epinephrine , solumedrol . OSH ,
become confused subsequently episode PEA arrest
intubate . receive epinephrine , atropine , magnesium ,
bicarb . addition , bilateral needle thoracostomie
report air return left , subsequently
bilateral chest tube place . approximately 15 - 20 minute
rescucitation , ROSC . receive vecuronium
start epi gtt asthma cool protocol ,
transfer [ * * Hospital1 18 * * ] evaluation . note ,
patient admit LGH [ * * 1 - 4 * * ] dyspnea ,
subsequently diagnose CAP asthma treat CTX
azithromycin . per family , also multiple
admission winter asthma exacerbation .
.
[ * * Hospital1 18 * * ] ED , 35.3 102 133/58 100%ac 500x20 , 5 , 1.0
ABG 7.16/66/162 . cth unremarkable .
CTA chest , afterwhich go PEA arrest .
Rescucitation last approximately 10 - 15 minute multiple
round epi bicarb , ROSC . admit
MICU management .
.
currently , patient intubate , sedate , parlyze .
Past Medical history :
Asthma
dilate cardiomyopathy
multiple admission dyspnea winter ( [ * * 1 - 26 * * ] ) .
Anxiety / depression
CKD
HLD
Obesity
HTN
Social History :
unknown
Family history :
unknown
Physical Exam :
admission :
VS : 35.9 124 129/67 99 % AC 480x24 , 5 , 1.0
Gen : ett place , intubate , sedate .
HEENT : ett place .
CV : tachy s1+s2
Pulm : poor air movement bilaterally . Diffuse wheeze
bilaterally .
Abd : / hypoactive BS
Ext : 1 + edema bilaterally
Neuro : unresponsive .
.
discharge : 98.5 102/65 76 20 95 - 98 % RA
cage bed prevent patient fall bed .
occasionally call . lung clear without wheeze .
pertinent result :
Labs Admission :
[ * * 2115 - 2 - 22 * * ] 08:50AM blood WBC-19.5 * RBC-4.76 Hgb-14.9 Hct-44.3
MCV-93 MCH-31.4 MCHC-33.7 rdw-12.9 Plt ct-201
[ * * 2115 - 2 - 22 * * ] 08:50AM blood pt-14.1 * PTT-25.9 INR(PT)-1.2 *
[ * * 2115 - 2 - 22 * * ] 08:50AM blood glucose-306 * UreaN-21 * creat-1.2 na-144
K-4.1 cl-111 * HCO3 - 28 angap-9
[ * * 2115 - 2 - 22 * * ] 08:50AM blood albumin-3.4 * Calcium-6.2 * Phos-5.5 *
Mg-2.2
[ * * 2115 - 2 - 22 * * ] 09:32AM blood caltibc-320 Ferritn-1129 * TRF-246
[ * * 2115 - 2 - 22 * * ] 07:17AM blood Type - ART pO2 - 162 * pco2 - 66 * ph-7.16 *
calTCO2 - 25 Base XS--6 Intubat - intubate
.
Labs Discharge
[ * * 2115 - 3 - 18 * * ] 11:34AM blood Type - art pO2 - 95 pco2 - 33 * pH-7.54 *
calTCO2 - 29 Base xs-5 Intubat - INTUBA
[ * * 2115 - 3 - 5 * * ] 05:35AM blood ALT-49 * ast-23 alkphos-53 totbili-0.9
[ * * 2115 - 3 - 19 * * ] 04:45am blood Glucose-73 UreaN-25 * Creat-1.4 * Na-133
K-4.1 cl-95 * HCO3 - 21 * AnGap-21 *
[ * * 2115 - 3 - 19 * * ] 04:45am blood WBC-12.4 * RBC-4.47 * Hgb-14.3 Hct-41.3
MCV-93 MCH-32.0 mchc-34.6 RDW-13.3 Plt ct-352
[ * * 2115 - 3 - 19 * * ] 04:45am blood Neuts-56 Bands-0 Lymphs-38 Monos-3 eos-3
baso-0 Atyps-0 Metas-0 Myelos-0
.
CXR ( MICU ): Mr read - cardiomegaly , RIJ SVC , ETT 4.5 cm
carina . blunt costophrenic angle bilaterally
low lung volume . loss retrocardiac diagphragm bilateral
opacity ( l > R )
.
CXR :
1 . NG tube 7.2 cm carina . [ * * Month ( ) 116 * * ] consider advance
optimal placement .
2 . severe cardiomegaly globular shape . absence
prior
comparison , differential broad , include moderate
pericardial
effusion , mediastinal hemorrhage , acute cardiac failure .
recommend
clinical correlation .
.
CTH : read , acute bleed
.
CTA Chest :
1 . evidence pulmonary embolism , although evaluation
subsegmental branch limited .
2 . moderate cardiomegaly without pericardial effusion .
3 . bilateral dependent atelectasis .
4 . multiple nondisplace rib fracture right ,
subacute . also possible subtle nondisplace fracture
left rib .
5 . nondisplace acute sternal fracture addition subacute
nondisplace sternal fracture .
.
TTE : left atrium moderately dilate . estimate right
atrial pressure 10 - 20mmhg . leave ventricular wall thickness
normal . left ventricular cavity severely dilate . LV
systolic function appear depressed ( ejection fraction ? 30
percent ) regional variation . considerable
beat - - beat variability left ventricular ejection
fraction due irregular rhythm / premature beat . right
ventricular free wall thickness normal . right ventricular
cavity dilate depressed free wall contractility .
aortic root mildly dilate sinus level . ascending
aorta mildly dilate . aortic valve leaflet ( 3 ) appear
structurally normal good leaflet excursion aortic
stenosis aortic regurgitation . mitral valve leaflet
structurally normal . mitral valve prolapse . mild
( 1 + ) mitral regurgitation see . pulmonary artery systolic
pressure could determine . pericardial
effusion .
.
ECG ( post - arr ): Sinus 1:1 conduction . LAA . LAD , RBBB ,
LAFB . std V4 - V6 .
.
ECG ( pre - arr ): sinus 1:1 conduction . LAD , bifascicular
block . lateral std .
.
ECG ( OSH , unclear pre / post arrest ): sinus 1:1 conduction .
Bifascicular ( RBBB , LAFB ) block . std V5 - 6 .
.
EEG [ * * 2 - 27 * * ]
impression : abnormal video EEG telemetry due
slow
disorganized background 6.5 Hz burst generalize
slowing
show clear reactivity . finding indicate
severe
encephalopathy . may consistent patient 's
history
anoxia ; however , toxic / metabolic disturbance , infection ,
medication
effect also among frequent cause
encephalopathy .
clear epileptiform discharge seizure see .
LUMBAR SPINE [ * * 2115 - 3 - 11 * * ]
CLINICAL information : evidence fracture , seizure , fall , low
back pain .
finding :
three view lumbar spine demonstrate mild narrowing
left
femoroacetabular joint . mild scoliosis
thoracolumbar spine . ventricular lead pacemaker
identify . fracture l2 L5 identify . however ,
compression fracture L1 , compression
superior endplate , sclerotic fracture line . give
mechanism fall , acute pain referable L1 ,
would consider acute finding . apparent
retropulsion posterior margin l1 spinal
canal . fracture identify time . Facet
joint align . early calcification aorta .
IMPRESSION : compression fracture L1 anterior wedge
deformity , likely acute finding . fracture
identify .
EKG : normal sinus rhythm . complete right bundle - branch block
leave anterior fascicular block . Diffuse ST - wave change
laterally .
CT Head :
comparison : [ * * 2115 - 2 - 22 * * ] .
TECHNIQUE : non - contrast axial image obtain
brain .
finding : intracranial hemorrhage , edema , loss
[ * * Doctor Last Name 352**]/white matter differentiation . ventricle sulci
normal size configuration . basilar cistern
compress . paranasal sinus demonstrate fluid sphenoid
air cell right posterior ethmoid air cell , likely relate
prolong hospitalization . Mastoid air cell well
aerate .
impression : evidence acute intracranial abnormality .
Brief Hospital course :
Mr. [ * * know lastname 3234 * * ] 36 year old gentleman PMH signifciant
dilate cardiomyopathy / p AICD , PE anticoagulation ,
asthma , HTN admit OSH dyspnea
transfer [ * * Hospital1 18 * * ] MICU PEA arrest x2 .
# PEA arrest subsequent anoxic brain injury . : suspect
original OSH PEA arrest due hypoxemia acidosis , [ * * Hospital1 18 * * ]
ED PEA arrest due acidosis admission ph 7.16 arrival .
tte evidence RV failure suggest PE . LVEF 30 %
know dilate cardiomyopathy . cool per protocol .
initially , EEG concern without evident brain
activity . hospital day 3 , comatose activity
prognosis guard . however , patient able
wean vent course next three
day mental status improve . alert , orient
place day week move 4 extremity .
become interactive transfer floor , initially
speak spanish English always make sense
start respond appropiately follow
command . hospital day 11 witness grand mal
seizure give ativan start Keppra
neurology consult . mental status bad 24 hour
seizure slowly return recent
baseline . somewhat aggitated Keppra switch
Topiramate . subsequent seizure [ * * 3 - 18 * * ] LUE
tonic clonic activity impaired consciousness
resolve spontaneously 1 - 2 minute . contineud
topamax per neuro recommendation . OT PT consult
work patient likely require long
rehabilitation course . time discharge patient
alert , orient ( though always date ) , follow command
impulsive poor motor planning lead several fall .
Neurology note indicate patient potential
toimprove neurologic standpoint . also may
recurrent seizure treat ativan IV IM
neccessarily indicate patient need return
hospital unless continue great 5 minute
multiple recurrent seizure complication
aspiration .
-patient Topiramate 25 mg po BID [ * * 3 - 22 * * ] pm
increase 50 mg po BID seven day increase 75 mg [ * * hospital1 * * ]
ongoing .
-patient follow Dr. [ * * last Name ( STitle ) * * ] [ * * Name ( STitle ) * * ] / p
arrest neurology clinic
-patient require intensive PT OT anoxic brain
injury unit .
.
# respiratory failure : believe due status asthmaticus ,
although incite event unclear . [ * * name2 ( NI ) 227 * * ] multiple cardiac arrest ,
also concern development ARDS . patient
initially treat broadly vancomycin , cefepime , flagyl ,
cipro , oseltamavir . treat IV soludemedrol
albuterol MDI . ventialte accord ards - net protocol .
admission , two chest tube place pneumothorace .
remove hospital day 1 . first several day ,
respiratory status comprimise lobar collapse , first
RUL rml . extubation initially
limit agitation require sedation requirement
high PEEP maintain oxygenation . oxygenation
improve diuresis agitation well control
seroquel . extubate [ * * 3 - 1 * * ] respiratory status
stable . Asthma treat standing PRN albuterol
ipratriopium slow prednisone taper l
complete [ * * 2115 - 3 - 18 * * ] restart Advair
-patient may require additional nebs top standing
advair though respiratory status stable ,
without wheeze last week .
- would like benefit outpatient pft schedule
see pulmonologist follow .
.
# Ventilator associate pneumonia : Patient develop fever
[ * * 2 - 27 * * ] new infiltrate chest xray intubate .
initially cover vanc / cefepime cipro . Cipro
eventually discontinue . grow organism
yeast sputum . complete 8 day course
Vanco / Cefepime .
.
# Myoclonus : mental status improve , note
myoclonic jerk . per neurology , likely [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 1683 * * ] Syndrome
anoxic injury purkinje cell . jerk
continue one week become rare .
.
# dilate [ * * last Name ( LF ) 89982 * * ] , [ * * first Name3 ( LF ) * * ] 30 % . / p ICD . Patient
diurese IV lasix ED transition po
lasix , home dose , floor . respiratory status remain
stable . also continue home dose carvedilol Lisinopril
ACE downtitrate 40 20 elevate Cr 1.9
[ * * 3 - 18 * * ] slightly low bp high 90s/60s . BP improve 100s/60s .
.
# hypertension : Patient 's home regimen continue
floor , SBP dip high 80 low 90
lisinopril decrease 20 mg po daily SBP remain
100 - 130 .
.
# l1 compression fracture : patient fall ,
complain low back pain l - spine Xray perform
show L1 compressin fracture cord impingement
imaging . patient localize deficit serial neuro
exam . treat pain medication include low dose
ultram , stand tylenol lidocaine patch . Calcitonin
try pain compression fracture seem
help symptom discontinue .
.
# leukocytosis : WBC > 20 persistently MICU even
treat infection . since new infection find
presume [ * * 12 - 26 * * ] steroid leukocytosis improve
prednisone taper . WBC 12 day discharge
.
# hyperglycemia : Patient know diabetic
feel [ * * 12 - 26 * * ] steroid , sugar control slide scale
insulin hospital long insulin
requirement prednisone taper .
.
# . [ * * last Name ( un ) * * ] : Cr 1.9 [ * * 3 - 18 * * ] 1.2 improve 1.4 [ * * 3 - 19 * * ]
decrease ACE 500cc bolus . repeat
creatinine lab [ * * 3 - 22 * * ] ensure stability .
# guardianship : guardianship paperwork start
hospital .
medication admission :
Carvedilol 25 [ * * hospital1 * * ]
Lasix 80 mg po bid
Xanax 0.25 mg 1 - 2 tab prn
albuterol MDI
Ibuprofen prn
Benadryl prn
Advair diskus
Lsinopril 40 daily
Discharge medication :
1 . bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need
Constipation .
2 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need Constipation .
3 . acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q6H ( every
6 hour ) need pain / fever .
4 . carvedilol 12.5 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
5 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
6 . furosemide 40 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
7 . lisinopril 10 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ) .
8 . olanzapine 5 mg Tablet , Rapid Dissolve Sig : [ * * 11 - 25 * * ] Tablet , Rapid
Dissolves po QHS ( day ( bedtime ) ) need sleep .
9 . calcium carbonate 200 mg ( 500 mg ) Tablet , Chewable Sig : one
( 1 ) Tablet , Chewable po BID ( 2 time day ) .
10 . cholecalciferol ( vitamin D3 ) 400 unit Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) .
11 . acetaminophen 500 mg Tablet Sig : two ( 2 ) Tablet PO TID ( 3
time day ) need pain / fever .
12 . lidocaine 5 % ( 700 mg / patch ) Adhesive Patch , Medicated Sig :
one ( 1 ) Adhesive Patch , Medicated Topical DAILY ( Daily ): 12
hour 12 hour every 24 hour period .
13 . ipratropium bromide 0.02 % solution Sig : one ( 1 ) neb
Inhalation every six ( 6 ) hour .
14 . albuterol sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) neb Inhalation every six ( 6 ) hour .
15 . albuterol sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) neb Inhalation Q2H ( every 2 hour )
need SOB .
16 . topiramate 25 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) 3 day : 1 [ * * hospital1 * * ] [ * * 3 - 22 * * ] pm increase 2
tablet [ * * hospital1 * * ] 7 day 3 tablet [ * * hospital1 * * ] ongoing .
17 . tramadol 50 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need back pain .
18 . fluticasone - salmeterol 250 - 50 mcg / dose Disk Device Sig :
one ( 1 ) inh Inhalation [ * * hospital1 * * ] ( 2 time day ) .
19 . lorazepam 2 mg / mL Syringe Sig : 1 - 2 mg injection twice day
need seizure last long 5 minute .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 979 * * ] - [ * * Location ( un ) 246 * * ]
discharge diagnosis :
Anoxic Brain Injury / p PEA arrest x2
Status Asthmaticus
Ventilator Associated Pneumonia
Chronic Systolic Heart Failure
L1 compression fracture
seizure hypoxic brain injury
Discharge condition :
Mental Status : Confused - sometimes .
Level consciousness : alert interactive .
Activity Status : ambulatory - require assistance aid ( walker
cane ) poor motor planning
Discharge instruction :
come hospital cardiac arrest
asthma exacerbation . another cardiac arrest
hospital admit MICU . require intubation
able wean machine breathe .
treat pneumonia asthma . mental status
slowly improve , though 2 seizure , last [ * * 3 - 18 * * ] .
start ons eizure medication .
.
please take medication prescribe follow
doctor [ * * name5 ( PTitle ) 7928 * * ] .
Followup Instructions :
Department : PULMONARY FUNCTION LAB
: WEDNESDAY [ * * 2115 - 4 - 3 * * ] 1:10 pm
: PULMONARY FUNCTION LAB [ * * telephone / Fax ( 1 ) 609 * * ]
building : [ * * hospital6 29 * * ] [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : MEDICAL specialty
: WEDNESDAY [ * * 2115 - 4 - 3 * * ] 1:30 pm
: DR [ * * last Name ( STitle ) * * ] /DR [ * * last Name ( STitle ) * * ] [ * * telephone / Fax ( 1 ) 612 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : COGNITIVE NEUROLOGY unit
: THURSDAY [ * * 2115 - 4 - 11 * * ] 1 pm
: [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 6403 * * ] , MD [ * * telephone / Fax ( 1 ) 1690 * * ]
building : Ks [ * * Hospital Ward Name 860 * * ] building ( [ * * Hospital Ward Name 1826**]/[**hospital Ward Name 1827 * * ] Complex ) [ * * Location ( un ) * * ]
campus : EAST good parking : Main Garage
|
[
"4275",
"4254",
"5849",
"2762",
"2760",
"5180",
"5859",
"4280"
] |
Admission Date : [ * * 2187 - 7 - 13 * * ] Discharge Date : [ * * 2187 - 7 - 23 * * ]
Date Birth : [ * * 2104 - 8 - 30 * * ] sex : F
Service : CARDIOTHORACIC
allergy :
Penicillin V / Methyldopa
attending:[**first Name3 ( LF ) 165 * * ]
Chief Complaint :
general malaise
Major Surgical Invasive Procedure :
dental extraction [ * * 2187 - 7 - 15 * * ]
redo sternotomy / AVR ( # 19 CE Magna)-[**2187 - 7 - 17 * * ]
history Present Illness :
82 yo F / p CABG [ * * 2177 * * ] severe recent NSTEMI ,
preop [ * * Hospital 1291 * * ] transfer [ * * hospital3 * * ] SOB ,
recurrent pulmonary edema .
Past Medical History :
right carotid endarterectomy
CABG [ * * hospital6 * * ] [ * * 2181 * * ] ( LIMA LAD , SVG RCA ,
SVG first diagonal , SVG OM2 )
NSTEMI [ * * 2187 - 5 - 1 * * ]
Renal insufficiency ( baseline creatinine 1.5 )
Hypertension
Severe Aortic stenosis
Dementia
Peripheral Vascular Disease
Anemia ( baseline hematocrit 32 - 34 )
Social History :
social history significant absence current tobacco
use . history alcohol abuse .
Family history :
mother die heart attack age 61 . dad die
cva age 47 . sister diabete . son
pass away . six miscarriage .
Physical Exam :
hr 64 RR 20 BP 129/44
NAD
Lungs scatter rale
Heart rrr 3/6 SEM radiate neck
Extrem warm
62 " 72 kg
pertinent result :
[ * * Hospital1 18 * * ] echocardiography REPORT
GENERAL comment : tee perform location list
. certify present compliance HCFA
regulation . patient general anesthesia throughout
procedure . tee relate complication . rest bradycardia
patient . see conclusion post - bypass datum
post - bypass study perform patient receive
vasoactive infusion ( see Conclusions list
medication ) .
Conclusions
PRE - BYPASS :
1 . left atrium dilate . mild spontaneous echo contrast
see body left atrium . left atrial appendage
thrombus exclude . atrial septal defect patent
foraman ovale see 2D , color Doppler saline contrast
maneuver .
2 . mild symmetric left ventricular hypertrophy .
leave ventricular cavity size normal . overall left ventricular
systolic function low normal ( LVEF 50 - 55 % ) .
3 . right ventricular chamber size free wall motion
normal .
4 . simple atheroma ascending aorta .
complex ( > 4 mm ) atheroma aortic arch . complex
( > 4 mm ) atheroma descending thoracic aorta .
5 . three aortic valve leaflet . aortic valve
leaflet severely thicken / deform . severe aortic
valve stenosis ( area 0.5 cm2 ) . aortic regurgitation see .
6 . mitral valve leaflet mildly thicken . mild ( 1 + )
mitral regurgitation see .
7 . small left pleural effusion .
Dr. [ * * last Name ( STitle ) * * ] notify person result
.
POST - BYPASS :
post - bypass study , patient receive vasoactive
infusion include phenylephrine AV paced .
1 . well - seat bioprosthetic valve see mitral
position normal leaflet motion gradient ( mean gradient
= 11 mmHg cardiac output 2.6 L / min ) . trivial central
aortic regurgitation see .
2 . regional global left ventricular systolic function
normal .
3 . right ventricular systolic function post - bypass moderately
hypokinetic .
4 . intra - atrial septum dynamic .
5 . aortic contour intact post - decannulation .
[ * * know lastname * * ] , [ * * know firstname 24357 * * ] L [ * * Medical Record Number 41597 * * ] F 82 [ * * 2104 - 8 - 30 * * ]
Radiology Report CHEST ( PORTABLE AP ) Study Date [ * * 2187 - 7 - 19 * * ] 2:14
pm
[ * * last Name ( LF ) * * ] , [ * * first Name3 ( LF ) * * ] csurg CSRU [ * * 2187 - 7 - 19 * * ] SCHED
CHEST ( portable AP ) clip # [ * * Clip Number ( Radiology ) 41598 * * ]
Reason : ? ptx / p ct removal
[ * * Hospital 93 * * ] MEDICAL condition :
82 year old woman / p cabg
reason examination :
? ptx / p ct removal
Final Report
study : single portable AP chest radiograph .
INDICATION : 82 - year - old female status post CABG chest tube
removal .
comparison : [ * * 2187 - 7 - 18 * * ] .
finding : Patient extubate removal right
basilar chest tube
Swan - Ganz catheter / NG tube . atelectasis left low
lobe
improve . small leave pleural effusion remain . upper lung
remain clear .
bilateral subclavian artery calcification note .
median sternotomy
wire remain stable condition .
IMPRESSION :
1 . interval removal multiple line tube without
pneumothorax .
2 . improvement left low lobe atelectasis .
3 . residual small leave pleural effusion .
study report review staff radiologist .
DR . [ * * First Name ( STitle ) * * ] [ * * Doctor Last Name 4391 * * ]
DR . [ * * First Name11 ( Name Pattern1 ) * * ] [ * * initial ( NamePattern1 ) * * ] [ * * last Name ( namepattern4 ) 5785 * * ]
approve : [ * * Doctor First Name * * ] [ * * 2187 - 7 - 19 * * ] 4:49 pm
Imaging Lab
Brief Hospital Course :
admit cardiac surgery . dental consult call
tooth extraction recommend . [ * * 7 - 15 * * ] 5 tooth
extract . [ * * 7 - 17 * * ] take operating room [ * * 7 - 17 * * ]
undergo redo sternotomy AVR .
transfer ICU stable condition . extubate
POD # 1 . chest tube remove transfer floor
POD # 2 begin increase activity level . gently
diurese toward preop weight . beta blockade titrate .
Pacing wire remove POD # 3.she several episode fib
coumadin start . Target INR 2.0 - 2.5 . continue
make good progress clear discharge rehab POD
# 6 . Pt . make followup appt . per discharge
instruction .
medication admission :
ASA 325 , lopressor 25 " , lipitor 10 , lovenox 40 , norvasc 5 ,
diovan 160,acidophilus [ * * hospital1 * * ]
Discharge medication :
1 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : 1 - 2 tablet po
every 4 - 6 hour need pain .
2 . ranitidine HCl 150 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
3 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
4 . Atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
5 . Metoprolol Tartrate 25 mg Tablet Sig : one ( 1 ) Tablet PO TID
( 3 time day ) .
6 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
7 . furosemide 20 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
8 . Metoprolol Tartrate 25 mg Tablet Sig : 0.5 Tablet po TID ( 3
time day ) .
9 . Enoxaparin 60 mg/0.6 mL Syringe Sig : Sixty ( 60 ) unit SC
Subcutaneous day .
10 . warfarin 3 mg Tablet Sig : one ( 1 ) Tablet po ( )
1 dose : 3 mg today [ * * 7 - 23 * * ] ; dose per rehab
provider;target INR 2.0 - 2.5 .
11 . Potassium Chloride 20 meq Packet Sig : one ( 1 ) packet PO BID
( 2 time day ): hold K > 4.8.[**Month ( ) 116 * * ] DC lasix stop .
discharge Disposition :
Extended Care
Facility :
tba
discharge Diagnosis :
/ p AVR
R CEA , CABG [ * * hospital6 * * ] [ * * 2181 * * ] ( LIMA LAD , SVG
RCA , SVG first diagonal , SVG OM2 ) , NSTEMI [ * * Month ( ) 547 * * ]
[ * * 2187 * * ] , Renal insufficiency ( baseline creatinine 1.5 ) ,
Hypertension , Severe , dementia , PVD , Anemia ( baseline
hematocrit 32 - 34 ) ; postop Fib
discharge condition :
Stable .
Discharge instruction :
call fever , redness drainage incision weight
gain 2 pound one day five one week .
Shower , bath , lotion , cream powder incision .
lifting 10 pound .
driving follow surgeon least one month .
Followup Instructions :
Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 10543 * * ] 2 week
Dr. [ * * First Name ( STitle ) * * ] 4 week [ * * telephone / Fax ( 1 ) 170 * * ]
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 173 * * ]
complete by:[**2187 - 7 - 23 * * ]
|
[
"4241",
"9971",
"2762",
"4280",
"5859",
"4439"
] |
Admission Date : [ * * 2183 - 3 - 23 * * ] Discharge Date : [ * * 2183 - 5 - 9 * * ]
Date Birth : [ * * 2124 - 10 - 29 * * ] sex :
Service : MEDICINE
allergy :
penicillin
attending:[**first Name3 ( LF ) 7591 * * ]
Chief Complaint :
weakness
Major Surgical Invasive Procedure :
bone marrow biopsy
history Present Illness :
58 / present [ * * hospital1 * * ] [ * * Location ( un ) 620 * * ] syncopal episode today
sustain facial hematoma . Pt remember go
bathroom early morning awake floor approx
2hrs laterwith left side facial bruising incontinence . Pt
report severe
nosebleed begin 2 day prior admission . saturday ,
feel lightheaded developpe severe right thigh
pain . Sunday , notice decrease appetite , leave thigh pain
fever / chill . review symptom , pt
noticing increase bruise general lethargy last
week . per report , wife try get see [ * * Name8 ( MD ) * * ]
MD month concern generalize
weakness .
.
Pt initially present [ * * hospital1 * * ] [ * * Location ( un ) * * ] febrile 101.2
receive Vanc Ceftazidime neutropenic fever .
undergo head CT reveal small foci petechial
hemorrhage within left frontal lobe small subarachnoid
hemorrhage .
initial VS arrival [ * * Hospital1 18 * * ] ed : 100.4 p 76 bp 110/55 r
18 O2 sit 99 % RA . Pt give Acyclovir possible Zoster .
undergo CTA negative PE receive 2L NS
IVF . Pt transfuse second bag plt prior
arrival ICU .
.
arrival , pt complain right & leave proximal thigh
pain approx [ * * 8 - 22 * * ] . otherwise , deny CP , SOB , HA , abd pain ,
nausea , visual change . feel exhausted still
mildly lightheaded .
Past Medical History :
Osteoarthritis ( knee )
Social History :
Pt work headmaster [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 1573 * * ] school . live
wife two healthy child , three grandchild . use
marathon runner . deny smoking illicit drug use .
report consume approx 1 drink per day .
Family history :
Father die metastatic prostate cancer 80 , mother
alive HTN insulin resistance .
Physical Exam :
vital : : 98.6 bp : 137/73 p : 83 r : 20 O2 : 975 RA
General : alert , oriented , large ecchymosis left orbit , eye
swollen shut
HEENT : sclera anicteric , dry MM , oropharynx dry blood
Neck : supple , JVP elevate , precervical lymphadenopathy
lung : clear auscultation bilaterally , wheeze , rale ,
ronchi
CV : RRR , normal S1 / S2 , / r / g
Abdomen : soft , NT , ND , NABS , rebound tenderness guarding ,
appreciable hepatosplenomegaly
Inguinal : inguinal lymphadenopathy
Ext : warm , well perfuse , 2 + pulse
Neuro : CN 2 - 12 intact ( except unable assess left eye due
swelling & eccyhmose ) . strength 5/5 four extremity
distally . unable assess proximal muscle strength low
extremity [ * * 3 - 17 * * ] pain . sensation intact distally . Gait
assess . saddle anesthesia , focal spinal tenderness .
pertinent result :
[ * * 2183 - 3 - 23 * * ] 08:46pm GLUCOSE-116 * UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2 - 24 anion GAP-13
[ * * 2183 - 3 - 23 * * ] 08:46pm ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286 *
CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8
[ * * 2183 - 3 - 23 * * ] 08:46pm ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1
MAGNESIUM-2.0 URIC ACID-5.1
[ * * 2183 - 3 - 23 * * ] 08:46pm WBC-0.7 * RBC-2.21 * HGB-7.6 * HCT-20.3 * MCV-92
MCH-34.5 * mchc-37.5 * RDW-17.5 *
[ * * 2183 - 3 - 23 * * ] 08:46pm - HOS - AVAILABLE
[ * * 2183 - 3 - 23 * * ] 08:46pm PLT COUNT-43 *
[ * * 2183 - 3 - 23 * * ] 08:46pm pt-17.0 * PTT-29.8 INR(PT)-1.5 *
[ * * 2183 - 3 - 23 * * ] 08:46pm FDP-160 - 320 *
[ * * 2183 - 3 - 23 * * ] 08:46pm fibrinoge-303
[ * * 2183 - 3 - 23 * * ] 08:46pm GRAN CT-230 *
[ * * 2183 - 3 - 23 * * ] 06:55pm PLT COUNT-53 * #
[ * * 2183 - 3 - 23 * * ] 03:40PM URINE COLOR - Yellow APPEAR - Clear SP [ * * last Name ( un ) 155**]->1.050
[ * * 2183 - 3 - 23 * * ] 03:40PM URINE BLOOD - MOD NITRITE - NEG PROTEIN-30
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-6.5
LEUK - NEG
[ * * 2183 - 3 - 23 * * ] 03:40PM URINE RBC-[**4 - 17 * * ] * WBC-[**4 - 17 * * ] BACTERIA - RARE
yeast - none EPI-0 - 2
[ * * 2183 - 3 - 23 * * ] 03:40PM urine MUCOUS - OCC
[ * * 2183 - 3 - 23 * * ] 03:16PM LACTATE-2.0
[ * * 2183 - 3 - 23 * * ] 03:10PM GLUCOSE-123 * UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 chloride-102 total CO2 - 24 anion gap-15
[ * * 2183 - 3 - 23 * * ] 03:10PM estGFR - use
[ * * 2183 - 3 - 23 * * ] 03:10PM ck(cpk)-147
[ * * 2183 - 3 - 23 * * ] 03:10PM CK - MB-1 cTropnT-<0.01
[ * * 2183 - 3 - 23 * * ] 03:10PM WBC-0.7 * RBC-2.63 * HGB-8.9 * HCT-24.2 * MCV-92
MCH-34.0 * MCHC-37.0 * RDW-17.8 *
[ * * 2183 - 3 - 23 * * ] 03:10PM NEUTS-8 * BANDS-4 LYMPHS-76 * MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-4 * myelos-2 * NUC RBCS-2 * other-6 *
[ * * 2183 - 3 - 23 * * ] 03:10PM HYPOCHROM - NORMAL ANISOCYT-1 +
POIKILOCY - OCCASIONAL MACROCYT-1 + MICROCYT - NORMAL
POLYCHROM - OCCASIONAL OVALOCYT - OCCASIONAL TEARDROP - OCCASIONAL
[ * * 2183 - 3 - 23 * * ] 03:10PM PLT SMR - low PLT COUNT-29 *
[ * * 2183 - 3 - 23 * * ] 03:10PM pt-15.9 * PTT-28.2 INR(PT)-1.4 *
[ * * 2183 - 3 - 23 * * ] 03:10PM GRAN CT-290 *
[ * * 2183 - 3 - 24 * * ] CT HEAD
impression :
1 . increase size left frontal right posterior cingulate
gyrus
intraparenchymal hemorrhage .
2 . increase size right frontal , right temporal ,
interhemispheric
subarachnoid hemorrhage .
3 . midline shift . evidence acute infarction .
[ * * 2183 - 3 - 24 * * ] MRI L / - SPINE
evidence acute spine injury within cervical , thoracic
lumbar
spine . note make fluid level within low lumbar
spine ,
consistent layer subarachnoid blood .
Pathology Examination
Name Birthdate Age Sex Pathology # [ * * Hospital1 18 * * ] [ * * know lastname 40120**],[**known firstname * * ] [ * * 2124 - 10 - 29 * * ] 58 Male [ * * Numeric Identifier 40121 * * ] [ * * Numeric Identifier 40122 * * ]
Report : DR . [ * * last Name ( STitle ) * * ] [ * * last Name ( namepattern4 ) * * ]
Gross Description : DR . [ * * last Name ( STitle ) * * ] . MARIAPPAN
SPECIMEN submit : Immunophenotyping , Bone Marrow
procedure date Tissue receive Report Date diagnose
[ * * 2183 - 3 - 24 * * ] [ * * 2183 - 3 - 24 * * ] [ * * 2183 - 3 - 25 * * ] DR . [ * * last Name ( STitle ) * * ] . MARIAPPAN / ttl
previous biopsy : [ * * Numeric Identifier 40123 * * ] BONE MARROW BIOPSY ( 1 JAR ) .
INTERPRETATION
Immunophenotypic finding consistent involvement :
immature population cell consistent acute myelogenous
leukemia . lack CD34 HLA - DR [ * * last Name ( STitle ) 40124 * * ] consistent
diagnosis acute promyelocytic leukemia . correlation
morphologic cytogenetic finding recommend .
Brief Hospital Course :
58 / present syncopal episode find
multiple small ICH new pancytopenia . complicated course
AMPL treatment
# leukemia : Patient find AMPL via bone marrow biopsy
day admission MICU . start ATRA
monitor closely symptom DIC , TLS ATRA syndrome .
transfuse need PRBC , platlet FFP .
develop overt sign DIC . induce Ara - c
daunurubicin . count respond appropriatly . repeat BM
biopsy show remission continue ATRA
follow Dr. [ * * last Name ( STitle ) 410 * * ] plan stage two
treatment .
.
# fever : initially Vancomycin cefepime first
start treatment due hx fever home ,
culture datum negative remain afebrile
antibiotic discontinue . remain afebrile [ * * 4 - 14 * * ]
spike fever . cultured blood grow
strep viridan . start vanco / cefepime time .
also headache day spike CT do
show appear brain abscess . antibiotic
eventually broaden vanco , meropenem , fluconzaole
flagyl brain abscess . continue spike , though
approximately week . complain thigh pain
ultrasound show bilateral fluid collection .
drain IR grow MSSA . develop pneumonia
febrile period transfer ICU
several day . require O2 discharge
ICU . ICU , neutrophil count start
drop , worried might drug effect .
vanco discontinue count begin recover .
eventually meropenem , voriconazole acyclovir
stop fever . repeat CT scan show resolution
PNA . serial repeat head ct show slow decrease size
abscess . MRI thigh show retain small
fluid collection bilaterally . plan complete 6 week
course antibiotic brain abscess .
reimage thigh MRI outpatient
depend result , either need surgical
drainage still prolong course abx . follow
ID .
.
# ICH : Pt multiple small ICH sustain fall acute
leave sided head injury setting profound
thrombocytopenia . CT head reveal small foci
intraparenchymal hemorrhage subarachnoid hemorrhage . (
hydrocephalus shift ) . [ * * 3 - 24 * * ] follow - Head CT reveal
interval increase hemorrhage without appreciable midline
shift infarction . pt 's neurologic exam remain stable .
Neurosurgery follow closely . platlet goal > 75K.
repeat head CT one month fall show brain abscesse
discuss . Neuro onc consult follow
along . decide biopsy . also require
heparin lovenox dvt , repeat head ct
anticoaulant remain stable without new bleed .
.
# thigh pain / weakness : etiology unclear unable get good
exam limit pain . may bone marrow pain .
evidence hematoma cellulitis . bowel bladder
dysfunction , saddle anesthesia , focal spinal tenderness
indicate acute cord compression . MRI / L - spine reveal
evidence acute cord compression . evidence
layering fluid likely SAH . although unlikely
cause pt 's leg pain ( nerve irritation secondary blood )
Neurosurgery recommend start Decadron [ * * 2182 - 3 - 24 * * ] .
keep decadron chemotherapy initiate .
eventually find abscess thigh ,
discuss .
.
# Afib - pt go afib ICU . blood
pressure remain stable start metoprolol .
high rate 130s-140s ; contine afib
week remain NSR week prior
discharge . metoprolol titrate 25 mg tid good
rate control .
.
# [ * * Name ( NI ) 6059 * * ] - pt one episode 16 b [ * * Name ( NI ) 6059 * * ] v. afib aberrancy .
Cards consult agressive electrolyte repletion
continue metoprolol .
occurrence .
.
# Vasovagal bradycardia - day prior admission ,
patient bowel movement , note telemetry
brady 30 , feel light head resolve 5
minute . appear vaso - vagal
occurrence . , card consult recommend
leave metoprolol dose 25 mg tid , bb
actually helps prevent vagal episode .
.
# dvt - patient ICU , develop bilaterally
pedal edema , think initially due large amount
ivf . new afib , though , ultrasound
find dvt R leg , r arm ( edematous
pain around new PICC line ) . Heparin start
overnight , hx ICHs , decide stop
heparin place IVC filter . put place
without complication . evenutally find
bilaterally leg dvt bilateral upper extremity dvt .
point , decide anticoagulate .
Heparin initially . repeat head CT show bleed .
convert lovenox outpatient treatment
dvt . also VQ scan finding DVT
show low prob PE .
.
# Access - pt initially subclavian line ,
pull patient febrile early [ * * Month ( ) 958 * * ] .
piv transfer ICU PICC line place .
PICC line remove DVT find arm .
piv IR guide subclavian line
place . outpatient continuation 6 week course
antibiotic , hickman place picc could place
due bilateraly UE dvt .
.
# Pt discharge walk around , pass PT go
stair . respiratory status much improve
O2 SOB . advise start work yet
take easy , although , ready get back work soon
possible .
medication admission :
none
Discharge medication :
1 . Heparin Flush 10 unit / mL Kit Sig : one ( 1 ) flush Intravenous
6x / day .
Disp:*180 flush * Refills:*2 *
2 . saline flush 0.9 % Syringe Sig : one ( 1 ) flush Injection
10x / day .
disp:*300 flush * Refills:*2 *
3 . Meropenem 1 gram Recon Soln Sig : one ( 1 ) recon soln
Intravenous every eight ( 8) hour 22 day : make
end date [ * * 5 - 30 * * ] ; total 6 week course .
Disp:*66 recon soln * Refills:*0 *
4 . Vesanoid 10 mg Capsule Sig : five ( 5 ) Capsule po twice day
14 day : substitution please .
Disp:*140 capsule(s ) * Refills:*0 *
5 . Acyclovir 200 mg Capsule Sig : two ( 2 ) Capsule po Q8H ( every 8
hour ) .
disp:*180 capsule(s ) * Refills:*2 *
6 . Metoprolol Tartrate 25 mg Tablet Sig : one ( 1 ) Tablet PO TID
( 3 time day ) .
Disp:*90 Tablet(s ) * Refills:*2 *
7 . voriconazole 200 mg Tablet Sig : 1.5 tablet po Q12H ( every 12
hour ) .
Disp:*90 Tablet(s ) * Refills:*2 *
8 . Enoxaparin 100 mg / mL Syringe Sig : one ( 1 ) syringe
Subcutaneous Q12H ( every 12 hour ) .
Disp:*60 syringe * Refills:*2 *
discharge Disposition :
Home Service
Facility :
Critical Care Systems
discharge Diagnosis :
APML
Intracranial hemorrhage
Syncope
discharge condition :
vital sign stable , walk around , lovenox , normal
neurological exam , afebrile
Discharge instruction :
admit hospital fall .
find low blood count bone marrow biospy show
leukemia . also small area
bleed head stable base repeat CT scan .
receive chemotherapy leukemia .
.
, develop infection
brain around area inital bleed find ,
well thigh . treat antibiotic
need continue go home .
.
also develop blood clot arm leg . place
filter inferior vena cave ( large vein
abdoman ) clot would go lung . also
anticoagulate heparin . go home lovenox
stay anticoagulate .
.
lastly , develop heart arrhythmia call atrial
fibrillation . , continue take medicine
metoprolol .
.
home nurse help wife antibiotic
lovenox shot . make sure start return
work slowly . probably good work work
home first week see feel
start think go back school .
discuss progress Dr. [ * * last Name ( STitle ) 410 * * ] follow
appointment .
.
return hospital fainting , headache ,
dizziness , chest pain , shortness breath , swell
extremity , palpitiation concern .
Followup Instructions :
please follow Dr. [ * * last Name ( STitle ) 410 * * ] [ * * Hospital Ward Name 23 * * ] 7 Tuesday [ * * 2183 - 5 - 13 * * ]
1:30 pm . phone number [ * * telephone / Fax ( 1 ) 3241 * * ] .
please follow infectious disease Dr. [ * * last Name ( STitle ) * * ]
[ * * 2183 - 5 - 19 * * ] 3:00 pm . phone number ( [ * * telephone / Fax ( 1 ) 4170 * * ] .
need repeat mri prior see Dr. [ * * last Name ( STitle ) * * ] .
give date time next appointment .
complete by:[**2183 - 5 - 15 * * ]
|
[
"5849",
"486",
"2875",
"4019",
"2859"
] |
Admission Date : [ * * 2127 - 7 - 11 * * ] Discharge Date : [ * * 2127 - 7 - 13 * * ]
Date Birth : [ * * 2070 - 1 - 18 * * ] sex : F
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 425 * * ]
Chief Complaint :
dizziness , nausea , vomit
Major Surgical Invasive Procedure :
none
history Present Illness :
HPI : 57 / spanish speak female h / HTN , DM 2 ,
hyperlipidemia , CAD / p 4v CABG [ * * 4 - 12 * * ] , asthma present
PCP regularly schedule visit , complain
dizziness , nausea , vomit one week , chest pain ,
find hypotensive . send ed
PCP . [ * * Name10 ( NameIs ) * * ] ED get atropine x 3 bradycardia , lasix ,
glucagon blood sugar 30 , start dopamine
drip hypotension , wean CCU
without futher hypotension . rule MI . AST / ALT
amylase / lipase normal . RUQ US do last month [ * * State 108 * * ]
reportedly normal .
.
decribe vomit one week
go doctor 's visit . vomit almost daily
one week . dizzy week , get bad
go sit standing . describe room
spinning lightheadedness . syncope
fall . chest pain last one minute occur
vomiting . mild cough week , sputum mild
fever .
.
.
Past Medical History :
HTN
Hyperlipidemia
DM 2
CAD / p 4v CABG ( [ * * 4 - 12 * * ] ) LIMA LAD , svg anterior
obtuse marginal , posterior obtuse marginal , RCA .
obesity
Asthma
/ p CCY
/ p c - section
/ p leave foot surgery
Social History :
marry . formerly [ * * Male First Name ( un ) 1056 * * ] , Spanish - speak .
history tobacco use , EtOH , IVDU .
Family history :
Mother CAD , CVA , DM2 . Father die complication
renal failure . extensive DM family .
Physical Exam :
vital : 98.6 BP 120/70 HR 69 rr 18 SAT 96 % RA
General : NAD
HEENT : NC , , amicteric , injection , PERRLA , EOMI , op clear .
Neck : jvp elevation . wound right neck tender
palpation , purulent drainage , erythema .
CV : Normal S1 , s2 / r / g.
Pulm : Minimal bibasilar crackle . wheeze .
Abd : Soft , NT , ND , + BS .
Ext : c / c / e. DP 2 + B / L. Evidence venous stasis change .
healing leave thigh wound pack dressing cover
gauze . drainage erythema .
pertinent result :
Labs discharge : BUN 35 Cr 1.3 CK 69 trop < 0.01 WBC 10.1 HCT
31.8
.
EKG : NSR 60 , normal axis , acute st change
.
last CXR lung clear
.
[ * * 2127 - 7 - 11 * * ] 03:07pm blood wbc-9.7 RBC-3.03 * Hgb-8.8 * Hct-25.7 *
MCV-85 MCH-29.0 mchc-34.1 RDW-15.3 Plt ct-445 *
[ * * 2127 - 7 - 13 * * ] 06:45am blood WBC-10.1 RBC-3.77 * Hgb-10.9 * hct-31.8 *
MCV-84 MCH-28.8 MCHC-34.2 RDW-15.4 Plt Ct-385
[ * * 2127 - 7 - 11 * * ] 03:07pm blood neuts-56.2 Lymphs-36.5 Monos-4.4 eos-2.6
Baso-0.2
[ * * 2127 - 7 - 11 * * ] 06:19PM blood Neuts-78.2 * Lymphs-17.2 * Monos-3.2
Eos-1.3 Baso-0.2
[ * * 2127 - 7 - 11 * * ] 03:07pm blood Plt ct-445 *
[ * * 2127 - 7 - 13 * * ] 06:45AM blood Glucose-119 * UreaN-35 * Creat-1.3 * Na-140
K-5.1 Cl-104 HCO3 - 24 AnGap-17
[ * * 2127 - 7 - 11 * * ] 08:25PM blood alt-18 AST-16 ck(cpk)-49 alkphos-89
Amylase-79 TotBili-0.1
[ * * 2127 - 7 - 11 * * ] 08:25PM blood Lipase-61 *
[ * * 2127 - 7 - 11 * * ] 03:07pm blood ctropnt-<0.01
[ * * 2127 - 7 - 11 * * ] 08:25PM blood CK - MB - NotDone cTropnT-<0.01
[ * * 2127 - 7 - 12 * * ] 06:22AM blood CK - MB - NotDone cTropnT-<0.01
[ * * 2127 - 7 - 11 * * ] 08:25PM blood calTIBC-324 Ferritn-265 * TRF-249
[ * * 2127 - 7 - 11 * * ] 06:29PM blood Lactate-0.8
[ * * 2127 - 7 - 11 * * ] 03:07PM URINE Color - Straw Appear - Clear Sp [ * * last Name ( un ) * * ] -1.005
[ * * 2127 - 7 - 11 * * ] 03:07PM URINE blood - NEG Nitrite - NEG Protein - NEG
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln - NEG ph-5.0 Leuks - NEG
.
bcx [ * * 7 - 11 * * ] : growth
ucx [ * * 7 - 11 * * ] : genital contamination
Brief Hospital course :
/ p : 57 / spanish speak female h / HTN , DM2 , CAD / p
4VCABG , hyperlipidemia , asthma present ED
hypotension , resolve , brief episode chest pain , rule
, abdominal pain , likely Gas / GERD .
.
1 . hypotension : patient nausea vomit prior
admission find hypotensive PCP 's office .
actually give lasix initially start dopamine
gtt . unclear note get fluid .
hypotension probably due dehydration vomit
week prior admission . dopamine gtt wean
patient issue hypotension .
discharge lisinopril atenolol . Lasix dose decrease
20 mg QD KCl / c'd halve lasix
k discharge 5.1 .
.
2 . Renal Failure : Patient come creatinine 1.6
baseline unknown . could chronic renal failure DM
give chronic renal insufficiency perhaps
also prerenal vomiting prior admission .
Creatinine steadily improve 1.3 discharge .
.
3 . anemia : Crit admission 25 . likely ACD DM . / p
transfusion 2 unit CCU . HCT improve . Crit 31.8 .
.
4 . DM2 : bedtime sugar 152 , fast 73 noon
118 . continue acto avandia well riss
patient advise take home dose lantus regular
insulin home .
.
5 . htn : blood pressure stable dopamine gtt
titrate CCU . issue hypertension
hypotension . discharged patient atenolol lisinopril .
.
6 . cad : Patient deny chest pain . lipid profile show LDL 84 ,
HDL 54 . continue ASA , atenolol , lisinopril . acute issue .
.
7 . Asthma : wheezing , stable sat . give patient
albuterol PRN .
.
medication admission :
Lisinopril 20 mg PO daily
Lasix 40 mg PO daily
Trazodone
Avandia 2 mg PO daily
Lantus 100 qd
regular insulin 20 , 30 pm
Protonix 40 mg PO daily
Zoloft
Albuterol
KCl 10 meq PO daily
Atenolol 25 mg PO daily
ASA 81 mg PO daily
Lipitor 10 mg PO daily
Actos 45 mg PO daily
Discharge medication :
1 . aspirin 81 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
2 . lisinopril 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
3 . Atenolol 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . Atorvastatin 10 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
5 . Protonix 40 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) po day .
disp:*30 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
6 . rosiglitazone 2 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
7 . pioglitazone 45 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
8 . trazodone 50 mg Tablet Sig : .5 Tablet PO bedtime need
insomnia .
disp:*15 Tablet(s ) * Refills:*0 *
9 . Lasix 20 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
discharge Disposition :
Home Service
Facility :
[ * * Hospital 2255 * * ] [ * * Name ( NI ) 2256 * * ]
discharge diagnosis :
hypotension [ * * 1 - 9 * * ] volume depletion vomiting
discharge condition :
Patient afebrile , hemodynamically stable tolerate
BP med .
Discharge instruction :
please take medication direct .
please follow - outpatient appointment .
please return ED develop dizziness , loss
consciousness , chest pain , trouble breathing , vomiting ,
difficulty urinate concern symptom .
Followup Instructions :
please follow - primary care provider , [ * * last Name ( namepattern4 ) * * ] . [ * * last Name ( STitle ) 23903 * * ]
week . number [ * * telephone / Fax ( 1 ) 17826 * * ] . time ,
check right upper quadrant ultrasound . Patient also need chem-7
check lasix , lisinopril . put patient
reduce dose lasix ( 20 mg QD ) hypotension take
KCl . see PCP week see really need
lasix 40 mg QD KCl .
|
[
"4589",
"5849",
"4019",
"2859",
"2720"
] |
Admission Date : [ * * 2174 - 4 - 18 * * ] Discharge Date : [ * * 2174 - 5 - 17 * * ]
Date Birth : [ * * 2135 - 11 - 15 * * ] sex : F
Service : MEDICINE
allergy :
Prochlorperazine / Heparin Agents
attending:[**first Name3 ( LF ) 3918 * * ]
Chief Complaint :
Abdominal Pain
Major Surgical Invasive Procedure :
Upper GI series small bowel follow
right heart catheterization
IR guide paracentesis
history Present Illness :
38 yo F w/ h / remission / p cord transplant [ * * 1 - 13 * * ] ,
anthracycline - induce cardiomyopathy ( EF 15 - 20 % [ * * 1 - 14 * * ] )
recurrent nausea vomit present abdominal pain ,
N / v x1 week
note , pt admit [ * * date range ( 1 ) * * ] nausea
vomitte unclear etiology . discharge ,
tolerate good po plan f / u neuro ?
abdominal migraine GI possible contribute
factor include food sensitivity gastroparesis .
ED , VS : 98.8 94 138/100 16 100 % [ * * 10 - 15 * * ] pain . CT / P
show small umbilical hernia ; interval increase size
mild fat stranding interval increase ascite compare
recent prior imaging . WBC 12.4 left shift , bili 2.1
1.1 , Cr 2.7 2.3 . Surgery consult give CT
finding feel indication surgery .
receive iv zofran morphine 4 mg iv 1L IVF .
arrival floor , patient report [ * * 11 - 14 * * ] total body pain
nausea . ice chip today throw
ED .
Review Systems :
( + ) per hpi
( - ) Review Systems : Denies fever , chest pain , SOB , diarrhea ,
constipation , dysuria , HA , change vision dizziness .
Past Medical History :
oncologic history :
:
- initially present [ * * 2172 - 8 - 5 * * ] right chest right upper
extremity pain paresthesia visual blurriness . WBC
149,000 ; receive leukapheresis , start hydroxyurea . Dx'ed
precursor b - cell .
- underwent phase induction daunorubicin , vincristine ,
dexamethasone , l - asparaginase , MTX ; phase II
cyclophosphamide , cytarabine , mercaptopurine , MTX
- Bone Marrow Aspirate / Biopsy [ * * 2172 - 10 - 26 * * ] show morphologic
evidence residual leukemia
- underwent allo double cord blood SCT [ * * 2173 - 1 - 11 * * ] , course
complicate neutropenic fever acute skin GVHD
MEDICAL history :
- embolic stroke [ * * 3-/2174 * * ] coumadin
- Cardiomyopathy due early anthracycline - relate
cardiotoxicity [ * * 10/2172 * * ]
- chronic kidney disease stage III / IV , baseline creatinine
~2.0 - 2.2
- Asthma
- HTN
- Cervical Intraepithelial neoplasia
- c - section [ * * 2165 * * ]
Social History :
smoke : never
EtOH : occasional past , none currently
drug : never
live / work : Single , two child ( age 7 18 ) . life
[ * * Location 686 * * ] . previously employ [ * * company 59330 * * ] , not
work since diagnose [ * * 2172 - 8 - 5 * * ] .
Family history :
Mother gastric cancer , pass age 40
Father HTN .
Physical Exam :
VS : 98 145/76 87 15 100 % RA
GEN : well appear F NAD
HEENT : slight dry MM , sclera anicteric , PERRL
card : RR S1 / S2 normal . prominent S3
Pulm : CTAB
Abd : hyperactive BS . initially soft palpate
stethoscope 4 quadrant suddenly exquisitely
tender right . guard initially . unable assess
HSM .
extremity : wwp , edema . pt 2 + .
Neuro : cns II - XII grossly intact . normal gait
Psych : overly dramatic affect
pertinent result :
admission :
[ * * 2174 - 4 - 18 * * ] 02:00PM blood WBC-12.4 * RBC-3.78 * Hgb-11.4 * Hct-36.3
MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5 * Plt ct-212
[ * * 2174 - 4 - 18 * * ] 02:00PM blood Neuts-67.3 Lymphs-23.8 Monos-7.7 Eos-0.5
Baso-0.7
[ * * 2174 - 4 - 18 * * ] 04:30PM blood pt-30.1 * PTT-29.4 INR(PT)-3.0 *
[ * * 2174 - 4 - 18 * * ] 02:00PM blood UreaN-30 * Creat-2.7 * Na-142 K-4.8 Cl-99
HCO3 - 31 AnGap-17
[ * * 2174 - 4 - 18 * * ] 02:00PM blood ALT-15 AST-18 AlkPhos-127 * TotBili-2.1 *
[ * * 2174 - 4 - 18 * * ] 02:00PM blood Lipase-63 *
[ * * 2174 - 4 - 18 * * ] 02:00PM blood cTropnT-<0.01
[ * * 2174 - 4 - 18 * * ] 02:00PM blood albumin-3.8 Calcium-9.3 phos-4.8 * mg-2.0
discharge :
[ * * 2174 - 5 - 17 * * ] 12:00am blood WBC-19.1 * RBC-3.86 * Hgb-11.3 * Hct-37.7
MCV-98 MCH-29.3 MCHC-30.0 * RDW-17.8 * Plt Ct-419
[ * * 2174 - 5 - 17 * * ] 12:00am blood neuts-81.3 * Lymphs-11.4 * Monos-6.9
eos-0.1 Baso-0.3
[ * * 2174 - 5 - 17 * * ] 12:00am blood pt-31.2 * PTT-28.6 INR(PT)-3.1 *
[ * * 2174 - 5 - 17 * * ] 12:00am blood fibrino-162
[ * * 2174 - 5 - 17 * * ] 12:00am blood glucose-152 * UreaN-78 * Creat-2.9 * Na-137
K-4.7 Cl-95 * HCO3 - 31 AnGap-16
[ * * 2174 - 5 - 17 * * ] 12:00am blood ALT-51 * AST-41 * ld(ldh)-327 * AlkPhos-107 *
TotBili-0.7
[ * * 2174 - 5 - 13 * * ] 12:11PM blood ctropnt-<0.01
[ * * 2174 - 5 - 17 * * ] 12:00am blood albumin-3.8 Calcium-8.7 phos-2.1 * Mg-2.7 *
UricAcd-8.7 *
[ * * 2174 - 4 - 27 * * ] 02:51am blood caltibc-246 * ferritn-107 TRF-189 *
[ * * 2174 - 5 - 2 * * ] 05:55am blood [ * * Doctor First Name * * ] -NEGATIVE dsDNA - NEGATIVE
[ * * 2174 - 4 - 28 * * ] HHV-8 DNA , QL PCR detect
[ * * 2174 - 4 - 27 * * ] QUANTIFERON(R)-TB GOLD NEGATIVE
NEGATIVE
[ * * 2174 - 4 - 29 * * ] ACE , SERUM 30 [ * * 10/2130 * * ]
U / L
Micro :
[ * * 2174 - 4 - 25 * * ] 1:07 pm PERITONEAL FLUID
GRAM STAIN ( Final [ * * 2174 - 4 - 25 * * ] ):
POLYMORPHONUCLEAR leukocytes see .
MICROORGANISMS SEEN .
FLUID CULTURE ( final [ * * 2174 - 4 - 28 * * ] ): growth .
ANAEROBIC CULTURE ( final [ * * 2174 - 5 - 1 * * ] ): growth .
ACID FAST CULTURE ( Preliminary ): MYCOBACTERIA isolate .
ACID FAST SMEAR ( Final [ * * 2174 - 4 - 30 * * ] ):
ACID fast bacilli see DIRECT SMEAR .
FUNGAL CULTURE ( final [ * * 2174 - 5 - 13 * * ] ): FUNGUS ISOLATED .
[ * * 2174 - 4 - 29 * * ] 10:15 pm blood CULTURE ( MYCO / F LYTIC BOTTLE )
BLOOD / FUNGAL CULTURE ( Preliminary ): FUNGUS ISOLATED .
BLOOD / AFB CULTURE ( Preliminary ): MYCOBACTERIA isolate .
CMV Viral Load ( Final [ * * 2174 - 5 - 6 * * ] ): CMV DNA detect .
ECG [ * * 2174 - 4 - 18 * * ] :
sinus rhythm . possible leave atrial abnormality . Lateral ST -
wave
abnormality . rule myocardial ischemia . poor r wave
progression . rule anterior wall myocardial
infarction indeterminate age . compare previous
tracing [ * * 2174 - 4 - 2 * * ] multiple describe abnormality persist .
CT abdomen / pelvis without contrast [ * * 2174 - 4 - 18 * * ] :
finding : small - - moderate right pleural effusion ,
small
size compare last CT torso . small pericardial
effusion . study suboptimal evaluation solid organ due
lack IV contrast . limitation mind ,
extra- intra - hepatic biliary duct dilatation . previously
describe presumably focal nodular hyperplasia segment VI
liver clearly visualize non - contrast CT .
presumably gallbladder wall edema third space
moderate amount ascite . likely gallbladder sludge .
Pancreas bilateral adrenal gland within normal limit
consider limitation contrast administration .
interval increase size fat - contain umbilical
hernia measure 2 cm transverse dimension mild fat
stranding(2:50 ) , correlate point tenderness / physical exam .
appendix dilate ( 2:49 ) , contain air
likely small appendicolith ( 2:53 ) . bowel
obstruction . evidence colonic wall thickening ,
although evaluation suboptimal give lack IV po
contrast adjacent ascite .. kidney normal size .
evidence hydronephrosis . due lack oral
contrast , evaluation mesenteric lymph node suboptimal .
scatter lymph node retroperitoneum , however ,
meet CT criterion pathologic enlargement .
CT PELVIS : free fluid pelvis - ascite .
uterus urinary bladder appear normal . rectum sigmoid
scatter diverticula ; however , evidence
diverticulitis .
osseous STRUCTURES : suspicious lytic sclerotic lesion .
soft tissue stranding suggest anasarca .
IMPRESSION :
1 . mild - - moderate right pleural effusion ; however , interval
decrease size compare prior .
2 . moderate ascite interval increase .
3 . drainable fluid collection , however , evaluation
suboptimal due lack IV oral contrast .
4 . diverticulosis .
5 . interval increase size small fat - contain umbilical
hernia mild fat stranding , correlate point tenderness .
6 . bowel obstruction . definite bowel wall thickening ,
although examination suboptimal .
7 . pericardial effusion , similar prior .
RUQ ultrasound [ * * 2174 - 4 - 18 * * ] :
finding : liver normal echogenicity . previously
describe presumably focal nodular hyperplasia segment VI
liver clearly visualize . intra-
extra - hepatic biliary duct dilatation . common bile duct
measure 2 mm . ascite . gallbladder wall
edema / thicken presumably third spacing ; gallbadder
distend . convincing evidence sludge
ultrasound . main portal vein patent . pancrea
suboptimally evaluate due overlap bowel gas .
small - - moderate right pleural effusion see recent CT .
IMPRESSION :
1 . ascite .
2 . Gallbladder wall edema presumably third spacing .
3 . small - - moderate right pleural effusion .
4 . biliary duct dilatation .
5 . previously describe presumme focal nodular hyperplasia
segment VI liver clearly visualize .
small bowel follow [ * * 2174 - 4 - 20 * * ] :
impression :
1 . small , anterior cervical web hinder passage
13 mm
barium tablet .
2 . fill defect mid esophagus carina
appear either extrinsic compression versus submucosal
lesion . correlation comparison CT torso , mediastinal
lesion less likely . submucosal esophageal lesion remain
within differential , direct visualization EGD
recommend . possibility include aberrant vessel
vicinity .
3 . mobile cecum appear obstructive
manner today 's examination .
Renal ultrasound [ * * 2174 - 4 - 20 * * ] :
finding : right kidney measure 10.5 cm . left kidney
measure 9.7
cm . evidence hydronephrosis , stone mass
bilaterally .
bladder unremarkable . moderate amount ascite
incidentally note .
IMPRESSION : hydronephrosis , stone mass within kidney .
Peritoneal Fluid [ * * 2174 - 4 - 25 * * ] :
ATYPICAL .
scatter atypical lymphoid cell background
reactive mesothelial cell
IR guide paracentesis [ * * 2174 - 4 - 25 * * ] :
impression :
ultrasound - guide diagnostic paracentesis , total 200
mL ascite remove .
TTE [ * * 2174 - 5 - 2 * * ] :
left atrium mildly elongate . leave ventricular wall
thickness cavity size normal . severe global
leave ventricular hypokinesis ( LVEF = 20 % ) . systolic function
apical segment relatively preserve . masse thrombi
see left ventricle . right ventricular chamber size
mildly increase moderate global free wall hypokinesis .
[ intrinsic right ventricular systolic function likely
depressed give severity tricuspid regurgitation . ]
aortic valve leaflet ( 3 ) appear structurally normal good
leaflet excursion aortic stenosis aortic
regurgitation . mitral valve appear structurally normal
trivial mitral regurgitation . mitral valve prolapse .
Severe [ 4 + ] tricuspid regurgitation see . mild
pulmonary artery systolic hypertension [ setting
least moderate severe tricuspid regurgitation , estimate
pulmonary artery systolic pressure may underestimate due
high right atrial pressure . ] small
circumferential pericardial effusion without echocardiographic
sign tamponade .
IMPRESSION : severe biventricular global hypokinesis . severe
tricuspid regurgitation . pulmonary artery systolic hypertension .
small circumferential pericardial effusion without evidence
tamponade physiology .
compare prior study ( image review ) [ * * 2174 - 4 - 1 * * ] ,
finding similar .
TTE [ * * 2174 - 5 - 10 * * ] :
left atrium dilate . left - - right shunt across
interatrial septum see rest consistent stretch
patent foraman ovale ( small atrial septal defect ) .
mild symmetric leave ventricular hypertrophy . left
ventricular cavity size normal mildly impair global
leave ventricular systolic function . aortic valve leaflet
( 3 ) appear structurally normal good leaflet excursion
aortic stenosis aortic regurgitation . mitral valve
appear structurally normal trivial mitral regurgitation .
tricuspid valve leaflet mildly thicken .
moderate ( 2 + ) tricuspid regurgitation . mild pulmonary
artery systolic hypertension . small pericardial
effusion . echocardiographic sign tamponade .
echocardiographic sign tamponade may absent
presence elevated right sided pressure .
compare prior study ( image review ) [ * * 2174 - 5 - 6 * * ] ,
ther pericardial effusion small . biventricular
sysotolic function appear slightly less vigorous compare
prior study ( low dose milrinone
prior study ) .
Cardiac cath [ * * 2174 - 5 - 5 * * ] :
comment :
1 . hemodynamic measurement patient demonstrate low
cardiac output . follow administration milrinone , cardiac
index increase low - normal range 2.5 L / min / m2 .
2 . moderate pulmonary hypertension right atrial v - wave
consistent severe TR note . Pulmonary vascular resistance
elevate 280 dyne - cm - sec5 .
FINAL DIAGNOSIS :
1 . severe systolic ventricular dysfunction .
2 . moderate diastolic ventricular dysfunction .
3 . pulmonary hypertension
LE ultrasound [ * * 2174 - 5 - 13 * * ] :
impression :
1 . evidence deep venous thrombosis either low
extremity .
2 . 3.6 cm [ * * Hospital Ward Name 4675 * * ] cyst right popliteal fossa previous .
superficial soft tissue edema right mid thigh , may
relate partial rupture [ * * Hospital Ward Name 4675 * * ] cyst .
TTE [ * * 2174 - 5 - 16 * * ] :
left atrium dilate . leave ventricular wall thickness
cavity size normal . diameter aorta sinus ,
ascending arch level normal . aortic valve leaflet
( 3 ) appear structurally normal good leaflet excursion
aortic stenosis aortic regurgitation . mitral valve
leaflet structurally normal . mitral valve
prolapse . trivial mitral regurgitation see . moderate [ 2 + ]
tricuspid regurgitation see . moderate pulmonary
artery systolic hypertension . small pericardial
effusion . effusion appear circumferential .
echocardiographic sign tamponade . echocardiographic sign
tamponade may absent presence elevated right side
pressure .
compare prior study ( image review ) [ * * 2174 - 5 - 10 * * ] ,
biventricular systolic function slightly bad . size
pericardial effusion slightly small .
Brief Hospital Course :
38 yo F w/ h / remission / p cord transplant [ * * 1 - 13 * * ] ,
anthracycline - induce cardiomyopathy ( EF 15 - 20 % [ * * 1 - 14 * * ] )
recurrent nausea vomit present 1 week abd pain ,
acute chronic renal failure new hyperbilirubinemia .
unclear unifying diagnosis .
# Acute Chronic Abdominal Pain : Pt note significant
abdominal pain well increase [ * * Month / Year ( 2 ) 4394 * * ] admission .
note , extensive work chronic abdominal pain
past clear cause . Abdominal CT unreveale
obvious source pain . gi consult
recommend sbft reveal significant
pathology . GI recommend bentyl antispasmodic effect .
also continue home MS contin IV morphine
breakthrough . pain persist [ * * last Name ( LF ) 4394 * * ] , [ * * first Name3 ( LF ) * * ]
decision make perform diagnositc paracentesis
ultrasound guidance . 200ml peritoneal fluid remove .
reveal 775 wbc , lymphocytic / monocytic predominance
1 % polys make SBP unlikely . Fluid send culture
show growth flow cytometry show
evidence recurrence . despite lack evidence SBP ,
start zosyn empirically stop [ * * 5 - 2 * * ] .
continue mild - moderate abdominal pain able
eat full meal bm . continue home
mscontin morphine IR .
.
# Anthracycline - induced/ GVHD cardiomyopathy : EF < 20 % echo
2/[**2174 * * ] . Pt maintain diuresis ,
subsequently hold setting rise creatinine
improvement creatinine . torsemide slowly reintroduce
uptitrated 40 mg [ * * hospital1 * * ] cause another bump creatinine
3.0 , renal cardiology consult . renal ultrasound
unreveale . take Cath lab place
milrinone / lasix gtt transfer CCU . volume
overload slowly improve peripheral edema / ascite slowly
improve well . repeat echo show improve EF 40 - 45 %
milrinone gtt . start solumedrol 30 mg IV
due concern GVHD direct towards myocardium .
discussion cardiology oncology team
also start cellcept management GVHD .
well milrinone lasix drip , drip
stop creatinine bump 3.0 feel
volume status near maximization . milrinone
discontiue transfer back [ * * Hospital1 3242 * * ]
management abdominal pain GVHD . continue
torsemide diuresis close follow - outpatient
cardiologist . note , frequent alarm telemetry
tachycardia cardiologist feel mostly due artifact ;
beta blocker uptitrated . repeat TTE prior discharge
show EF 35 - 40 % . discharge home cellcept
prednisone possible GVHD .
# Acute Renal Failure : admission Cr 2.7 ( recent baseline
2 ) , last discharge Cr 2.3 . Renal see patient
think likely overdiuresis ( home torsemide
regiman 20 mg [ * * hospital1 * * ] ) conjunction [ * * last Name ( LF ) * * ] , [ * * first Name3 ( LF ) * * ] recommend
hold diuresis . Cr subsequently improve ,
setting worsen [ * * first Name3 ( LF ) 4394 * * ] cardiomyopathy ,
decision make slowly add back diuresis , eventually
titrate toresemide 40 mg [ * * hospital1 * * ] [ * * last Name ( un ) * * ]
restart . , however , Cr begin climb
3.0 . give delicate balance renal failure
cardiomyopathy , cardiology / renal consult . give
depressed EF , rise Cr think [ * * 3 - 9 * * ] volume
overload . send cath lab start
milrinone / lasix gtt transfer CCU goal
diuresis 1l per day . actively diurese
milrinone lasix drip total net negative close
9L. Cr return baseline time discharge
discharge home torsemide .
# Hyperbilirubinemia : unclear cause , could relate
viral infection transaminitis support . RUQ u /
without cause pain . trend normal value
remain stable time discharge
# leukocytosis : patient uptrende WBC setting
starting solumedrol , cluture send reveal
growth .
.
# H / Embolic Stroke : new opening PFO base
recent echo likely contribute recent stroke .
maintain coumadin 4 mg daily , anticoagulation
hold day paracentesis remain subtherapeutic
several day , maintain heparin drip bridge
therapeutic INR [ * * 3 - 10 * * ] . maintain decrease
dose coumadin throughout hospital admission INR within
goal 2 3 . arrange follow -
outpatient [ * * hospital3 * * ] .
medication admission :
Carvedilol 25 mg [ * * hospital1 * * ]
Fluticasone - salmeterol [ * * hospital1 * * ]
Morphine 15 mg q6h prn pain
Valsartan 40 mg qd
Torsemide 20 mg [ * * hospital1 * * ]
Multivitamin qd
Albuterol prn
Lorazepam 0.5 mg q6h prn nausea
Warfarin 4 mg qd
Ondansetron 8 mg tid prn
Pentamidine 300 mg inhalation qmonth
Colace 100 mg qd prn
Discharge medication :
1 . fluticasone - salmeterol 250 - 50 mcg / dose Disk Device Sig :
one ( 1 ) disk Device Inhalation [ * * hospital1 * * ] ( 2 time day ) .
2 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
3 . lorazepam 0.5 mg Tablet Sig : one ( 1 ) Tablet po every six ( 6 )
hour need nausea .
Disp:*60 Tablet(s ) * Refills:*0 *
4 . albuterol sulfate 90 mcg / actuation HFA Aerosol Inhaler Sig :
two ( 2 ) Puff Inhalation Q4H ( every 4 hour ) need sob
wheeze .
5 . Zofran 8 mg Tablet Sig : one ( 1 ) Tablet po every eight ( 8)
hour need nausea .
6 . multivitamin Tablet Sig : one ( 1 ) Tablet po day .
7 . metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig : one ( 1 ) Tablet Extended Release 24 hr po DAILY ( Daily ) .
disp:*30 Tablet Extended Release 24 hr(s ) * Refills:*0 *
8 . morphine 15 mg Tablet Extended Release Sig : one ( 1 ) Tablet
Extended Release po Q12H ( every 12 hour ) .
Disp:*60 Tablet Extended release(s ) * Refills:*0 *
9 . dicyclomine 20 mg Tablet Sig : one ( 1 ) Tablet PO four time
day .
disp:*120 Tablet(s ) * Refills:*0 *
10 . allopurinol 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*0 *
11 . sulfamethoxazole - trimethoprim 400 - 80 mg Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*0 *
12 . acyclovir 400 mg Tablet Sig : one ( 1 ) Tablet po Q12H ( every
12 hour ) .
Disp:*60 Tablet(s ) * Refills:*0 *
13 . torsemide 20 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ) .
Disp:*60 Tablet(s ) * Refills:*0 *
14 . simethicone 80 mg Tablet , Chewable Sig : one ( 1 ) Tablet ,
Chewable PO QID ( 4 time day ) need abdominal pain
gas .
Disp:*120 Tablet , Chewable(s ) * Refills:*0 *
15 . mycophenolate mofetil 500 mg Tablet Sig : two ( 2 ) Tablet PO
BID ( 2 time day ) .
disp:*120 Tablet(s ) * Refills:*0 *
16 . prednisone 20 mg Tablet Sig : three ( 3 ) Tablet PO DAILY
( Daily ) .
Disp:*90 Tablet(s ) * Refills:*0 *
17 . magnesium hydroxide 400 mg/5 ml Suspension Sig : thirty ( 30 )
ML PO Q6H ( every 6 hour ) need constipation .
disp:*500 ML(s ) * Refills:*0 *
18 . morphine 15 mg Tablet Sig : one ( 1 ) Tablet po every twelve
( 12 ) hour need pain .
19 . warfarin 2 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*0 *
discharge disposition :
home
discharge Diagnosis :
Primary :
-Abdominal Pain
-acute chronic renal failure
-systolic Heart failure
secondary :
-ALL
-history embolic stroke
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
Ms. [ * * know lastname * * ] ,
admit hospital abdominal pain . pain
treat pain medication , new medication call
Bentyl . also switch long acting form
morphine . test look small bowel
negative . point sure cause
pain , increase swelling abdoman
likely contribute pain .
undergo right heart catheterization [ * * know lastname 461 * * ]
assess heart function worsen heart failure
cause fluid belly worsen kidney disease .
cardiac intensive care unit place
medication improve heart function . repeat
[ * * know lastname 461 * * ] prior discharge show heart
function improve somewhat stable . follow
closely cardiologist several heart
medication change . start steroid
mycophenolate mofetil feel heart
problem may due leukemia .
also worsening renal failure .
follow kidney consult team
hospital . kidney function stable prior discharge .
make follow change medication :
-Mycophenolate Mofetil 1000 mg twice day start
-prednisone 60 mg daily start
-Coumadin decrease 2 mg daily
-Torsemide increase 40 mg daily
-please hold valsartan see cardiologist
-Metoprolol succinate 100 mg daily start ; please stop
carvedilol
-Bentyl ( dicyclomine ) start abdominal pain
-simethicone start abdominal discomfort / gas
-your morphine switch long - act Morphine 15 mg twice
day
-bactrim single strength , 1 tablet daily , start help
prevent infection
-Acyclovir 400 mg twice day start help prevent
infection
-allopurinol 100 mg daily start uric acid
level high
weigh every morning , [ * * Name8 ( MD ) 138 * * ] MD weight go
3 lbs .
Followup Instructions :
follow appointment [ * * Name8 ( MD ) 1988 * * ] .
need follow [ * * hospital3 * * ] Thursday ,
[ * * 2174 - 5 - 19 * * ] , INR ( coumadin level ) check . please come
[ * * Hospital Ward Name 23 * * ] Center [ * * Location ( un ) 895 * * ] lab test 9
5 pm .
Department : HEMATOLOGY / ONCOLOGY
: FRIDAY [ * * 2174 - 5 - 20 * * ] 3:30 pm
: [ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , MD [ * * telephone / Fax ( 1 ) 22 * * ]
building : [ * * hospital6 29 * * ] [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : HEMATOLOGY / ONCOLOGY
: FRIDAY [ * * 2174 - 5 - 20 * * ] 3:30 pm
: [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern1 ) 10565 * * ] , NP [ * * telephone / Fax ( 1 ) 22 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 24 * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
[ * * first Name8 ( NamePattern2 ) 449 * * ] [ * * last Name ( NamePattern1 ) 437 * * ] MD , Cardiology
[ * * last Name ( LF ) 766 * * ] , [ * * 2174 - 5 - 30 * * ] 11:00AM
SC [ * * Hospital Ward Name * * ] CLINICAL CTR , [ * * Location ( un ) * * ]
Department : WEST [ * * Hospital 2002 * * ] CLINIC
: THURSDAY [ * * 2174 - 6 - 9 * * ] 10:00
: [ * * First Name11 ( Name Pattern1 ) 177 * * ] [ * * last Name ( namepattern4 ) 720 * * ] , M.D. [ * * telephone / Fax ( 1 ) 721 * * ]
building : De [ * * hospital1 * * ] building ( [ * * Hospital Ward Name 121 * * ] Complex ) [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Street address(1 ) 592 * * ] garage
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 3922 * * ]
complete by:[**2174 - 5 - 26 * * ]
|
[
"4254",
"5849",
"4280",
"4168"
] |
Admission Date : [ * * 2193 - 6 - 27 * * ] Discharge Date : [ * * 2193 - 6 - 30 * * ]
Date Birth : [ * * 2162 - 12 - 8 * * ] sex :
Service : SURGERY
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 598 * * ]
Chief Complaint :
chest , lower back hip pain , / p crush injury
Major Surgical Invasive Procedure :
none
history Present Illness :
Mr. [ * * know lastname 88968 * * ] 30 year old man untreated hypertension
suffer crush injury chest ( tractor load weight
roll onto chest ) require extraction fork lift .
deny LOC ; VS stable [ * * Location ( un ) * * ] . upon ED
presentation , c / hip low back pain , yet deny chest
pain , dyspnea , abdominal pain , headache neck pain .
Cardiology consult give concern contusion , cardiac
injury . note new rbbb ECG TWI .
patient CPK 1464 TnT<0.01 . mb 5 . Pt 's chest pain
improve narcotic . also deny dyspnea , although
hurt take deep breath .
stop take anti - hypertensive lack insurance .
atypical chest pain past evaluate
[ * * hospital1 * * ] ECG . deny exertional chest symptom .
orthopnea PND . remain ROS positive back pain pain
hip . ROS negative .
Past Medical History :
HTN ( currently treat )
Social History :
Married ( wife , [ * * Name ( NI ) * * ] [ * * Name ( NI ) 88969 * * ] , [ * * telephone / Fax ( 1 ) 88970 * * ] emergency contact ) .
Non - smoker , alcohol . illicit .
Family history :
premature cad .
Physical Exam :
HEENT : pupil equal , round reactive light ,
extraocular muscle intact
Oropharynx within normal limit
chest : clear auscultation
Cardiovascular : regular Rate Rhythm
Abdominal : soft , Nontender
GU / Flank : costovertebral angle tenderness
Extr / back : cyanosis , club edema
Neuro : speech fluent
Pertinent result :
[ * * 2193 - 6 - 27 * * ] 02:03pm blood wbc-5.0 rbc-5.25 Hgb-15.0 Hct-42.7
MCV-81 * MCH-28.6 MCHC-35.2 * RDW-14.0 Plt ct-225
[ * * 2193 - 6 - 27 * * ] 02:10PM blood PT-12.4 PTT-22.9 INR(PT)-1.0
[ * * 2193 - 6 - 27 * * ] 02:03pm blood Plt ct-225
[ * * 2193 - 6 - 27 * * ] 09:36pm blood glucose-111 * UreaN-7 Creat-1.0 Na-140
K-3.2 * Cl-108 HCO3 - 23 AnGap-12
[ * * 2193 - 6 - 27 * * ] 09:36pm blood glucose-674 * UreaN-7 Creat-1.0 na-136
K-2.6 * Cl-102 HCO3 - 28 angap-9
[ * * 2193 - 6 - 27 * * ] 02:03pm blood UreaN-10 Creat-1.3 *
[ * * 2193 - 6 - 27 * * ] 09:36pm blood ck(cpk)-909 *
[ * * 2193 - 6 - 27 * * ] 02:03pm blood ALT-40 AST-42 * CK(CPK)-1464 * AlkPhos-64
TotBili-0.6
[ * * 2193 - 6 - 27 * * ] 02:03pm blood Lipase-48
[ * * 2193 - 6 - 27 * * ] 09:36pm blood CK - MB-5 cTropnT-<0.01
[ * * 2193 - 6 - 27 * * ] 02:03pm blood ctropnt-<0.01
[ * * 2193 - 6 - 27 * * ] 09:36pm blood calcium-8.3 * phos-2.8 Mg-1.9
[ * * 2193 - 6 - 27 * * ] 09:36pm blood calcium-6.8 * Phos-1.8 * Mg-1.6
[ * * 2193 - 6 - 27 * * ] 02:03pm blood calcium-9.1
[ * * 2193 - 6 - 27 * * ] 02:03pm blood ASA - NEG Ethanol - NEG Acetmnp - NEG
Bnzodzp - NEG Barbitr - NEG Tricycl - NEG
[ * * 2193 - 6 - 27 * * ] 02:10PM blood Glucose-105 Lactate-1.5 na-145 K-3.5
cl-107
[ * * 2193 - 6 - 27 * * ] 02:10PM blood hgb-14.8 calcHCT-44
.
[ * * 2193 - 6 - 27 * * ] 09:36PM urine Color - Straw Appear - Clear Sp [ * * last Name ( un ) * * ] -1.013
[ * * 2193 - 6 - 27 * * ] 02:24PM URINE Color - Yellow Appear - Clear Sp [ * * last Name ( un ) * * ] -1.016
[ * * 2193 - 6 - 27 * * ] 09:36PM urine blood - sm Nitrite - NEG Protein - NEG
Glucose-300 Ketone - NEG Bilirub - NEG Urobiln - NEG pH-7.5 Leuks - NEG
[ * * 2193 - 6 - 27 * * ] 02:24PM URINE blood - NEG Nitrite - NEG Protein-30
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln-2 * ph-6.5 Leuks - NEG
[ * * 2193 - 6 - 27 * * ] 09:36PM urine RBC-12 * WBC-1 Bacteri - NONE yeast - none
Epi-0
[ * * 2193 - 6 - 27 * * ] 02:24PM URINE RBC-3 * WBC-2 Bacteri - none yeast - none
epi-<1
[ * * 2193 - 6 - 27 * * ] 02:24PM URINE mucous - RARE
[ * * 2193 - 6 - 27 * * ] 02:24PM URINE Hours - RANDOM
.
[ * * 2193 - 6 - 27 * * ] 9:36 pm MRSA SCREEN ; source : Nasal swab .
( Final [ * * 2193 - 6 - 30 * * ] ): MRSA isolate .
.
[ * * 2193 - 6 - 28 * * ] 11:25am blood WBC-4.3 rbc-5.24 Hgb-15.1 Hct-44.0 MCV-84
MCH-28.8 mchc-34.2 RDW-14.4 Plt Ct-228
[ * * 2193 - 6 - 28 * * ] 11:25am blood Plt ct-228
[ * * 2193 - 6 - 28 * * ] 11:25am blood Glucose-133 * UreaN-5 * Creat-1.0 Na-142
K-3.6 Cl-109 * HCO3 - 25 AnGap-12
[ * * 2193 - 6 - 28 * * ] 11:25am blood CK(CPK)-718 *
[ * * 2193 - 6 - 28 * * ] 04:47AM blood CK(CPK)-827 *
[ * * 2193 - 6 - 28 * * ] 11:25am blood CK - MB-5 cTropnT-<0.01
[ * * 2193 - 6 - 28 * * ] 04:47AM blood CK - MB-5 cTropnT-<0.01
[ * * 2193 - 6 - 28 * * ] 11:25am blood Calcium-8.3 * Phos-2.0 * Mg-2.2
[ * * 2193 - 6 - 28 * * ] 04:50AM blood type-[**last Name ( un ) * * ] pH-7.32 *
[ * * 2193 - 6 - 28 * * ] 04:50AM blood freeca-1.11 *
.
[ * * 2193 - 6 - 28 * * ] 09:57AM URINE Hours - RANDOM
[ * * 2193 - 6 - 28 * * ] 09:57AM URINE Myoglob - PRESUMPTIVE
.
[ * * 2193 - 6 - 29 * * ] 05:55am blood wbc-5.9 RBC-5.40 Hgb-15.2 Hct-44.6 MCV-83
MCH-28.2 MCHC-34.2 RDW-14.2 Plt ct-220
[ * * 2193 - 6 - 29 * * ] 05:55am blood Plt ct-220
[ * * 2193 - 6 - 29 * * ] 05:55am blood
[ * * 2193 - 6 - 29 * * ] 05:55am blood Glucose-87 UreaN-15 Creat-1.2 na-141
K-3.6 Cl-107 HCO3 - 25 angap-13
[ * * 2193 - 6 - 29 * * ] 05:55am blood calcium-9.0 phos-2.9 mg-2.1
.
[ * * 2193 - 6 - 27 * * ] Cardiology ECG
Sinus rhythm . right bundle - branch block left anterior
fascicular block . probable leave ventricular hypertrophy .
previous tracing available comparison .
Rate 67 , PR 192 , QRS 170 , QT / QTc 424/436 , P 65 , QRS -72 , -26
.
[ * * 2193 - 6 - 27 * * ] 1:45 pm , trauma # 2 ( AP CXR & PELVIS PORT )
impression : acute intrathoracic pelvic injury .
.
[ * * 2193 - 6 - 27 * * ] 1:59 pm , CT HEAD W / CONTRAST
impression : acute intracranial injury skull fracture .
.
[ * * 2193 - 6 - 27 * * ] 2:00 pm , CT ABD & PELVIS CONTRAST , CT CHEST
W / CONTRAST
impression : acute injury chest , abdomen pelvis .
acute
fracture .
.
[ * * 2193 - 6 - 27 * * ] 2:00 pm , CT C - spine W / CONTRAST
impression : acute fracture malalignment .
.
[ * * 2193 - 6 - 27 * * ] 5:01 pm , MR CERVICAL SPINE W / CONTRAST
[ * * 2193 - 6 - 27 * * ] 5:01 pm , MR L SPINE W / CONTRAST
[ * * 2193 - 6 - 27 * * ] 5:01 pm , MR THORACIC SPINE W / CONTRAST
IMPRESSION :
1 . evidence fracture ligamentus injury .
2 . mild degenerative change spine .
.
[ * * 2193 - 6 - 28 * * ] 10:02:43 , ECHO , portable TTE ( complete )
impression : rv systolic dysfunction pericardial effusion
suggest significant cardiac contusion . Symmetric leave
ventricular hypertrophy mild global systolic dysfunction .
dilate thoracic aorta mild functional aortic
regurgitation . mild mitral regurgitation .
finding consistent hypertensive heart
disease .
.
[ * * 2193 - 6 - 28 * * ] Cardiology ECG
Sinus rhythm . right bundle - branch block left anterior
fascicular block . compare previous tracing change .
Brief Hospital course :
Mr. [ * * know lastname 88968 * * ] 30 year old man untreated hypertension
suffer crush injury chest ( tractor load weight
roll onto chest ) require extraction fork lift .
deny LOC ; VS stable [ * * Location ( un ) * * ] . upon ED
presentation , c / hip low back pain , yet deny chest
pain , dyspnea , abdominal pain , headache neck pain .
Cardiology consult , give concern cardiac contusion ,
injury . Assesment : chronic RBBB HTN versus RV contusion
conduction delay RV . LV function appear
normal . hx c / w acute coronary syndrome . note
new rbbb ECG TWI . CPK 1464 TnT<0.01 , mb 5 ,
AST 42 , Ca 9.1 , 3 RBC urine , Cr 1.3 , Hct 42.7 .
patient initially manage TICU close fluid
status monitoring . patient hemodynamically stable .
receive agressive hydration goal Uop > 100cc / hr .
patient 's pain control HD2 , patient
well . ck cycle trend . Creatinine
normalize , IVF rate cut back . patient 's diet
advanced transition po pain med transfer
floor .
floor , tolerate regular diet , ambulate
physical therapy . continue intermittent muscular
pain chest , lower back , hip , unchanged previous
day . pain control oral narcotic pain medication .
CT imaging MRI spine show fracture ligamentous
injury , CT show acute injury fracture chest ,
abdomen , pelvis . ready discharge [ * * 2193 - 6 - 30 * * ]
home .
medication admission :
none
discharge medication :
1 . acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO TID ( 3
time day ) .
2 . oxycodone 5 mg Tablet Sig : 1 - 2 tablet po Q4H ( every 4 hour )
need pain .
Disp:*40 Tablet(s ) * Refills:*0 *
3 . diazepam 5 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need muscle spasm .
Disp:*10 Tablet(s ) * Refills:*0 *
discharge disposition :
home
discharge diagnosis :
rhabdomyolysis
muscular pain
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
admit ACS service .
fracture organ injury see imaging . may feel lot
muscular ache next couple week body
heal . please resume home medication . take
prescribe narcotic pain , drive operate heavy
machinery take medication . also take tylenol
ibuprofen pain , exceed 4 g tylenol per day .
Followup Instructions :
follow - acute care surgery clinic need :
[ * * telephone / Fax ( 1 ) 600 * * ] .
[ * * first Name8 ( NamePattern2 ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 601 * * ]
complete by:[**2193 - 6 - 30 * * ]
|
[
"4019"
] |
Admission Date : [ * * 2140 - 12 - 8 * * ] Discharge Date : [ * * 2140 - 12 - 12 * * ]
Date Birth : [ * * 2076 - 5 - 24 * * ] sex :
Service : CT SURGERY
history PRESENT illness : Mr. [ * * know lastname 24524 * * ] 64 - year - old
male history progressive exertional dyspnea
quit smoke approximately six month ago . Workup
exertional dyspnea include exercise treadmill
test ultimately positive ischemic change
well echocardiogram subsequently elective
cardiac catheterization . Cardiac catheterization complete
[ * * 2140 - 12 - 5 * * ] show leave main coronary artery disease
modest calcification distal 50 % taper . left anterior
descend also moderate calcification proximal
70 % lesion D1 r1 . d2 moderate vessel 90 %
proximal tubular lesion , D1 r1 ectatic proximal
vessel large distal vessel . left circumflex artery
nondominant vessel proximal 90 % lesion
moderate calcification well . right coronary artery
dominant vessel , total proximal occlusion
bridge left - right collateral . posterior
descend artery know good target . additional
finding catheterization abdominal aorta
large infrarenal aneurysm begin 13 mm renal ,
bilaterally single without disease . large extent
aneurysm 4.8 cm length 11.7 cm .
proximal runoff reveal moderate ostial leave iliac lesion .
common femoral artery superficial femoral artery
bilaterally normal .
give patient 's significant three vessel coronary artery
disease symptom occasional angina dyspnea
exertion , determined would appropriate
candidate coronary artery bypass grafting .
Cardiothoracic Surgery service consult
catheterization procedure , follow history
obtain .
PAST MEDICAL history : history inferior myocardial
infarction electrocardiogram , mild chronic obstructive
pulmonary disease , hypertension , hypercholesterolemia , 6 cm
infrarenal abdominal aortic aneurysm note previously
pick incidentally examination cardiologist
several month ago , benign prostatic hypertrophy , gout ,
great 75 pack year smoking history recently
quit last six month . hypothyroid .
allergy : know drug allergy .
medication admission : Aspirin 325 mg mouth
daily , Lipitor 10 mg mouth daily , atenolol 50 mg
mouth daily , allopurinol 100 mg mouth daily ,
Flomax .4 mg mouth daily , tapazole 20 mg mouth
daily , Mavik 1 mg mouth daily .
LABORATORY DATA : preoperative hematocrit 36 . BUN
creatinine 17 1.1 . Catheterization datum state .
Chest x - ray show acute cardiopulmonary process .
electrocardiogram significant sinus bradycardia
54 , q wave II , III AVF . abnormal ST /
wave change . early j - point elevation .
early r wave progression well .
PHYSICAL EXAMINATION : heart rate 54 , blood pressure 134/70 ,
acute distress , chest pain , carotid bruit
auscultate . heart regular , prominent s2 ,
murmur . lung clear auscultation except
decrease breath sound throughout . abdominal
examination soft , nontender , nondistended .
pulsatile mass palpate xiphoid umbilicus ,
approximately 5 cm examination .
hepatosplenomegaly , renal bruit . Flank
examination negative . low extremity palpable
dorsalis pedi posterior tibial pulse distally
bilaterally .
HOSPITAL COURSE : give presentation , elect
bring operating room [ * * 2140 - 12 - 8 * * ] . first
discharge elective catheterization [ * * 2140 - 12 - 5 * * ]
ultimately readmitte [ * * 2140 - 12 - 8 * * ] , undergo
elective coronary artery bypass graft x 4 Dr. [ * * last Name ( STitle ) * * ] ,
include left internal mammary artery left anterior
descending , right saphenous vein graft diagonal ,
well saphenous vein graft obtuse marginal
saphenous vein graft right posterior descend
artery . patient tolerate procedure well .
intraoperative finding transesophageal echocardiogram
ejection fraction 45 50 % , calcify aorta , good
distal target . pericardium leave open .
right radial - line . right internal jugular cordis
place , CVP , right atrial catheter . two ventricular
wire two atrial wire , two mediastinal tube one
pleural tube . mean arterial pressure 77 ,
right atrial pressure 9 . find normal
sinus rhythm rate 74 . propofol drip
20 mcg / kg / minute sedation .
transfer Cardiac Surgical Recovery Unit ,
first 24 hour surgery , drip
wean rapidly extubate . remain
sinus rhythm 88 , blood pressure 120 130s .
hematocrit 25 postoperatively , bun
creatinine 18 1 . neurologically , remain intact .
start lasix , Lopressor , aspirin . Chest tube
remove , well diet advance .
subsequently transfer floor postoperative
day number one . ambulate postoperative
day number one , feel well . work Physical
Therapy aggressively , continue pulmonary toilet
incentive spirometry , cough deep breathing .
electrolyte replete need .
postoperative day number two , continue feel well .
low - grade temperature 100.9 , otherwise
remainder vital normal , heart rate 94
sinus , blood pressure 114/60 . Lopressor
titrate accordingly . bun creatinine 23
1.0 , hematocrit 24 .
postoperative day number four , patient ambulate .
wire , chest tube Foley remove
point . sinus tachycardia sinus rhythm ,
90 103 . blood pressure range 106 110
50 60 . oxygen saturation 95 % room air .
stable sternum , evidence drainage . abdominal
examination unchanged admission . extremity
warm well perfuse , palpable pulse dorsalis
pedi posterior tibial bilaterally .
subsequently patient deem stable appropriate
discharge .
discharge medication : Lopressor 75 mg mouth twice
day , Lipitor 10 mg mouth daily , lasix 20 mg mouth
daily seven day , K - Dur 20 meq mouth daily
seven day , Protonix 40 mg mouth daily , aspirin
325 mg mouth daily , allopurinol 100 mg mouth
daily , tapazole 20 mg mouth daily , Flomax .4 mg
mouth daily , percocet 5/325 one two tablet mouth
every four six hour need , Colace 100 mg mouth
twice day .
DISCHARGE STATUS : home VNA .
condition DISCHARGE : stable , afebrile , normal sinus
rhythm , evidence sternal drainage .
DISPOSITION : home VNA instruction
undergo heavy lifting great ten pound 30
day , driving 30 day . Wound may get wet shower .
follow Dr. [ * * last Name ( STitle ) * * ] four week , follow
cardiologist primary care physician three
week time discharge . VNA assist
patient . happen dismiss day seven
ten , return Wound Care Clinic ,
receive wound checkup .
discharge DIAGNOSIS :
1 . significant three vessel coronary artery disease status
post coronary artery bypass graft x 4 , left internal
mammary artery left anterior descending , saphenous vein
graft diagonal , obtuse marginal also right posterior
descend artery .
2 . Hypertension
3 . Hyperlipidemia
4 . 6 cm abdominal aortic aneurysm
5 . Benign prostatic hypertrophy
6 . mild chronic obstructive pulmonary disease
7 . 50 pack year smoker
8 . history inferior myocardial infarction coronary
artery disease
9 . Hypothyroidism
10 . questionable history osteoarthritis
[ * * First Name11 ( Name Pattern1 ) 1112 * * ] [ * * last Name ( NamePattern1 ) * * ] , M.D. [ * * MD Number(1 ) 3113 * * ]
dictate by:[**last Name ( namepattern4 ) 3204 * * ]
medquist36
: [ * * 2140 - 12 - 11 * * ] 22:42
: [ * * 2140 - 12 - 12 * * ] 00:35
JOB # : [ * * Job number 24525 * * ]
|
[
"412",
"496",
"2449",
"4019",
"2749"
] |
Admission Date : [ * * 2195 - 8 - 12 * * ] Discharge Date : [ * * 2195 - 9 - 14 * * ]
Date Birth : [ * * 2195 - 8 - 12 * * ] sex :
Service : neonatology
history : Baby [ * * know lastname 2470 * * ] baby boy bear 35 - 3/7
week 24 year old G2 , p1 mother estimate date
confinement [ * * 2195 - 9 - 13 * * ] . prenatal laboratory
include blood type o+ , antibody negative , hepatitis B
surface antigen negative , rpr nonreactive , rubella immune
GBS status unknown .
MATERNAL history DELIVERY : maternal history
notable previous primary c - section postpartum
hemorrhage require uterine artery ligation . pregnancy
reportedly unremarkable day prior delivery
mother develop contraction . come
hospital preterm labor , note cervical dilation
take repeat c - section . sepsis risk factor
identify , mother receive intrapartum
antibiotic prophylaxis . delivery infant emerge
vigorous apgar 8 9 , require brief blow -
O2 . increase work breathing note persist .
Infant bring NICU .
NICU moderate grunting , flaring retraction
apparent room air saturation low 80 . Infant
place CPAP .
PHYSICAL EXAMINATION TIME admission : Weight : 2760
gram , 75th percentile . head circumference : 33.5 cm , 75th
percentile . length : 46 cm , 50th percentile . vital sign :
Temperature 98.4 , heart rate 150s , respiratory rate 40s-50s ,
blood pressure 37/29 MAP 34 O2 saturation 95%-
98 % 40 % FIO2 . general , well develop , pre-
term infant , active vigorous , moderate grunting ,
flaring retraction rest . skin warm , mildly pale .
sluggish capillary refill . rash . heent exam reveal
fontanel soft flat . positive red reflex bilaterally .
palate intact . neck supple . lesion . chest coarse ,
moderately aerate . positive grunt , flare
retraction . Cardiac regular rate rhythm . soft
systolic murmur . Abdomen soft . hepatosplenomegaly .
mass . three - vessel cord . quiet bowel sound . GU : normal male .
testes palpable bilaterally . anus patent . extremity : warm .
lesion . Hips / back : Stable . neurologic : appropriate tone
activity .
SUMMARY HOSPITAL COURSE systems : respiratory :
patient initially place CPAP quickly , day
life 1 due persist increase work breathing
increase O2 requirement , intubate place
conventional ventilator . Patient also receive Survanta x2 ,
day life # 4 wean cpap . day life # 5
wean nasal cannula day life # 6 , [ * * 2195 - 8 - 18 * * ] , patient room air remain room air
discharge . two day prior discharge , infant
experience brief period duskiness associate cry .
apneic time . infant monitor
additional two day without recurrence .
previously observe , infant remain well .
think breath hold event .
Fluids , electrolyte , nutrition : Patient make NPO
1st 5 day life supplement parenteral nutrition
period . day life # 6 start p.o./p.g .
feed breast milk / Enfamil 20 . Patient continue advance
p.o . feeding , day life # 30 achieve full p.o .
feed breast milk 24 / enfamil powder . weight time
discharge 3535 g.
Cardiovascular : Patient note soft murmur
time birth . ekg perform reveal normal
sinus rhythm . Murmur since resolve
GI : Patient note hyperbilirubinemia day life
# 4 . Bilirubin note 12.7/0.5 . Phototherapy
discontinue day life # 6 rebound bilirubin
7.7/0.3 . Phototherapy never restart .
Hematology : patient know setup ,
transfusion ever give throughout hospital course .
infectious disease : CBC blood culture do birth .
Patient start ampicillin gentamicin 48-
hour rule . length course antibiotic
increase 7 - day course antibiotic due
persistent O2 requirement respiratory need
patient despite additional sign symptom infection .
blood culture negative , final [ * * 2195 - 8 - 18 * * ] . lp
perform [ * * 2195 - 8 - 15 * * ] , result unremarkable ,
CSF culture negative , final [ * * 2195 - 8 - 18 * * ] . Patient currently continue Nystatin treatment
oral thrush .
neurologic : Patient normal physical exam note
normal suck , normal grasp , normal tone alert . head
ultrasound indicate .
Sensory : Audiology : hearing screen perform
automate auditory brainstem response . Patient pass
hearing screen [ * * 2195 - 8 - 23 * * ] .
ophthalmology : eye exam indicate ex-35-
weeker weigh 1500 g , require
prolong O2 throughout hospital course .
Psychosocial : [ * * Hospital1 18 * * ] social work involve
family . contact social worker [ * * Name ( NI ) 36130 * * ] [ * * Name ( NI ) 6861 * * ] ,
reach [ * * telephone / Fax ( 1 ) * * ] .
condition discharge : Patient currently stable
condition .
discharge disposition : home mother .
PRIMARY CARE PEDIATRICIAN : [ * * Hospital 17566 * * ] pediatric locate
[ * * Location ( un ) 5871 * * ] , ; phone number [ * * telephone / Fax ( 1 ) 37911 * * ] ; fax [ * * telephone / Fax ( 1 ) 37912 * * ] .
primary care pediatrician Dr. [ * * first Name4 ( NamePattern1 ) 1060 * * ] [ * * last Name ( NamePattern1 ) * * ] .
CARE / recommendation : time discharge patient
maintain full p.o . feed breast milk 24 ad lib .
medication : currently include Nystatin need
treatment oral thrush .
CAR SEAT positioning screening : car seat position
screening pass [ * * 2195 - 9 - 11 * * ] .
IMMUNIZATIONS RECEIVED : Patient receive hepatitis B
vaccine [ * * 2195 - 8 - 11 * * ] .
IMMUNIZATIONS RECOMMENDED : Synergist RSV prophylaxis
consider [ * * Month ( ) * * ] [ * * Month ( ) 958 * * ] infant meet
follow 3 criterion : 1 ) bear less 32
week , 2 ) bear 32 35 week 2
follow : 1 ) daycare RSV season , 2 ) smoker
household , 3 ) neuromuscular disease , airway abnormality
school - age sibling , infant chronic lung
disease . influenza immunization recommend annually
fall infant reach 6 month age .
age 1st 24 month child 's
life , immunization influenza recommend
household contact - - home caregiver .
FOLLOW - appointment recommended patient : Patient
recommend follow PMD , Dr. [ * * first Name4 ( NamePattern1 ) 1060 * * ] [ * * last Name ( NamePattern1 ) * * ] ,
[ * * Hospital 17566 * * ] Pediatrics [ * * last Name ( LF ) 766 * * ] , [ * * 2195 - 9 - 14 * * ] . time
appointment schedule mother .
discharge diagnosis : Prematurity , Respiratory Distress Syndrome ,
Presumed Pneumonia , Hyperbilirubinemia , Monilial Infection
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) * * ] , [ * * MD Number(1 ) 55780 * * ]
dictate by:[**last Name ( NamePattern1 ) 62404 * * ]
medquist36
: [ * * 2195 - 9 - 11 * * ] 15:05:27
: [ * * 2195 - 9 - 11 * * ] 16:00:25
Job # : [ * * Job number 63522 * * ]
|
[
"769",
"7742",
"V290",
"V053"
] |
Admission Date : [ * * 2176 - 2 - 5 * * ] Discharge Date : [ * * 2176 - 2 - 15 * * ]
Date Birth : [ * * 2106 - 8 - 2 * * ] sex : F
Service : MEDICINE
allergy :
Aspirin / Heparin Agents
attending:[**first Name3 ( LF ) 2181 * * ]
Chief Complaint :
mental status change
Major Surgical Invasive Procedure :
Intubation
history Present Illness :
69 yo F history ESRD HD , DM , recently admit
[ * * Hospital1 18 * * ] ORIF left distal femur fracture ( uncomplicated
hospital course ) refer ED today develop acute
change mental status associate decrease responsiveness
dialysis treatment today . history per daughter state
last speak mother night PTA " fine "
( ask daughter finance , etc . ) . deny
mother ever seizure , stroke past . denie
baseline weakness numbness . States patient live
prior recent hip fracture .
.
per sparse history dialysis note , patient give percocet
approximately 9:55am approximately 10:30AM develop
acute mental status change , include confusion . patient
continue dialysis stable vital sign ( BP
130's-140's/60 's , HR 40's-50 's ) . completion dialysis ,
EMS call transfer hospital .
.
EMS note significant note " rapid deterioration
mental status " , right gaze , dry blood lip , response
pain , aphasia . EMS note decrease hr 30 's x 2 transfer ,
FSBS = 185 .
.
presentation ED [ * * Hospital1 18 * * ] , exam notable minimal
responsiveness , GCS 13 , withdrawl extremity pain ,
follow occasional command , non - verbal ( groan ) . VSS
98.8 , hr 58 , BP 132/102 , O2 sit 98 % . Labs notable WBC
9.5 86 n 2 b , Cr 5.1 ( hx ESRD HD ) , AST 59 , LDH 450 ,
AP 218 , bili 3.9 , lactate 2.8 . blood cxs x 2 send ED .
Head CT demonstrate evidence intracranial bleed edema .
CXR wnl . MRI / scan perform ( read pende ) . evaluation
neuro yield diagnosis possible seizure activity . Pt
give narcan 0.4 mg IV x 1 , Ativan total 2 mg IV , dilantin load
( total 2gm IV ) . intubate airway protection
( give FFP prior intubation INR 1.9 , coumadin outpt
/ p hip surgery ) transfer ICU
managment .
Past Medical History :
1 . diabete type 2
2 . ESRD HD Q , W , F
3 . / p infection left knee
4 . h / MRSA / C.diff
5 . nash [ * * 3 - 7 * * ] tylenol
6 . / p ORIF left distal femur fracture [ * * 2176 - 1 - 23 * * ]
Social History :
soh : live home daughter . [ * * Name ( NI ) * * ] ETOH / TOB / illict .
Family history :
FH : non - contributory
Physical Exam :
Gen- intubate sedate
heent- Pinpoint pupil , reactive b / l. 2 cm heal scar r
upper forehead . c / /
Neck- Supple , unable assess JVP
Chest- CLA anteriorly , b / l
CV- Regular , bradycardic . / r / g
abd- + bs . soft . nd . hepatosplenomegaly . masse
[ * * Name ( NI ) * * ] - 1 + le edema . 2 + dp pulse .
.
transfer floor :
Physical Exam :
VS : BP 131 - 143/41 - 57 , hr 74 - 85 RR 20 O2 92 - 96 % RA
Gen - lie bed , slur speech , intermittently open eye ,
intermittently answer question
HEENT - PERRLA . 2 cm heal scar r upper forehead . anicteric
sclerae
Neck - Supple , unable assess JVP , patient left
subclavian line
Chest - decrease breath sound left base
CV - RRR , S1S2 normal , systolic murmur [ * * 4 - 8 * * ] radiate
axillae
Abd - + bs . soft . nd . hepatosplenomegaly . masse , mild
tenderness RUQ deep palpation .
Ext - trace LE edema . 2 + dp pulse .
pertinent result :
[ * * 2176 - 2 - 5 * * ] 02:10PM PT-16.8 * PTT-36.5 * INR(PT)-1.9
[ * * 2176 - 2 - 5 * * ] 02:10PM PLT SMR - LOW PLT count-149 * #
[ * * 2176 - 2 - 5 * * ] 02:10PM neuts-86 * BANDS-2 LYMPHS-5 * MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[ * * 2176 - 2 - 5 * * ] 02:10PM wbc-9.5 # RBC-3.92 * HGB-13.2 # HCT-37.7 # MCV-96
MCH-33.6 * mchc-35.0 RDW-20.1 *
[ * * 2176 - 2 - 5 * * ] 02:10PM ASA - NEG ETHANOL - NEG ACETMNPHN - NEG
bnzodzpn - NEG barbitrt - NEG tricyclic - NEG
[ * * 2176 - 2 - 5 * * ] 02:10PM T4 - 19.8 *
[ * * 2176 - 2 - 5 * * ] 02:10PM TSH-3.6
[ * * 2176 - 2 - 5 * * ] 02:10PM CALCIUM-9.4 phosphate-4.0 # MAGNESIUM-1.8
[ * * 2176 - 2 - 5 * * ] 02:10PM lipase-524 *
[ * * 2176 - 2 - 5 * * ] 02:10PM ALT(SGPT)-15 AST(SGOT)-59 * LD(LDH)-450 * ALK
phos-218 * TOT BILI-3.9 *
[ * * 2176 - 2 - 5 * * ] 02:10PM glucose-186 * UREA N-29 * CREAT-5.1 *
SODIUM-131 * POTASSIUM-3.8 CHLORIDE-93 * total CO2 - 22 anion GAP-20
.
Imaging :
[ * * 2176 - 2 - 5 * * ] CT head w / contrast : evidence intracranial
hemorrhage edema .
[ * * 2176 - 2 - 5 * * ] CXR : unremarkable chest radiograph .
[ * * 2176 - 2 - 5 * * ] MRI brain w / contrast [ * * 2176 - 2 - 5 * * ] : evidence acute
brain ischemia . small arachnoid cyst right
cerebellopontine angle cistern . limited MR angiography study-
distal vasculature poorly visualize , could
secondary low cardiac output .
[ * * 2176 - 2 - 6 * * ] Liver U / - limited examination . patent hepatic artery
vein portal vein flow appropriate
direction .
[ * * 2176 - 2 - 7 * * ] EEG - markedly abnormal portable eeg due slow
disorganize background frequent generalized sharp wave
discharge . finding indicate widespread encephalopathy
affect cortical subcortical structure . medication ,
metabolic disturbance , infection among common
cause . sharp wave prominent frequent suggest
increase risk seizure . nevertheless ,
particularly rhythmic high frequency
recording suggest ongoing seizure time
recording . prominent focal finding although
encephalopathy obscure finding . concern
seizure persist clinically , repeat tracing could
assistance .
[ * * 2176 - 2 - 8 * * ] MR [ * * Name13 ( STitle ) 430 * * ] - severely limited study . large gross change
identify compare [ * * 2176 - 2 - 5 * * ] , subtle acute
change discernable today 's study . indeed
high clinical suspicion acute change [ * * 2 - 5 * * ] , repeat imaging may necessary .
[ * * 2175 - 2 - 9 * * ] abdominal U / - ascite . Marked splenomegaly
Brief Hospital Course :
# mental status change : initial exam notable minimal
responsiveness , withdrawal extremity pain , follow
occasional command , non - verbal ( groan ) . vss 98.8 , hr
58 , BP 132/102 , O2 sit 98 % . Head CT demonstrate evidence
intracranial bleed edema . CXR wnl . MRI / scan
perform show evidence ischemia . evaluation
neuro yield diagnosis possible seizure activity . Pt
give narcan 0.4 mg IV x 1 , Ativan total 2 mg IV , dilantin load
( total 2gm IV ) . intubate airway protection
transfer ICU managment . also
cover possible encephalitis/ meningitis Acyclovir ,
CTX , Vanco Ampicillin . LP do show
sign meningitis encephalitis . pt continue
wax [ * * Doctor Last Name 688 * * ] mental status . find elevate
lft think component hepatic
encephalopathy . First EEG support seizure activity . repeat
EEG show slow activity c / w encephalopathy . possible hepatic
encephalopathy : Ammonia elevate 65 , therefore pt
start lactulose attempt improve MS . repeat
30 's . Abx discontinue . [ * * 2 - 8 * * ] pt self extubate
reintubate extubate [ * * 2 - 9 * * ] . NG tube
place nutrition . follow two day pt
lucid stable . call floor
management . pt continue improve become
lucid orient x3 . Dilantin continue orally 300 mg
QD . Free Dilantin level check therapeutic
level therefore Dilantin increase 150 TID . Free
Dilantin level repeat three day . Lactulose
Rifaximin continue . Lactulose titrate three
bowel movement .
.
# Liver disease : per pt 's daughter pt tylenol induce
liver damage past . per daughter ETOH / drug abuse
past . Hep neg , b surface pos , core neg , Hep C neg . Serum IgG ,
IgA , IgM elevate without specific pattern suggestive
disease process . [ * * Doctor First Name * * ] negative , Anti - sm AMA
mildly positive ( titer 1:20 ) . HSV PCR negative . possible
primary biliary cirrhosis also consistent obstructive
enzyme pattern . also possible steatosis hepatis obesity .
RUQ U / show splenomegaly , ascite , focal lesion
liver , sign biliary dilatiation . flow appropriate
direction portal vein . lft follow
trend . follow LFT , CBC Chem 7
obtain following week . pt follow
arrange Dr. [ * * last Name ( STitle ) 497 * * ] [ * * 2 - 13 * * ]
9.40am . liver biopsy might consider investigate
etiology problem . pt give
hepatitis vaccine stable . advice
avoid hepatotoxic medication .
.
# Transient Leukocytosis intermittent fever spike : Urine
WBC , one time positive urine culture klebsiella . Pt
initially treat suspect meningitis Ampicillin ,
Vancomycin Ceftraixone . antiobiotic discontinue five
day hospital course . pt afebrile
discontinuation antibiotic remain normal
WBC . pt find new systolic murmur exam ,
radiate axilla , consistent mild mitral
regurgitation . follow ECHO obtain . give fact
blood culture negative pt remain
afebrile physical sign examination find
consistent endocarditis suspicion endocarditis
consider low workup obtain .
.
# ESRD : Pt continue outpatient dialysis schedule house .
tolerate dialysis well .
.
# Hypernatremia : transient . due lack free water
prolong initial period without feed complicate NGT
placement . free water deficit calculate 4l. Pt
replete free water bolus via NGT 250cc TID .
Hypernatremia resolve .
.
# Anemia - pt baseline anemia - three point decrease
baseline around 29 . likely sequestration spleen
possible low grade hemolysis due liver disease
addition renal anemia ESRD . hemolysis lab difficult
interpret setting liver disease . iron study
consistent anemia chronic disease , iron deficiency .
Erythropoetin administer dialysis .
.
# Thrombocytopenia & elevate INR : HIT AB POSITIVE . also
splenomegaly chronic liver disease , likely sequestering .
heparin contain product avoid . thrombocyte
consistently 50,000 .
.
# DM2 : endocrinology consult slide scale
adjust per recommendation . Lantus 20 ris continue
outpatient . Pt one time episode hypoglycemia 49 .
ISSC decrease unit two day prior discharge .
fine adjustment achieve rehabilitation center .
.
# ORIF : pt see orthopedic house . Knee XR
obtain . dislocation hardware see . pt
remain weight bearing l leg 5 week . F / u
appointment ortho obtain 5 week .
medication admission :
1 . Colace 100 mg [ * * hospital1 * * ]
2 . pantoprazole 40 mg QD
3 . Acetaminophen 500 mg q6
4 . Metoprolol Tartrate 25 mg [ * * hospital1 * * ]
5 . warfarin 1 mg QD
6 . calcium Carbonate 500 mg TID
7 . hydromorphone 2 mg q6
8 . senna 8.6 mg [ * * hospital1 * * ]
9 . Bisacodyl 10 mg Tablet , QD
10 . sevelamer 800 mg TID
discharge medication :
1 . rifaximin 200 mg Tablet Sig : two ( 2 ) Tablet PO TID ( 3 time
day ) .
Disp:*180 Tablet(s ) * Refills:*2 *
2 . b Complex - vitamin C - Folic Acid 1 mg Capsule Sig : one ( 1 ) Cap
po DAILY ( Daily ) .
disp:*30 Cap(s ) * Refills:*2 *
3 . Epoetin Alfa 10,000 unit / mL Solution Sig : one ( 1 ) Injection
ASDIR ( DIRECTED ) .
Disp:*qs * Refills:*2 *
4 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
disp:*30 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
5 . lactulose 10 g/15 mL Syrup Sig : fifteen ( 15 ) ML po TID ( 3
time day ) .
Disp:*1350 ML(s ) * Refills:*2 *
6 . Insulin Regular Human 300 unit/3 mL Insulin Pen Sig : one ( 1 )
Subcutaneous direct .
Disp:*qs * Refills:*2 *
7 . Phenytoin 50 mg Tablet , Chewable Sig : three ( 3 ) Tablet ,
Chewable PO TID ( 3 time day ) .
Disp:*270 Tablet , Chewable(s ) * Refills:*2 *
8 . Insulin Glargine 100 unit / mL Solution Sig : direct
Subcutaneous bedtime .
Disp:*qs * Refills:*2 *
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 85 * * ] - [ * * Location ( un ) 86 * * ]
discharge diagnosis :
mental status change
EEG seizure like activity
Liver failure
Hepatic encephalopathy
...................
Diabetes type 2
ESRD HD Q , W , F
/ p ORIF left distal femur fracture [ * * 2176 - 1 - 23 * * ]
discharge condition :
good , Pt [ * * Name ( NI ) 9830**]3 , mental status change resolve
Discharge instruction :
please come back hospital see primary care doctor
experience worsen mental status , confusion ,
headache , jaundice concern .
.
please take medication instruct .
Followup Instructions :
please follow Dr. [ * * last Name ( STitle ) 497 * * ] [ * * 2 - 13 * * ]
9.40am liver disease .
.
please follow Neurology , Dr. [ * * last Name ( STitle ) * * ] [ * * 3 - 22 * * ]
11.00am , [ * * Location ( un ) * * ] [ * * Hospital Ward Name 23 * * ] building .
.
please also follow primary care doctor .
.
follow orthopedic fracture : provider :
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern1 ) 2235 * * ] , MD phone:[**telephone / fax ( 1 ) 1228 * * ] Date / Time:[**2176 - 3 - 19 * * ]
9:00
|
[
"5856",
"2760",
"5990",
"2761",
"2875",
"5715"
] |
Admission Date : [ * * 2183 - 10 - 23 * * ] Discharge Date : [ * * 2183 - 10 - 28 * * ]
Date Birth : [ * * 2117 - 8 - 8 * * ] sex : F
Service : MEDICINE
history PRESENT ILLNESS : 65 - year - old woman ,
past medical history significant chronic alcohol
abuse , history alcoholic ketoacidosis , also
depression , COPD , multiple ED visit admission
intoxication , admit ICU severe
hypophosphatemia setting recurrence
alcoholic ketoacidosis . patient 's alcohol level 370
admission . anion gap 37 bicarbonate
11 . phosphate level 0.3 .
PAST MEDICAL history :
1 . chronic alcohol abuse history alcoholic
ketoacidosis .
2 . depression .
3 . COPD .
4 . recently treat herpe zoster .
5 . benign essential tremor .
6 . history adrenal mass .
allergie : know drug allergy .
medication :
1 . combivent 1 - 2 puff [ * * hospital1 * * ] .
2 . naltrexone 50 mg po qd .
3 . Neurontin 40 mg po tid .
4 . desipramine 10 mg po qd .
5 . Zoloft 50 mg po qd .
SOCIAL history : 60 - pack year tobacco history . history
alcohol abuse . history IV drug abuse . patient
former nurse .
PHYSICAL EXAM : vital sign - blood pressure 138/64 , heart
rate 104 , respiratory rate 24 , oxygen saturation 96 % 4
liter face mask .
GENERAL : chronically ill - appear woman visible
tremor odor alcohol upon .
HEENT : Sclerae anicteric . mucous membrane moist . PERRLA .
neck : JVD .
CHEST : clear auscultation . rhonchi , rale
wheezing .
CARDIOVASCULAR : regular rate rhythm . S1 , s2 normal .
murmur , rub gallop .
ABDOMEN : Obese , soft , nontender bowel sound .
extremitie : good distal pulse . club , cyanosis
edema .
NEURO : Nonfocal exception respond name
call .
pertinent labs DIAGNOSTICS : CBC reveal white count
5.5 , 11 % band , hematocrit 42.8 , platelet
count 239 . chem-7 significant sodium 140 ,
potassium 3.8 , chloride 93 , bicarbonate 11 , BUN 24 ,
creatinine 1.2 , glucose 186 . anion gap 36 . ETOH level
370 . Acetone level positive . abg room air ph
7.40 , PCO2 26 , PO2 85 .
ASSESSMENT : 65 - year - old woman , history
alcohol abuse , present hypophosphatemia
alcoholic ketoacidosis . ed , also coffee
ground emesis , although hematocrit remain stable .
HOSPITAL COURSE - following summary [ * * Hospital 228 * * ]
hospital course system :
1 ) HYPOPHOSPHATEMIA : patient receive ample phosphate
repletion - house , day discharge
long hypophosphatemic .
2 ) ALCOHOLIC ketoacidosis : patient aggressively
treat insulin glucose , fluid , electrolyte
repletion Medical Intensive Care Unit extent
anion gap acidosis resolve .
3 ) COFFEE GROUND EMESIS : patient see
gastrointestinal team - house . hematocrit
follow hospital drop significantly .
start PPI . make NPO first ,
slowly advance diet . undergo egd prior
discharge reveal [ * * Doctor First Name * * ] -[**doctor last Name * * ] tear , erythema ,
erosion antrum compatible gastritis ,
esophageal varix , otherwise normal egd .
continue PPI continue 4 week .
Biopsy result time dictation pende .
gastrointestinal team recommend follow - appointment
outpatient , well screening colonoscopy .
4 ) ALCOHOL INTOXICATION : patient maintain
CIWA scale monitor withdrawal . receive
valium accordingly . patient visit substance
abuse team , patient request transfer
inpatient psych facility treatment alcohol
dependence .
5 ) ESSENTIAL tremor : patient treat nadolol
subsequent improvement essential tremor .
continue one , however , baseline .
6 ) DEPRESSION : patient continue Zoloft .
7 ) FEN : patient undergo aggressive electrolyte
repletion , mention . make NPO first ,
hematocrit remain stable
abdominal complaint , advanced tolerate full
diet .
8) prophylaxis : patient treat Protonix ,
mention , well Pneumoboots bowel regimen .
DISCHARGE STATUS : [ * * hospital1 * * ] inpatient substance abuse
treatment .
discharge condition : Fair .
discharge diagnosis :
1 . alcoholic ketoacidosis hypophosphatemia .
2 . essential tremor .
3 . depression .
4 . chronic obstructive pulmonary disease .
5 . Gastritis .
6 . alcohol abuse .
FOLLOW - plan : patient follow - GI
colonoscopy , well follow - coffee ground
emesis . patient follow - primary care
physician need . patient receive inpatient
psych care [ * * hospital1 * * ] .
DISCHARGE medication :
1 . diazepam 10 mg po q 6 h prn CIWA scale great 10 .
2 . calcium carbonate 500 mg po tid meal .
3 . montelukast sodium 10 mg po qd .
4 . Protonix 40 mg po q 12 h.
5 . Nadolol 20 mg po qd .
6 . Multivitamin 1 tablet po qd .
7 . folate 1 mg po qd .
8 . Thiamine 100 mg po qd .
9 . albuterol ipratropium nebs q 6 h prn .
10.sertraline 50 mg po qd .
11.tylenol 325 - 650 mg po q 6 h prn .
dr.[**last Name ( STitle ) * * ] , [ * * first Name3 ( LF ) * * ] 12*ADF
dictate By:[**Last Name ( NamePattern1 ) 1595 * * ]
medquist36
: [ * * 2183 - 10 - 27 * * ] 13:25
: [ * * 2183 - 10 - 27 * * ] 13:33
JOB # : [ * * Job number 47678 * * ]
|
[
"2762",
"496",
"5789",
"311"
] |
Admission Date : [ * * 2179 - 9 - 19 * * ] Discharge Date : [ * * 2179 - 9 - 25 * * ]
Date Birth : [ * * 2109 - 10 - 29 * * ] sex :
Service : CARDIOTHORACIC
allergy :
lipitor
attending:[**first Name3 ( LF ) 1505 * * ]
Chief Complaint :
Dyspnea exertion
Major Surgical Invasive Procedure :
[ * * 2180 - 9 - 18 * * ] Aortic Valve Replacement ( 23 mm ce pericardial ) , Coronary
Artery Bypass Graft x 1 ( LIMA LAD )
history Present Illness :
69 / male h / atrial fibrillation , aortic stenosis ,
coronary artery disease increase symptom
dyspnea exertion . along fatigue dizziness .
refer surgical intervention .
Past Medical history :
Aortic Stenosis , Coronary Artery Disease , Gastroesophageal
Reflux Disease , Atrial Fibrillatoin / p Ablation , / p PPM [ * * 2174 * * ] ,
Erectile Dysfunction / p Hernia repair , / p Bilat knee
arthroscopy
Social History :
deny tobacco ETOH use .
Family history :
NC
Physical Exam :
VS : 72 18 154/98 6 ' 195 #
Gen : WDWN male NAD
skin : Unremarkable
HEENT : EOMI , PERRL NCAT
Neck : Supple , , -JVD , -carotid bruit
Chest : CTAB
Cardiac : irreg rhythm 3/6 SEM radiate carotids
Abd : Soft , NT / ND + BS
Ext : warm , well - perfuse -edema , -varicositie
Neuro : grossly intact , A&O x 3
pertinent result :
[ * * 2179 - 9 - 20 * * ] echo : prebypass : 1 . left atrium normal size .
spontaneous echo contrast thrombus see body
leave atrium leave atrial appendage . 2 . leave ventricular wall
thickness cavity size normal . overall left ventricular
systolic function low normal ( LVEF 50 - 55 % ) . right ventricular
chamber size free wall motion normal . 3 . ascending
transverse thoracic aorta normal diameter free
atherosclerotic plaque . simple atheroma
descending thoracic aorta . 4 . three aortic valve
leaflet , moderately thicken . severe aortic
valve stenosis ( area < 0.8cm2 ) . 5 . mild ( 1 + ) aortic regurgitation
see . mitral valve leaflet moderately thicken . 6 .
pericardial effusion . 7 . Dr. [ * * last Name ( STitle ) * * ] notify
person result [ * * 2179 - 9 - 20 * * ] 1209 . postbypass : 1 . Pt
currently phenylephrine infusion 2 . pt thicken LV
wall underfilled ventricle . Wall motion unchanged
prebypass , EF 50 % 3 . aortic annular ring
see well seat perivalvular leak . +1 Aortic
insufficiency 4 . contour aortic root smooth
aortic cannular remove .
[ * * 2179 - 9 - 21 * * ] CXR : compare previous radiograph ,
relevant change . monitoring support device
unchanged position . evidence pneumothorax
evidence major pleural effusion . subtle retrocardiac
atelectasis . focal parenchymal opacity suggestive
pneumonia . mild overinflation stomach .
[ * * 2179 - 9 - 19 * * ] 05:25pm blood wbc-6.3 rbc-5.04 Hgb-15.7 Hct-44.2 MCV-88
MCH-31.2 mchc-35.6 * RDW-13.5 Plt ct-210
[ * * 2179 - 9 - 22 * * ] 05:35AM blood wbc-21.5 * # rbc-4.63 hgb-14.0 Hct-41.6
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.9 Plt Ct-142 *
[ * * 2179 - 9 - 19 * * ] 05:25PM blood PT-15.1 * PTT-30.8 INR(PT)-1.3 *
[ * * 2179 - 9 - 20 * * ] 09:11PM blood pt-15.9 * PTT-39.0 * INR(PT)-1.4 *
[ * * 2179 - 9 - 19 * * ] 05:25pm blood Glucose-92 UreaN-19 Creat-1.2 Na-142
k-3.9 Cl-108 HCO3 - 26 AnGap-12
[ * * 2179 - 9 - 22 * * ] 05:35AM blood Glucose-153 * UreaN-20 Creat-1.2 Na-133
K-4.5 cl-100 HCO3 - 19 * AnGap-19
[ * * 2179 - 9 - 19 * * ] 05:25pm blood alt-23 ast-23 ld(ldh)-203 alkphos-56
totbili-0.9
[ * * 2179 - 9 - 25 * * ] 08:16AM blood wbc-7.6 RBC-4.02 * Hgb-12.1 * Hct-35.8 *
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt ct-174 #
[ * * 2179 - 9 - 22 * * ] 12:27PM URINE blood - NEG Nitrite - NEG Protein - TR
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln - NEG ph-5.5 Leuks - NEG
Brief Hospital course :
Mr. [ * * know lastname 1274 * * ] admit day surgery /
Coumadin h / Atrial Fibrillation . discontinue 5 day
surgery . upon admission start Heparin
appropriately work surgery . [ * * 9 - 20 * * ] bring
operating room undergo aortic valve replacement
coronary artery bypass graft x 1 . please see operative
report surgical detail . follow surgery
transfer CVICU invasive monitoring stable
condition . later op day wean sedation , awake
neurologically intact extubate . post - op day one EP
consult interrogate pacemaker . later day Mr.
[ * * know lastname 1274 * * ] appear well transfer
telemetry floor care .
Mr [ * * know lastname 1274 * * ] chronic afib difficult control
metoprolol advanced . - start coumadin
POD 2 . rub notice start Ibuprofen .
remainder postoperative course essentially
unremarkable . [ * * 9 - 22 * * ] due elevated WBC ct . blood urine
culture send empiric antibiotic start . Urine
Cx originally positive sensitive ABX repeat finalize
negative . WBC ct improve normal temp.remaine
afebrile , time discharge blood culture pende ,
decide continue full week antibiotic coverage .
restare preoperative dose Digoxin , along
preoperative Coumadin regiment 5 mg alt . 2.5 mg daily ,
VNA . advise follow appointment .
medication admission :
Atenolol 100 mg [ * * hospital1 * * ] , Prilosec 20 mg qd , Tricor 146 mg qd , Digoxin
0.25 mg qd , Vit C , E , Zetia 10 mg qd , Coumadin ( stop [ * * 9 - 14 * * ] )
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:*1 *
3 . hydromorphone 2 mg Tablet Sig : 1 - 2 tablet po Q3H ( every 3
hour ) need .
Disp:*40 Tablet(s ) * Refills:*0 *
4 . Ezetimibe 10 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*1 *
5 . fenofibrate Micronized 145 mg Tablet Sig : one ( 1 ) Tablet PO
daily ( ) .
disp:*30 Tablet(s ) * Refills:*1 *
6 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
disp:*30 Tablet , Delayed Release ( e.c.)(s ) * Refills:*1 *
7 . warfarin 2.5 mg Tablet Sig : 1 - 2 tablet po day : resume
5 mg alternate 2.5 mg daily [ * * Name8 ( MD ) * * ] MD .
Disp:*90 Tablet(s ) * Refills:*0 *
8 . Digoxin 250 mcg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
Disp:*60 Tablet(s ) * Refills:*0 *
9 . Metoprolol Tartrate 50 mg Tablet Sig : 2.5 Tablets po TID ( 3
time day ) .
disp:*225 Tablet(s ) * Refills:*0 *
10 . Lasix 20 mg Tablet Sig : two ( 2 ) Tablet po twice day 7
day .
Disp:*28 Tablet(s ) * Refills:*0 *
11 . Potassium Chloride 20 meq Tab Sust . Rel . Particle / Crystal
Sig : two ( 2 ) Tab Sust . Rel . Particle / Crystal PO twice day 7
day .
Disp:*28 Tab Sust . Rel . Particle / Crystal(s ) * Refills:*0 *
12 . ampicillin 250 mg Capsule Sig : two ( 2 ) Capsule PO Q6H ( every
6 hour ) 4 day .
Disp:*32 Capsule(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
tba
discharge Diagnosis :
Aortic Stenosis / p Aortic Valve Replacement
Coronary Artery Disease / p Coronary Artery Bypass Graft x 1
PMH : Gastroesophageal Reflux Disease , Atrial Fibrillatoin / p
Ablation , / p PPM [ * * 2174 * * ] , Erectile Dysfunction / p Hernia repair ,
/ p Bilat knee arthroscopy
discharge condition :
good
Discharge instruction :
monitor wound sign infection . include redness ,
drainage increase pain . event drainage
sternal wound , please contact [ * * name2 ( NI ) 5059 * * ] ( [ * * telephone / Fax ( 1 ) 4044 * * ] .
report fever great 100.5 . report weight gain 2
pound 24 hour 5 pound 1 week .
lotion , cream powder incision heal .
Shower daily . bath swimming . gently pat wound dry .
lift great 10 pound 10 week .
driving 1 month
take medication direct
Followup Instructions :
wind clinic 2 week
Dr [ * * last Name ( STitle ) * * ] 4 week
Dr [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 4469 * * ] [ * * 2 - 14 * * ] week
complete by:[**2179 - 9 - 25 * * ]
|
[
"4280",
"5990",
"4241",
"2875"
] |
Admission Date : [ * * 2124 - 7 - 14 * * ] Discharge Date : [ * * 2124 - 7 - 19 * * ]
Date Birth : [ * * 2067 - 12 - 2 * * ] sex :
Service : MEDICINE
allergy :
Iodine ; Iodine contain
attending:[**first Name3 ( LF ) 2297 * * ]
Chief Complaint :
hypotension
Major Surgical Invasive Procedure :
none
history Present Illness :
56 year old alcoholic cirrhosis end - stage liver disease
" " [ * * location 24355 * * ]
past month repeat episode LE cellulitis
include ? nec fascitis one occasion .
rehab hospital today ( send VA )
feel well per report , want / C'd get
lab concern ( hct , cr ) send [ * * Hospital 6451 * * ] Hospital . find Hct 27 , SBP
60 's , Melena . start levophe ns " wide
open " one 20 Ga IV . transfer .
arrival ED , afebrile , hr 91 , BP 72/36 RR 20
Sat 96 % 2l. give 2 18 Ga PIV , Rt . femoral TLC ,
Vitamin K , litre NS , FFP ( 3 u ) , 1 U PRBC IV protonix .
GI renal consult . Cr . 3.6 , k 5.8 ,
note ECG change 12 - lead ;
give kayexelate .
.
MICU admission request .
Past Medical history :
alcoholic cirrhosis end - stage liver disease -
transplant list anywhere per pt . ( evaluate ) .
CRI ( ? baseline Cr . )
Mult . recent episode cellulitis
DM2
Social History :
etoh , last drink per pt . 10 yy ago ; IVDU , Army ,
also work delivery man
family history :
DM - mother , deny hx . CHD family
Physical Exam :
VS : BP 60 be 40 's hr 115 , AF , R 25 , 96 % NC
HEENT EOMI , sclerae icteric
COR : tachy , regular , [ * * 12 - 27 * * ] hsm
PULM : CTA ant
ABD : distended tense ascite
EXT : 4 + LE edema
NEURO : Alert , orient place , time , event
Brief Hospital course :
Patient admit MICU . condition continue
deteriorate despite measure make DNR / DNI
consensus family [ * * 2124 - 7 - 18 * * ] . continue decline
morning [ * * 2124 - 7 - 19 * * ] , verbal discussion
three child , patient make COMFORT MEASURES .
treat morphine respiratory distress pressor
withdraw . Patient pass away shortly thereafter
pronounce decease [ * * 7 - 19 * * ] 00:20 [ * * First Name8 ( NamePattern2 ) 11556 * * ] [ * * last Name ( NamePattern1 ) 18721 * * ] MD
[ * * first Name8 ( NamePattern2 ) 2894 * * ] [ * * last Name ( NamePattern1 ) * * ] MD .
.
.
.
IMP:56 / ETOH cirrosis end - stage liver disease
present OSH rehab hypotension , melena
.
# hypotension : likely cause GIB / hypovolemia .
Place line , cont . bolus Map less 65 . add
vasopressin respond levophe IVF . Monitor UOP .
Serial Hct . transfuse hct less 25 . FFP correct
coagulopathy . discuss GI .
.
# melena - , call GI . [ * * Month ( ) 116 * * ] need NGL . Serial Hct . PPI IV
BID . Octreotide gtt .
.
# cirrhosis / liver disease : obstructive picture . Patient
pericentesis x 2 order relieve abdominal ascite .
first remove 4.5 liter clear yellow ascite fluid
second remove 2 liter .
Consult liver . continue lactulose . Follow INR . check albumin .
hold diuretic hypotense .
.
# renal failure : ? baseline Cr . Possible HRS vs. pre - renal
volume depletion [ * * 12 - 23 * * ] GIB . consult liver renal , continue
volume repletion , maintain SBP . consider albumin post
tap , consider add midodrine . Patient start CVVH .
.
# hyperkalemia : resolve .
.
# FEN : IVF , lyte prn , NPO give GIB .
.
# PPX : PPI [ * * hospital1 * * ] , coagulopathic .
.
# access : 2 piv , TLC lt . groin .
.
# Code : COMFORT MEASURES
.
# communication : daughter - [ * * Name ( NI ) * * ] , [ * * first Name3 ( LF ) * * ] , daughter [ * * Name ( NI ) * * ]
.
# disposition : MICU
medication admission :
Aldactone
Calcium
Lasix
Insulin
Lactulose
Nepro
Ocycodone
Discharge medication :
decease
discharge Disposition :
expire
discharge Diagnosis :
decease
discharge condition :
decease
Discharge instruction :
decease
Followup Instructions :
decease
|
[
"5845",
"2875",
"5859",
"2767"
] |
Admission Date : [ * * 2139 - 9 - 8 * * ] Discharge Date : [ * * 2139 - 9 - 26 * * ]
Date Birth : [ * * 2082 - 11 - 16 * * ] sex : F
Service : Newurosurgery
history PRESENT ILLNESS : patient 57 year old
female past medical history sudden onset
midback pain severe headache . say feel like
bomb give speech [ * * country 2784 * * ] . finish
speech vomit . [ * * 2139 - 9 - 4 * * ] . headache
persist . return United States follow
day increase fatigue , headache backache . go
[ * * hospital3 * * ] Emergency Department [ * * 2139 - 9 - 7 * * ] ,
CTA reveal large bilobe 1.2 2.0 centimeter ACA
aneurysm , transfer [ * * Hospital 4415 * * ]
[ * * 2139 - 9 - 7 * * ] , workup . CTA repeat confirm
previously mention aneurysm . transfer
[ * * Hospital1 69 * * ] embolization
aneurysm .
PAST MEDICAL history : None .
PAST surgical history : none .
allergie : know drug allergy .
medication admission : None .
SOCIAL history : ETOH thirty pack year smoker .
PHYSICAL EXAMINATION : neurologically completely
intact . Speech clear . pupil reactive light
accommodation , 3.0 millimeter brisk . facial
asymmetry . drift . Speech clear fluent , awake ,
alert oriented time three . vital sign reveal blood
pressure 92 106 60 70 , respiratory rate 14 18 .
HOSPITAL COURSE : patient admit go directly
angiography suite bilobe ACA
aneurysm coil . coiling partially do
time . actual angiogram coiling , patient
complain chest pain . see cardiology
angiography suite chest pain resolve .
feel anxiety produce . postoperatively , vital
sign temperature 96.0 , blood pressure 103/60 , pulse 69 ,
respiratory rate 18 , oxygen saturation 99 % . patient
awake , alert oriented time three . unsure
hospital recently transfer . know
month day . negative drift , symmetric smile .
pupil equal reactive time light
accommodation , 2.5 2.0 . left
conjunctival hematoma . positive pedal pulse . Groin
intact sheath . upper low extremity reveal
motor strength [ * * 3 - 23 * * ] . follow command .
headache . white blood cell count 9.4 , hematocrit
32.9 . preoperative hematocrit 37.7 . prothrombin
time 15.4 , partial thromboplastin time 150 . INR 1.6 .
first postoperative day , patient 's vital sign
99 100 range . awake alert
orient time three . complain seven ten
headache , diplopia . extraocular movement full .
visual field intact . negative drift . Grip [ * * 3 - 23 * * ] .
positive femoral right pulse . remain neurologic
Intensive Care Unit receive Nimodipine 30 mg
q2hour , normal saline 150 per hour . central line
place . blood pressure keep less 140 . Heparin
continue 600 per hour . [ * * 2139 - 9 - 9 * * ] , patient
bring back complete coil . postoperatively ,
awake , alert oriented time three . speech
fluent . Naming intact . follow command .
right groin sheath remain intact . blood pressure
keep 100 130 range . need remain
Heparin apparent vessel possibly thrombose
want wean . Heparin keep 600 per
hour . want area thrombose quickly .
coiling go well successful . remain
Heparin postoperatively . patient remain
Intensive Care Unit Heparin partial thromboplastin
time keep 60 80 . sheath remain
place . [ * * 2139 - 9 - 14 * * ] , patient awake , alert
orient complaint grip [ * * 3 - 23 * * ] , drift .
patient 's Heparin drip reduce [ * * 2139 - 9 - 14 * * ] ,
start Aspirin 325 mg daily . however ,
patient start complain blurry vision
peripheral type tunneling left eye last thirty
forty - five minute . retinal fellow consult
find evidence vascular occlusion .
decrease vision left eye , however ,
patient claim last great 1.5 year .
feel ocular migraine left eye .
patient continue stay Heparin . [ * * 2139 - 9 - 15 * * ] ,
partial thromboplastin time 50 . see
retinal specialist still feel ocular
migraine sign want follow -
outpatient . Heparin stop [ * * 2139 - 9 - 16 * * ] . Aspirin 81 mg
continue . sodium 136 , drop 134 .
monitor twice day . [ * * 2139 - 9 - 16 * * ] , patient
undergo cerebral angiogram check progressive
thrombus coil leave internal carotid artery . stable
appearance coil note day .
start Plavix 75 mg daily Aspirin 325 mg
daily . long need Heparin . postoperative check ,
awake , alert . extraocular movement full ,
drift . [ * * 2139 - 9 - 18 * * ] , remain awake alert
headache time . extraocular movement full .
face symmetric . sodium 134 . ,
angiogram previous day show spasm . intravenous
fluid keep 150 per hour . continue
Nimodipine . [ * * 2139 - 9 - 18 * * ] , ask retinal specialist
reexamine patient complain decrease
vision left eye last one two day .
ophthalmic examination within normal limit .
decrease acuity left eye unclear . possibility
include mass effect , compression aneurysm .
recommend consider intravenous steroid , also
recommend get ESR , CRP neurologic
ophthalmology consultation . Neurophthalmology see
patient feel compression optic
neuropathy feel relate ACA
aneurysm mass effect . request steroid .
patient start Decadron 4 mg p.o . q6hours .
[ * * 2139 - 9 - 19 * * ] , vision improve . [ * * 2139 - 9 - 21 * * ] , patient
underwent status post neuroform stent mediate coiling
right internal carotid artery aneurysm . postoperatively ,
well intraoperative complication .
postoperatively , stay Plavix Aspirin .
sheath remain place overnight remain
Heparin overnight . postoperatively , alert without
complaint , deny headache double vision . left
groin ooze around sheath . dressing replace .
pupil equal , round , reactive light
accommodation . extraocular movement full . visual
field full confrontation . recommend one unit
pack red blood cell . blood pressure keep
120 range continue Aspirin Plavix .
postoperatively , hematocrit 28.5 [ * * 2139 - 9 - 22 * * ] ,
receive one unit pack red blood cell . Sheath
remove . [ * * 2139 - 9 - 23 * * ] , vital sign temperature 98.2 ,
blood pressure 97/49 . White blood cell count 10.0 ,
hematocrit 32.1 , platelet count 364,000 . patient
neurologically intact . sign hematoma .
[ * * 2139 - 9 - 24 * * ] , patient transfer
Neurologic Intensive Care Unit . give physical
therapy consultation . intravenous fluid decrease
100 per hour . diet increase tolerate .
give intravenous bolus systolic blood pressure
less 100 . remain surgical floor .
patient discharge [ * * 2139 - 9 - 26 * * ] .
discharge instruction :
1 . strenuous exercise , driving clear Dr.
[ * * last Name ( STitle ) 1132 * * ] .
2 . follow - Dr. [ * * last Name ( STitle ) 1132 * * ] one week
neurophthalmology , give telephone number
call .
medication DISCHARGE :
1 . Protonix 40 mg p.o . daily .
2 . Percocet 5/325 one two tablet p.o . q3 - 4hours
need .
3 . Plavix 75 mg p.o . daily .
4 . Aspirin 325 mg p.o . daily .
5 . Decadron wean week .
condition discharge : patient discharge
neurologically stable [ * * 2139 - 9 - 26 * * ] .
[ * * Name6 ( MD ) * * ] [ * * last Name ( namepattern4 ) * * ] , M.D. [ * * MD Number(1 ) 1133 * * ]
dictate by:[**last Name ( NamePattern4 ) 26792 * * ]
medquist36
: [ * * 2139 - 10 - 28 * * ] 13:00
: [ * * 2139 - 10 - 31 * * ] 10:17
JOB # : [ * * Job number 50244 * * ]
|
[
"2761",
"3051"
] |
Admission Date : [ * * 2198 - 2 - 1 * * ] Discharge Date : [ * * 2198 - 2 - 19 * * ]
Date Birth : [ * * 2129 - 10 - 28 * * ] sex :
Service : CSU
history PRESENT ILLNESS : 68 year old white male
abnormal stress test 02/[**2194 * * ] . undergo cardiac
cath reveal 100 percent RCA lesion . angina
[ * * 2196 * * ] abnormal stress test re-
cathe , show 100 percent RCA lesion , 50 percent
leave main stenosis , left circumflex stenosis .
symptom surgery defer . month
angina abnormal treadmill EF
27 percent . angio [ * * 2198 - 1 - 31 * * ] reveal 95 percent
ostia leave main , 70 percent diagonal 2 lesion , 80 percent
OM 100 percent RCA lesion normal LV .
transfer [ * * Hospital1 18 * * ] treatment .
PAST MEDICAL history : past medical history
significant history non - insulin dependent diabetes ,
hypercholesterolemia , hypertension , prostate CA , status
post removal basal cell carcinoma back two
week prior admission . also status post cataract
surgery .
medication : medication admission nitroglycerin
drip , Metformin , Lipitor , aspirin , multivitamin , Metamucil ,
Atenolol .
allergy : known allergy .
FAMILY history : family history significant coronary
artery disease .
SOCIAL history : smoke cigarette drink
alcohol occasionally .
REVIEW systems : review system .
PHYSICAL EXAMINATION : well develop , well nourished
white male apparent distress . vital sign stable .
Afebrile . heent exam normocephalic atraumatic .
extraocular movement intact . Oropharynx benign . Neck
supple . full range motion . lymphadenopathy
thyromegaly . Carotids 2 plus equal bilaterally without
bruit . lung clear auscultation percussion .
cardiovascular exam regular rate rhythm . Normal S1
s2 rub , murmur gallop . Abdomen soft
nontender positive bowel sound . masse
hepatosplenomegaly . extremity without cyanosis , club
edema . pulse 2 plus equal bilaterally
throughout . Neuro exam nonfocal .
HOSPITAL COURSE : Dr. [ * * last Name ( STitle ) * * ] consult [ * * 2198 - 2 - 2 * * ]
patient undergo CABG times five free LIMA
LAD reverse saphenous vein graft diagonal ,
OM1 , OM2 PVA . cross clamp time 89 minute . total
bypass time 125 minute . transfer CSRU
Neo stable condition . stable postop night .
extubate . postoperative day one start
beta blocker nitro wean . Postop day two
transfer floor stable condition
chest tube discontinue . Postop day three
epicardial pacing wire discontinue . Postop day number
four begin sternal drainage . start
Kefzol wound paint Betadine tid .
drainage low two sternal wire
seem pull x - ray , postop day
number five undergo sternal - wiring . tolerate
procedure well transfer back floor .
continue improve chest tube discontinue
postop day number one - wiring . also change
Levofloxacin Vanco . continue improve
continue intermittent sternal drainage .
culture negative . PICC line place
continue Vanco . eventually drainage stop
completely two day drainage Vanco
discontinue discharge home week
Levofloxacin . postop day number 17 discharge
home stable condition .
LABORATORY DATA : lab discharge white count
10,000 , hematocrit 28.1 , platelet 767,000 , sodium 139 ,
potassium 5.2 , chloride 104 , CO2 28 , BUN 17 , creatinine 0.9 ,
blood sugar 116 .
discharge medication :
1 . glucophage , 500 mg po bid .
2 . Colace , 100 mg po bid .
3 . aspirin , 81 mg po q day .
4 . Percocet , 1 2 po q4 - 6h prn pain .
5 . lipitor , 10 mg po q day .
6 . Plavix , 75 mg po q day .
7 . Lopressor , 100 mg po tid .
8 . Lisinopril , 10 mg po q day .
9 . Levofloxacin , 500 mg po q day 7 day .
see Dr. [ * * last Name ( STitle ) * * ] four week Dr. [ * * last Name ( STitle ) 37063 * * ]
one two week .
discharge diagnosis : discharge diagnosis include :
1 . coronary artery disease .
2 . Hypertension .
3 . Hyperlipidemia .
4 . non - insulin dependent diabete .
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , M.D. [ * * MD Number(2 ) 5897 * * ]
dictate by:[**last Name ( NamePattern1 ) * * ]
medquist36
: [ * * 2198 - 2 - 19 * * ] 15:54:20
: [ * * 2198 - 2 - 19 * * ] 16:33:56
Job # : [ * * Job number 58744 * * ]
|
[
"4111",
"4019"
] |
Admission Date : [ * * 2111 - 5 - 25 * * ] Discharge Date : [ * * 2111 - 5 - 29 * * ]
Date Birth : [ * * 2063 - 5 - 8 * * ] sex : F
Service : MEDICINE
allergy :
Penicillins / cephalosporin
attending:[**first Name3 ( LF ) 30 * * ]
Chief Complaint :
Overdose
Major Surgical Invasive Procedure :
none
history Present Illness :
Pt 47 yo female chronic pain low back
torticolli hospitalize 7 previous medication
overdoses(always deny SI)(most recently 2 day ago )
present / p OD combination meds ( baclofen , vicodin ,
soma , fentanyl patch , methadone ) . unclear suicide attempt ,
deny past od . recent
hospitalization indicate / diazepam , methadone , baclofen .
today find halfway house staff " nod " minimally
responsive ( sternal rub ) . report available .
unable contact halfway house / n.
Past Medical history :
PMH :
1 . polysubstance overdose -- Pt 5 suicide attempt within
five month period [ * * 2109 * * ] . also recently admit [ * * Date range ( 1 ) 76337 * * ]
overdose vicodin / soma / baclofen state
suicide attempt , rather attempt control pain .
2 . substance abuse - EtOH .
3 . Depression- see [ * * Hospital1 1680 * * ] HRI Mind Body Institute
4 . ? bipolar disorder
5 . Chronic buttock / back pain : trigger point injection
low back region .
6 . cervical torticolli : receive botox injection , severe
left - sided head tilt together may compensatory
tilt opposite direction thoracic spine . pain
region right sternomastoid right posterior cervical
muscle .
7 . gastroesophageal reflux disease .
8 . h / MRSA sputum [ * * 2108 * * ] , treat
9 . h / assault require ICU admit last year .
10 . h / multiple miscarriage , 1 late pregnancy , h / 2 yo
daughter drowning .
11 . recently start methadone pain control [ * * 2 - 17 * * ]
.
provider :
PCP : [ * * last Name ( namepattern4 ) * * ] . [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 5781 * * ] [ * * company 191 * * ] , [ * * telephone / Fax ( 1 ) 250 * * ]
Neuro : Dr. [ * * last Name ( STitle ) * * ] [ * * Hospital1 18 * * ] , [ * * telephone / Fax ( 1 ) 1942 * * ]
Ortho : Dr. [ * * First Name8 ( NamePattern2 ) * * ] [ * * Name ( STitle ) 1022 * * ] , [ * * telephone / Fax ( 1 ) 7807 * * ]
Spinal surgeon : Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 28003 * * ]
[ * * first Name4 ( NamePattern1 ) 1193 * * ] [ * * last Name ( NamePattern1 ) 1194 * * ] Management Service : Dr. [ * * last Name ( STitle ) * * ] , [ * * telephone / Fax ( 1 ) 49911 * * ]
.
PSYCHIATRIC history :
diagnosis : depress [ * * telephone / Fax ( 1 ) * * ] , question bipolar disorder
h / alcohol abuse , narcotic abuse ; sexual assault
hospitalization : HRI , [ * * Doctor Last Name 16471 * * ] , [ * * hospital3 44097 * * ] .
Suicide attempt : patient deny
current [ * * hospital3 2447 * * ] : Dr. [ * * last Name ( STitle ) 105809 * * ]
therapist : [ * * first name5 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 105810 * * ] [ * * Location ( un ) 86 * * ] [ * * Hospital1 1680 * * ] Trauma Center
[ * * Location ( un ) 577 * * ] [ * * telephone / Fax ( 1 ) 7353 * * ] ( L / hour line )
Counselor : [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , [ * * telephone / Fax ( 1 ) 105817 * * ]
Social History :
live [ * * location 3952 * * ] House . Smokes [ * * 11 - 16 * * ] ppd 10 yrs . document
h / EtOH abuse past , + abuse prescription med
Family history :
NC
Physical Exam :
VS 95.0 117/59 78 14 98 % 2L NC
Gen : disheveled woman sleep , respond painful / noxious
stimulus
HEENT : anicteric , PERRL -- > 4 mm b , op clear w/ MMM
CV : reg s1 / s2 , s3 / s4 / / r
Pulm : CTA B ( poor effort ) , wheeze crackle
Abd : + bs , soft , NT , ND
Ext : warm , 2 + dp b , edema
Neuro : respond noxious stimulus , + gag reflex , move 4
extr .
pertinent result :
Pertinent Admission Labs :
wbc 7.7 , hct 33.5 , INR 1.0 . Serum ASA 9 , Ammonia 26 , Utox +
benzo methadone ( neg cocaine , opiate )
lft : ALT 14 , AST 19 , / p 98 , Tbili 0.1
.
EKG : NSR 80 , nl axis , nl interval , ST / change
CXR : r atelectasis
Brief Hospital Course :
47 / female chronic pain low back torticollis
hospitalize 7 previous medication overdose
present / p likely OD minimal responsiveness . brief
[ * * Hospital 11822 * * ] hospital course outline .
1 . mental status change / respiratory depression : likely
secondary medication effect substance abuse / overdose .
note initial tox screen positive benzo methadone .
remainder tox screen negative . give narcan
initially max dose 1mg / hr without increase
responsiveness . therefore discontinue . mental
status gradually improve next 24 hour . note ,
need intubation respiratory support
evidence withdrawl sign symptom . keep
diazepam 5 mg q4prn CIWA scale > 12 , however require
valium . CIWA scale subsequently discontinue .
benzo opioid analgesic stop .
2 . psych : initially hold med admission . Neurontin ,
lamictal , seroquel restart upon improvement MS . Pt
extensive psychiatric history include history polysubstance
abuse OD . Psych consult day admission - recommend
1:1 sitter , obtain . also recommend hold
give benzo , addictive substance - per psych ,
unlikely patient withdraw long half life ,
although keep CIWA case . CIWA . discontinue
lamictal per psych recs . increase seroquel dose symptom
anxiety . plan section 35 patient mandatorily receive
drug rehab .
3 . torticolli : recieve botox injection Dr. [ * * last Name ( STitle ) * * ]
hospital stay .
medication admission :
1 . Quetiapine Fumarate 100 mg Tablet Sig : one ( 1 ) Tablet po QHS
( day ( bedtime ) ) .
2 . Pantoprazole Sodium 40 mg Tablet , Delayed Release ( E.C. ) Sig :
one ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
3 . gabapentin 300 mg Tablet Sig : one ( 1 ) Tablet PO three time
day .
4 . lamictal 25 mg Tablet Sig : one ( 1 ) Tablet po day . 7
tablet
5 . ASA prn
Discharge medication :
1 . Pantoprazole Sodium 40 mg Tablet , Delayed Release ( E.C. ) Sig :
one ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
2 . gabapentin 300 mg Capsule Sig : one ( 1 ) Capsule PO TID ( 3
time day ) .
3 . Quetiapine Fumarate 100 mg Tablet Sig : one ( 1 ) Tablet PO HS
( bedtime ) .
4 . ibuprofen 600 mg Tablet Sig : one ( 1 ) Tablet po Q8H ( every 8
hour ) need .
5 . Acetaminophen 325 mg Tablet Sig : 1 - 2 tablet PO q4 - 6h ( every
4 6 hour ) need .
6 . nicotine 14 mg/24 hr Patch 24hr Sig : one ( 1 ) patch 24hr
Transdermal DAILY ( Daily ) .
7 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
8 . Quetiapine Fumarate 25 mg Tablet Sig : two ( 2 ) Tablet PO TID
( 3 time day ) need .
9 . Quetiapine Fumarate 25 mg Tablet Sig : two ( 2 ) Tablet po QAM
( day ( morning ) ) .
discharge Disposition :
Extended Care
discharge Diagnosis :
primary diagnosis :
1 . respiratory depression
2 . alter mental status
3 . substance abuse / overdose
secondary diagnosis :
1 . torticolli
2 . h / suicide attempt
3 . h / substance abuse
4 . depression
5 . MRSA sputum [ * * 2108 * * ]
discharge condition :
section 35 involuntary detox
Discharge instruction :
Report nausea , vomiting , fever , chill , shortness breath
pain control current regiman medical issue
primary physician .
Followup Instructions :
follow - primary physician medical issue
|
[
"2859"
] |
Admission Date : [ * * 2178 - 12 - 25 * * ] Discharge Date : [ * * 2178 - 12 - 27 * * ]
Date Birth : [ * * 2116 - 2 - 19 * * ] sex : F
Service : MEDICINE
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 7055 * * ]
Chief Complaint :
transfer [ * * hospital3 * * ] admit
atypical chest pain SOB
Major Surgical Invasive Procedure :
-central venous line insertion R IJ
-multiple attempt secure arterial access
history Present Illness :
62f hx severe pulm HTN , CAD / p DES Lcx / LAD
[ * * 10/2177 * * ] , prior CVA / p b / l CEA 's , PVD , COPD admit
OSH [ * * 12 - 23 * * ] atypical chest pain SOB . rule
ACS enzyme ( mb 8 - > 7 - > 5 ; Trop 0.06 - > 0.07 - > 0.06 )
EKG without acute ischemic change find
BNP 11 k admission . assess severe
decompensate r - sided chf diurese 40 mg iv lasix
ed later day experience [ * * 9 - 9 * * ] back pain desat
50 's transfer CCU close monitoring
hr 60 's BP 's 90 's . ECHO [ * * 12 - 24 * * ]
show severe pulmonary hypertension , RV pressure
overload , modestly depressed rv function , LVEF 55 - 65 % .
.
CCU describe feel gradually short
breath past 2 month become acutely bad
past 1 - 2 week . interestingly , 1 month ago
start sildenafil treatment pulm htn feel
become short breath take medication
stop take 2 week ago start feel
acutely short breath . state
gain 2 - 3lbs past two week notice increase
ankle swelling , increase need oxygen ( usually
88 - 92 3LNC home prior past 2 week
use oxygen night ) . 2 pillow orthopnea ,
deny PND . deny dietary indiscretion , recent illness ,
fever , chill , cough , sputum production , symptom .
accord family never low back pain
problem patient state back pain get well
positional change rub . also , baseline daily
function decrease normally able move around
room house able walk 10
foot due shortness breath addition basleine
vascular claudication .
.
review system , / deny prior history stroke ,
tia , deep venous thrombosis , pulmonary embolism , bleed
time surgery , myalgias , joint pain , cough , hemoptysis , black
stool red stool . / deny recent fever , chill
rigor . review system negative .
.
Cardiac review system notable absence chest pain ,
paroxysmal nocturnal dyspnea , palpitation , syncope
presyncope .
Past Medical History :
1 . CARDIAC risk factor : + Diabetes , + dyslipidemia , +
Hypertension
2 . cardiac HISTORY : CAD / p LAD cypher stente
- CABG : n /
- PERCUTANEOUS CORONARY INTERVENTIONS :
- PACING / ICD : n /
3 . PAST MEDICAL history :
-Occult SBE aortic valve vegetation
-Severe pHTN
-Severe PVD / p multiple vascular surgery
-Rt fem-[**doctor last Name * * ] bypass
-Rt CEA follow CVA prior [ * * 2173 * * ]
-Lt CEA follow TIA [ * * 2173 * * ]
-stenting LCx DPromus [ * * Name Prefix ( Prefixes ) * * ]
-[**last Name ( Prefixes ) * * ] Prox / Mid LAD Promus Stent
Social History :
Pt liver two daughter home .
Tob : 0.5ppd x40years ( since age 17 )
EtOH : social - 2 beer every 2 week
Illicit drug use : deny
family history :
Father mi 50 's stroke 60 's . sibling
DM .
Physical Exam :
admission PHYSICAL exam :
VS : t=96.7 bp=103/66 hr=72 rr=10 O2 sat= 93 % non - rebreather
GENERAL : NAD . orient x3 . mood , affect appropriate .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
neck : supple JVP earlobe
CARDIAC : PMI locate 5th intercostal space , midclavicular
line . rr , normal S1 , loud s2 . / r / g. S3 apex . thrill ,
lift .
lung : rale halfway basis
ABDOMEN : soft , obese , NTND . HSM tenderness . abd aorta
enlarge palpation . abdominial bruit .
extremity : 2 + pit mid shin , several old scar
prior vascular surgery procedure . femoral bruit .
skin : mild stasis dermatitis change .
pulse :
right : Carotid 2 + Femoral 2 + popliteal 1 + dp 2 + PT 2 +
leave : Carotid 2 + Femoral 2 + popliteal 1 + dp dopplerable , PT
dopplerable
.
discharge PHYSICAL EXAM :
Patient expire .
pertinent result :
ADMISSION labs :
.
[ * * 2178 - 12 - 25 * * ] 06:24PM blood WBC-12.5 * RBC-4.46 Hgb-11.4 * Hct-35.8 *
MCV-80 * MCH-25.5 * MCHC-31.7 RDW-17.5 * Plt ct-348
[ * * 2178 - 12 - 25 * * ] 06:24PM blood Neuts-77 * Bands-0 Lymphs-18 Monos-4 Eos-0
baso-0 Atyps-1 * Metas-0 Myelos-0 NRBC-1 *
[ * * 2178 - 12 - 25 * * ] 06:24PM blood Hypochr-3 + Anisocy-1 + Poiklo-2 +
Macrocy - NORMAL Microcy-2 + Polychr - NORMAL Ovalocy - OCCASIONAL
Target - OCCASIONAL burr-2 +
[ * * 2178 - 12 - 25 * * ] 06:24PM blood pt-17.0 * PTT-34.3 INR(PT)-1.5 *
[ * * 2178 - 12 - 25 * * ] 06:24PM blood Glucose-40 * UreaN-45 * Creat-1.8 * Na-131 *
K-3.6 Cl-93 * HCO3 - 22 AnGap-20
[ * * 2178 - 12 - 25 * * ] 06:24PM blood ck(cpk)-180
[ * * 2178 - 12 - 26 * * ] 05:17AM blood alt-81 * AST-65 * LD(LDH)-365 * CK(CPK)-149
AlkPhos-88 TotBili-1.2
[ * * 2178 - 12 - 25 * * ] 06:24PM blood CK - MB-13 * mb indx-7.2 cTropnT-0.37 *
[ * * 2178 - 12 - 25 * * ] 06:24PM blood Calcium-8.7 Phos-5.6 * mg-1.4 *
.
PERTINENT labs :
.
[ * * 2178 - 12 - 25 * * ] 06:24PM blood CK - MB-13 * mb indx-7.2 cTropnT-0.37 *
[ * * 2178 - 12 - 26 * * ] 05:17AM blood CK - MB-11 * MB Indx-7.4 * cTropnT-0.31 *
[ * * 2178 - 12 - 26 * * ] 08:54PM blood CK - MB-9 cTropnT-0.35 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood CK - MB-29 * MB Indx-10.1 * cTropnT-1.00 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood cortsol-32.8 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood tsh-2.1
[ * * 2178 - 12 - 26 * * ] 05:41am blood lactate-1.7
[ * * 2178 - 12 - 26 * * ] 03:52pm blood Lactate-2.5 *
[ * * 2178 - 12 - 26 * * ] 11:26pm blood Lactate-7.5 *
[ * * 2178 - 12 - 27 * * ] 01:50AM blood Lactate-8.7 *
[ * * 2178 - 12 - 27 * * ] 04:24AM blood Lactate-11.1 *
[ * * 2178 - 12 - 27 * * ] 05:05AM blood Lactate-10.3 *
[ * * 2178 - 12 - 27 * * ] 11:38am blood Lactate-5.1 *
[ * * 2178 - 12 - 26 * * ] 03:52pm blood type - art pO2 - 52 * pco2 - 35 pH-7.42
calTCO2 - 23 Base XS
[ * * 2178 - 12 - 27 * * ] 01:50AM blood Type-[**Last Name ( un ) * * ] pO2 - 40 * pco2 - 69 * ph-7.02 *
calTCO2 - 19 * Base XS--15
[ * * 2178 - 12 - 27 * * ] 04:24AM blood type - central pO2 - 53 * pco2 - 60 * ph-7.10 *
calTCO2 - 20 * Base XS--11
[ * * 2178 - 12 - 27 * * ] 05:05AM blood type - central pO2 - 52 * pco2 - 58 * ph-7.16 *
calTCO2 - 22 Base xs--8
[ * * 2178 - 12 - 27 * * ] 11:38am blood type-[**last Name ( un ) * * ] pO2 - 42 * pco2 - 73 * ph-7.20 *
calTCO2 - 30 Base XS--1
.
DISCHARGE LABS :
.
[ * * 2178 - 12 - 27 * * ] 11:16am blood WBC-26.6 * # RBC-4.37 Hgb-11.3 * Hct-36.8
MCV-84 MCH-25.8 * MCHC-30.6 * RDW-16.9 * Plt Ct-335
[ * * 2178 - 12 - 27 * * ] 04:23AM blood glucose-506 * UreaN-41 * Creat-1.8 * Na-131 *
K-4.2 cl-89 * HCO3 - 19 * angap-27 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood alt-226 * ast-262 * LD(LDH)-905 *
ck(cpk)-288 * AlkPhos-89 TotBili-1.7 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood CK - MB-29 * MB Indx-10.1 * cTropnT-1.00 *
[ * * 2178 - 12 - 27 * * ] 04:23AM blood albumin-3.4 * Calcium-8.1 * Phos-7.3 * #
mg-2.5
[ * * 2178 - 12 - 27 * * ] 11:38am blood type-[**last Name ( un ) * * ] pO2 - 42 * pco2 - 73 * ph-7.20 *
calTCO2 - 30 Base XS--1
[ * * 2178 - 12 - 27 * * ] 11:38am blood Lactate-5.1 *
.
MICRO / PATH :
.
Blood Cultures x 2 : pende
MRSA Screen : pende
.
IMAGING / study :
.
CXR Portable [ * * 12 - 25 * * ] :
impression : mild interstitial pulmonary edema present , along
small right pleural effusion , decrease since [ * * 9 - 5 * * ] . heart size top normal , main pulmonary artery
substantially dilate , indicate persistent pulmonary
arterial hypertension . previous mediastinal adenopathy
document chest CT [ * * Month ( ) 216 * * ] difficult assess
probably worsen . pneumothorax .
.
Aorta / branch U / [ * * 12 - 25 * * ] :
impression : evidence abdominal aortic aneurysm .
atherosclerosis .
.
CXR Portable [ * * 12 - 25 * * ] :
Tip new right internal jugular line end region
superior cavoatrial junction . pneumothorax increase
small right pleural effusion . interval increase mediastinal
caliber due vascular
engorgement , due elevated central venous pressure ,
probably function biventricular heart failure , reflect
mild increase heart size , moderate increase pulmonary
edema . severe pulmonary atrial enlargement , indication
mark pulmonary arterial hypertension , aortic valvular
calcification , could hemodynamically significant
( particularly setting decrease LV filling ) , severe ,
global coronary calcification show Chest CT [ * * Month ( ) 216 * * ]
[ * * 2178 * * ] , discuss Dr [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 30814 * * ] time dictation .
.
r LENI [ * * 12 - 26 * * ] :
impression : limited assessment right low extremity due
early
termination examination . DVT see examine
vein .
.
CXR Portable [ * * 12 - 27 * * ] :
finding : comparison study [ * * 12 - 25 * * ] ,
placement endotracheal tube tip upper
clavicular level , approximately 6.5 cm carina .
nasogastric tube extend upper stomach , though side
hole within low portion esophagus . continue
enlargement cardiac silhouette substantial pulmonary
arterial enlargement consistent pulmonary artery
hypertension . moderate pulmonary edema well .
.
TTE [ * * 12 - 27**]:the left atrium mildly dilate . estimate right
atrial pressure least 15 mmHg . leave ventricular wall
thickness cavity size normal . severe global
leave ventricular hypokinesis . basal inferolateral wall
contract good ( LVEF = 25 % ) . right ventricular cavity
moderately dilate severe global free wall hypokinesis .
[ intrinisic right ventricular systolic function
depressed give severity tricuspid regurgitation . ]
abnormal septal motion / position consistent right
ventricular pressure / volume overload . aortic valve leaflet
mildly thicken ( ? # ) . aortic regurgitation see .
mitral valve leaflet mildly thicken . mitral
valve prolapse . mild ( 1 + ) mitral regurgitation see . moderate
severe [ 3 + ] tricuspid regurgitation see .
pericardial effusion .
IMPRESSION : suboptimal image quality . normal leave ventricular
cavity size extensive systolic dysfunction c / w diffuse
process ( multivessel CAD , toxin , metabolic , etc . ) . marked right
ventricular cavity dilation free wall hypokinesis
abnormal septal motion c / w mark pulmonary artery hypertension
( quantify ) . moderate severe tricuspid regurgitation .
mild mitral regurgitation .
compare prior study ( image review ) [ * * 2178 - 10 - 16 * * ] ,
biventricular systolic function deteriorate heart
rate much high . biventricular cavity size similar .
Brief Hospital course :
62f hx severe pulm HTN , CAD / p DES Lcx / LAD
[ * * 10/2177 * * ] , prior CVA / p b / l CEA 's , PVD , [ * * Hospital 2182 * * ] transfer
OSH evaluation management right - sided diastolic CHF
exacerbation background severe pulmonary hypertension
rapidly decompensate pass away despite maximal
medical therapy .
.
ACTIVE diagnosis :
.
# right - sided Diastolic CHF Exacerbation : Pt clinical
evidence rale halfway lung field , JVD , peripheral
edema admission CXR evidence pulmonary edema BNP
11,000 OSH , echo demonstrating fluid overload RV
S3 gallop exam . rule ACS OSH
negative enzyme non - ischemic EKG 's transfer
dopamine drip pressure support max O2 venturi mask
moderate respiratory distress satting low 90 's .
arrival CCU , R IJ place without complication
start sildenafil 20 mg QID hope
pressor support vasodilatation pulmonary vasculature
would increase cardiac output allow gentle diuresis .
unfortunately find anuric despite measure
cr 1.8 transfer 0.8 - 0.9 day prior
OSH . late morning day follow transfer , dobutamine
add attempt improve ionotropy
medication start bp begin drop next
hour norepinephrine add maintain MAPs > 65 .
medication titrate try achieve
stable blood pressure keep range 70/40 - 140/50 .
stability could reach . time hr
100 - 130 's . CCU team ( include CCU attend )
attempt place arterial line well BP monitoring
give severe peripheral vascular disease
unsuccesful via radial aproach . Anesthesia contact[**name ( NI ) * * ]
attempt axial arterial line deem feasible .
anesthesia attend attempt obtain l femoral
arterial line without success . right side attempt
give previous fem-[**doctor last Name * * ] bypass .
oxygenation worsen switch 100 %
non - rebreather . around 1600 dobutamine stop
feel contribute persistently low bp 's .
remain stable around 2100 BP begin
decrease . 250 ml NS bolus give without response
phenylephrine start point . also around
time oxygen saturation begin drop bipap start .
point patient dopamine , norepinephrine
phenylephrine BP support bipap respiratory support
BP 79/55 - 101/57 O2 sit 90 % . 2300 ( ~3
hrs BiPAP ) give tenious state persistently low bp ,
persistnently low O2 sit tachypnea discussion hold
patient family regard endotracheal
intubation . give worseining cardiopulmonary status CCU
team recommend intubation try achieve well
oxygenation , prevent respiratory colapse allow we
manage worsen heart failure maintae patent
airway adequate oxygenation . Anesthesia call 0000
non - emergent intubation . perform succesfully
patient tolerate well . ~0030 , milrinone add
attempt improve ionotropy . point anesthesia
attend ask assistance place arterial line
give need well blood pressure oxygenation
parameter . right radial attempt well leave femoral
without success . around 0100 - 0130 bp begin drop ,
milrinone stop vasopressin add . despite 4
pressor bp continue drop . point give
4 amp bicarb , 1 mg epinephrine 1 amp calcium
carbonate . family update condition . despite
addition bp continue drop
point bicarb drip epinephrine drip start .
stabilize around 0200 remain hr
120 - 130 's SBP 80 - 100 's next several hour .
around 0500 ventilator begin alarm due high
peak / plateau pressure . think due pulmonary
edema repeat succitioning bring frothy fluid .
continue max dose 5 pressor throughout day
maximal respiratory setting sake oxygenation .
condition continue deteriorate despite maximal medical
support . family make aware grave circumstance
start carefully consider code status . code
later morning 2 day follow transfer pulseless
electrical activity code briefly resuscitative
effort halt per family request . cause rapid
decline unclear hypothesis team include possibly
PE ( suboptimal LENI negative ) .
abdominal ultrasound look possible ruptured AAA give
report acute onset low back pain OSH
negative .
.
# Anuric Acute Kidney Injury : Cr 1.8 admission
oliguria / near anuria , 0.6 - 0.7 baseline . 0.9 yesterday
OSH make urine . think due brief hypotensive
episode receive bolus 40 mg IV lasix OSH .
# Severe Chronic Pulmonary Hypertension / Cor Pulmonale : Unclear
etiology . perhaps relate mild - moderate copd CT
( although - assure spirometry record ) possibly
recurrent embolic phenomena . treat aggressively
unfortunately poor outcome .
.
CHRONIC diagnosis :
.
# COPD / Hypoxia : PT mild - moderate copd change
recent CT chest essentially normal PFT 's . require
3LNC home often wear sleep recently
day even rest . 20 - 40 pack - year smoking
history . home copd medication . end
ventilate respiratory support .
.
# cad : Pt severe 3vd prior [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] 2 LCx LAD
8/[**2177 * * ] . non - ischemic EKG admission OSH . enzyme
unimpressive x 3 . chest pain discomfort . continue
aspirin , plavix , statin .
.
# HLD : Stable . continue statin .
.
# Severe PVD : Stable . continue statin .
.
# NIDDM complicate Neuropathy : stable . manage HISS
- house well lyrica gabapentin prior
hemodynamic compromise .
.
TRANSITIONAL ISSUES :
-To deep regret CCU team , Mrs. [ * * know lastname * * ] poorly
hospital course . team take solace fact
surround large , love family hopefully
feel little pain suffering final hour .
medication admission :
- Plavix 75 mg PO daily
- gabapentin 200 mg po QHS
- Aspirin 81 mg PO daily
- Metoprolol succinate 100 mg PO daily
- Ativan 1 mg PO TID PRN
- Metformin 100 mg po BID
- glyburide 2.5 mg PO daily
- Lisinopril 2.5 mg PO daily
- torsemide 40 mg PO daily
- Lyrica 100 mg po BID
- tylenol pm 1 tab QHS
- Simvastatin 40 mg PO daily
- Prilosec 20 mg PO daily
- Niacin 500 mg PO BID
Discharge medication :
N /
discharge disposition :
expire
discharge Diagnosis :
-Severe Pulmonary Hypertension / Cor Pulmonale
-biventricular diastolic congestive heart failure
-severe peripheral vascular disease
-chronic obstructive pulmonary disease
Discharge condition :
Deceased
Discharge instruction :
Patient transfer OSH acute decompensate
biventricular heart failure complicate severe pulmonary
hypertension . manage aggressively pressor ( 5
max dose ) goal optimize cardiac function
hope induce diuresis . unfortunately hemodynamic
decline rapidly . Code call PEA initiation
chest compression epi x 1 time code call
per family preference .
Followup Instructions :
N /
complete by:[**2178 - 12 - 28 * * ]
|
[
"5849",
"4280",
"496",
"3572",
"4439"
] |
Admission Date : [ * * 2169 - 8 - 3 * * ] Discharge Date : [ * * 2169 - 8 - 10 * * ]
Date Birth : [ * * 2169 - 8 - 3 * * ] Sex : F
Service : NB
identification : [ * * know lastname 63410 * * ] [ * * know lastname 63411 * * ] 7 day old former 40 [ * * 5 - 4 * * ] wk
infant meconium aspiration syndrome neonatal depression
discharge [ * * Hospital1 18 * * ] NICU .
history PRESENT ILLNESS : [ * * know lastname 63410 * * ] [ * * know lastname 63411 * * ] bear [ * * 2169 - 8 - 3 * * ]
2.74 kg product 40 [ * * 5 - 4 * * ] week gestation pregnancy
37 year - old , G4 , P1 2 woman . prenatal screen :
blood type b positive , antibody negative , Rubella immune , RPR
nonreactive , hepatitis B surface antigen negative , HIV
negative , group Beta strep status negative . pregnancy
notable normal fetal survey amniocentesis
karyotype 46XX . day delivery , mother present
decrease fetal movement . fetal heart rate monitoring
show non - reassuring pattern decrease variability
late deceleration , mother take urgent cesarean
section delivery . delivery , meconium stain amniotic
fluid nuchal cord note . infant emerge limp
poor tone absent respiratory effort .
intubated meconium suction cord .
subsequent resuscitation include vigorous stimulation
positive pressure ventilation approximately 1 minute ,
gradual improvement color , tone onset
respiratory effort . apgar 3 1 minute , 7 5
minute 8 10 minute . Cord blood ph 6.95 .
due persistent work breathing oxygen requirement ,
infant admit Neonatal Intensive Care Unit .
PHYSICAL EXAMINATION admission : Wt 2740 gm ( 10 - 25 % ) HC 34.5
cm ( 50 - 75 % ) . BP 59/38 ( 51 ) . o2sat 70s-80s 100 % blow -
oxygen . well developed infant moderate respiratory distress ,
stunned appear decrease responsiveness open eye .
fontanelle soft flat . palate intact . red reflex present
bilaterally . neck supple . Chest coarse , poorly aerate ,
moderate grunting , flaring , retraction . Cardiac regular
rate rhythm without audible murmur . Abdomen soft ,
hepatomegaly , 3 - vessel cord thin meconium stain .
normal female genitalia , anus patent . tone grossly normal ,
activity decrease , clonus .
HOSPITAL COURSE systems including pertinent LABORATORY
datum :
system # 1 , respiratory : secondary significant hypoxia , [ * * know lastname 63410 * * ]
place continuous positive airway pressure shortly
admission NICU 100 % oxygen . initial oxygen
saturation reveal pre - ductal saturation mid-80
post - ductal saturation mid-70s , consistent persistent
pulmonary hypertension . CXR reveal diffuse increase
interstitial marking consistent aspiration , well
small right pneumothorax . initial blood gas ph 7.06
witha PC02 52 , pO2 55 . oxygen saturation gradually
improve mid- high-90s , subsequent blood gas reveal
ph 7.22 , pco2 41 , pO2 68 . initially receive normal
saline bolus presence pulmonary hypertension
metabolic acidosis , subsequently receive sodium bicarbonate .
respiratory status steadily improve . pneumothorax
resolve first 24 hour life . able
transition nasal cannula 02 second day life
day life 3 , wean room air . time discharge ,
breathe comfortably room air respiratory rate
30 60 breath per minute .
system # 2 , cardiovascular : describe , [ * * know lastname 63410 * * ] 's initial
course consistent pulmonary hypertension . receive
two normal saline bolus , remain hemodynamically stable
throughout . murmur note . baseline heart rate
120 160 beat per minute recent blood pressure 65/54
mean 57 .
system # 3 , Fluids , electrolyte nutrition : [ * * know lastname 63410 * * ]
initially n.p.o . treat intravenous fluid .
umbilical , arterial venous catheter place . initial
blood glucose 13 . require multiple bolus
dextrose eventual continuous infusion 15 % dextrose
normalization blood glucose level . Enteral feed
start day life 3 gradually advanced . able
wean glucose infusion day life number 5 . Serum
electrolyte within normal limit throughout . time
discharge , breast feed ad lib . discharge weight
2.895 kg corresponding head circumference 34 cm
length 47.5 cm .
system # 4 , infectious disease : [ * * know lastname 63410 * * ] evaluate
sepsis upon admission Neonatal Intensive Care Unit .
White blood cell count 33,800 differential 39 %
polymorphonuclear cell , 2 % band neutrophil . blood
culture obtain prior start intravenous Ampicillin
Gentamycin . blood culture growth 48 hour .
[ * * know lastname 63410 * * ] receive 7 day course antibiotic presume
sepsis possible meconium pneumonitis . Gentamycin level
within normal limit . lumbar puncture perform
reassure without evidence meningitis .
system # 5 , hematologic : Hematocrit birth 57 % . initial
platelet count 72,000 . follow daily
day life 3 platelet count fall 36,000 .
receive platelet transfusion post transfusion count
176,000 . subsequent platelet count initially decrease
remain stable , value 111 , 96 , 105 , 96 .
recent platelet count day discharge 96,000 .
Coagulation study reveal normal PT , PTT , fibrinogen ,
mildly elevate - dimer . maternal blood send platelet
antibody screen ; HLA - antibody present ,
platelet - specific antibody detect . HLA - antibody
think contribute alloimmune thromobocytopenia .
overall thrombocytopenia likely secondary mild
neonatal depression .
[ * * know lastname 63410 * * ] blood type b+ Coombs negative .
system # 6 , Gastrointestinal : liver function test send
day life number 1 mildly elevate .
repeat value day life 4 show gradual decline .
peak serum bilirubin occur day life 4 , total 12.4
0.6 mg / dl . treat phototherapy .
system # 7 , Neurology : perinatal course consistent mild
neoantal depression . head compute tomography scan
perform [ * * 2169 - 8 - 6 * * ] result within normal limit , without
evidence hemorrhage . evaluate
neurology service [ * * hospital3 1810 * * ] , think
improve exam mild hypertonia . Follow -
neonatal neurology program 1 month discharge arrange .
time discharge , neurological examination
reassure normal tone reflexe .
system # 8 , Sensory / Audiology : hearing screening
perform automate auditory brain stem response .
[ * * know lastname 63410 * * ] pass ear .
system # 9 , Psychosocial : family [ * * country 63412 * * ]
plan return end [ * * Month ( ) 216 * * ] . parent
involved [ * * know lastname 63410 * * ] care admission .
[ * * Hospital1 69 * * ] social work department
involve family . contact social worker
[ * * Name ( NI ) 36130 * * ] [ * * Doctor Last Name 56162 * * ] reach [ * * telephone / Fax ( 1 ) 8717 * * ] .
condition DISCHARGE : good .
discharge disposition : home parent .
PRIMARY PEDIATRICIAN : Dr. [ * * first Name4 ( NamePattern1 ) 2270 * * ] [ * * last Name ( NamePattern1 ) 63413 * * ] , [ * * Hospital1 2921 * * ] , [ * * Country * * ] . , [ * * Hospital1 3494 * * ] , , phone
number [ * * telephone / Fax ( 1 ) 51263 * * ] .
CARE recommendation TIME discharge :
1 . feeding : ad lib breast feeding .
2 . medication : Tri - vi-[**male First Name ( un ) * * ] 1 ml p.o . daily .
3 . state newborn screen send [ * * 8 - 7 * * ] [ * * 2169 - 8 - 10 * * ]
notification abnormal result date . initial
screen send [ * * 2169 - 8 - 7 * * ] obtain prior
initiation feed .
4 . immunization administer : Hepatitis B vaccine give
[ * * 2169 - 8 - 10 * * ] .
5 . immunization recommend :
Synagis RSV prophylaxis consider [ * * Month ( ) * * ]
[ * * Month ( ) 958 * * ] infant meet follow three
criterion : ( 1 ) bear less 32 week ; ( 2 ) bear
32 35 week two following : Daycare
RSV season , smoker household , neuromuscular
disease , airway abnormality school age sibling ; ( 3 )
chronic lung disease .
Influenza immunization recommend annually Fall
infant reach six month age .
age , first 24 month child 's life ,
immunization influenza recommend house hold
contact home caregiver .
FOLLOW - :
Infant see one day discharge pediatrician ,
include repeat platelet count .
Appointment schedule Dr. [ * * last Name ( STitle ) * * ] Neonatal
Neurology Program [ * * hospital3 1810 * * ] [ * * 2169 - 9 - 6 * * ] ,
1 pm .
discharge diagnosis :
1 . meconium aspiration syndrome .
2 . persistent pulmonary hypertension .
3 . right pneumothorax .
4 . presume pneumonia .
5 . hypoglycemia .
6 . Thrombocytopenia .
7 . neonatal depression .
[ * * first Name8 ( NamePattern2 ) * * ] [ * * Name8 ( MD ) * * ] , MD [ * * MD Number(2 ) 56682 * * ]
dictate by:[**last Name ( Titles ) * * ]
medquist36
: [ * * 2169 - 8 - 10 * * ] 03:15:26
: [ * * 2169 - 8 - 10 * * ] 06:13:18
Job # : [ * * Job number 63414 * * ]
|
[
"V053"
] |
Admission Date : [ * * 2181 - 4 - 20 * * ] Discharge Date : [ * * 2181 - 4 - 22 * * ]
Date Birth : [ * * 2135 - 4 - 5 * * ] sex :
Service : MEDICINE
allergy :
Drug Allergy Information File
attending:[**first Name3 ( LF ) 23197 * * ]
Chief Complaint :
intoxication / seizure
Major Surgical Invasive Procedure :
Intubation
history Present Illness :
46 / hx etoh abuse ( per ED signout ) possible
depression present emergency room around 6 pm
evening . obviously intoxicated . find EMS
front liquor store bring eval . initial vital
98.1 , p 100 , bp 112/94 , r 20 , 95 % RA .
ed , climb side rail bed fall .
transfer Red Zone fall find
mostly non - responsive despite noxious stimulus . CT scan
head c - spine time negative .
ej femoral line place . almost intubated
become arousable .
.
next hour , alert interactive .
speech slur appear drunk . interview
exam , patient complain abdominal pain , bloody
vomit stool ( guiac negative ) , suicidal ideation .
fight brother - - law feel
depressed . also claim want
hurt brother - - law , . Psych consult SI / HI
wait interview sober .
.
yellow zone wait evaluation ,
abrupt onset fall go ground
unresponsive minute two . witness
tonic - clonic seizure . receive 2 mg ativan time .
several minute later another tonic - clonic seizure ,
give 2 mg ativan . intubate time
airway protection . initially start midazolam
gtt aggitate . switch propofol gtt .
another CT head c - spine preliminarily read
normal .
.
arrival floor , intubate sedate .
move 4 extremity would follow command
appropriately .
.
Past Medical History :
ETOH abuse
Hx pancreatitis
Depression
Social History :
smoke occasionally , drink heavily daily basis , also
history ? heroin v. cocaine use [ * * Male First Name ( un ) 1056 * * ] ( move 2
month ago ) , unmarried
Family history :
per brother - - law , HTN
Physical Exam :
vital - afebrile , 141/96 , 81 , 18 , 100 % cmv 18 x 550 , 100 % x5
Gen - thin man , intubated , sedate , intermittently aggitate
try pull restraint
HEENT - PERRLA , ET tube place
CV - RRR , , r , g
Lungs - CTA B , refer vent sound
Abd - soft , NT , ND , hsm masse
Ext - warm , well perfuse , palp pulse , track mark ; LE scar
Neuro - could obtain secondary infection
pertinent result :
[ * * 2181 - 4 - 20 * * ] 07:30PM ASA - NEG ethanol-295 * ACETMNPHN - NEG
bnzodzpn - POS barbitrt - NEG tricyclic - NEG
[ * * 2181 - 4 - 20 * * ] 07:30PM LIPASE-78 *
[ * * 2181 - 4 - 20 * * ] 07:30PM cTropnT-<0.01
[ * * 2181 - 4 - 20 * * ] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK
phos-64 TOT BILI-0.1
[ * * 2181 - 4 - 20 * * ] 07:30PM wbc-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86
MCH-28.1 mchc-32.7 RDW-14.4
CT C - spine W / contrast Study Date [ * * 2181 - 4 - 21 * * ] 1:05
impression : evidence acute injury cervical spine .
Head CT
NON - contrast head ct : intracranial hemorrhage , mass
effect ,
[ * * Doctor Last Name 352**]-white matter differentiation , abnormality . ventricle
extra - axial space within normal limit .
evidence
fracture . mucosal thickening within bilateral maxillary sinus
ethmoid
sinus air cell sphenoid sinus mild .
aerosolize
secretion nasopharynx .
IMPRESSION : acute intracranial abnormality .
Brief Hospital Course :
46 / hx etoh abuse ( per ED report ) , come
intoxicated complain abdominal pain ,
n / v / diarrhea , suicidal ideation . seizure
intubate airway protection .
.
# Seizure : seizure activity initial one ED .
[ * * Month ( ) 116 * * ] due EtOH intoxication . CT head , lab
unremarkable .
.
# Abdominal Pain : resolve pt extubate .
.
# respiratory failure : pt intubate alter
mental status airway protection setting seizure .
successfully extubate morning follow admission ,
respiratory problem .
.
# EtOH / SI : pt see psychiatry find
capacity make medical decision . decline rehab / detox
report psychiatric follow [ * * hospital1 * * ] CHC
Tuesday . pt discharge care girlfriend
plan take church stay overnight .
medication admission :
1 . bupropion HCl 150 mg Tablet Sustained Release Sig : one ( 1 )
Tablet Sustained Release po twice day .
2 . Seroquel 25 mg Tablet Sig : one ( 1 ) Tablet po bedtime .
Discharge medication :
1 . bupropion HCl 150 mg Tablet Sustained Release Sig : one ( 1 )
Tablet Sustained Release po twice day .
2 . Seroquel 25 mg Tablet Sig : one ( 1 ) Tablet po bedtime .
3 . thiamine HCl 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . Folic Acid 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
discharge disposition :
home
discharge diagnosis :
Intoxication
Discharge condition :
Mental Status : clear coherent , fluent spanish
level consciousness : alert interactive
Activity Status : Ambulatory - Independent
Discharge instruction :
admit intoxication . intubate (
breathing tube place ) protect airway .
evaluate psychiatry , feel safe
return home family , close psychiatric follow .
.
please continue take seroquel wellbutrin .
add folate thiamine nutritional status .
Followup Instructions :
please follow psychiatrist [ * * hospital1 * * ] St.
Community Health Center plan Tuesday .
|
[
"4019",
"311"
] |
Admission Date : [ * * 2147 - 6 - 8 * * ] Discharge Date : [ * * 2147 - 6 - 12 * * ]
Date Birth : [ * * 2088 - 3 - 18 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 689 * * ]
Chief Complaint :
polyuria , polydipsia
Major Surgical Invasive Procedure :
none
history Present Illness :
59 HTN , glaucoma present polyuria
polydipia . regular health status 3
week prior admission , start note polyuria ,
polydipsia , alter taste eat . dryness
mouth get worsen chew food eventually
taste food like " cardboard " . could swallow
food " stay mouth " . state could sense
recognize sweetness , salt taste , bitter taste sour
taste food . deny f / c / n / v , dysuria , cough ,
diarrhea .
.
ED , vital show 96.0 hr 90 , reg BP 177 - 193/96 rr 23
SO2 96 % r / a. note ARF creatinine 1.8
hyperglycemia sugar 360 , AG 22 , positive urine
ketone . start insulin gtt , give 3L NS ,
admit MICU care .
Past Medical History :
1 . hypertension
2 . Glaucoma
Social History :
marry , live wife , daughter .
[ * * Name ( NI ) 1403 * * ] pharmaceutical company drug development . occasional
ETOH , Smoke [ * * 12 - 20 * * ] cigarette / day , use smoke 10 - 15years ,
deny drug .
Family history :
Mother diabete stroke . Father die patient
20 year , sure cause .
Physical Exam :
vital : 97.9 78 174/70 17 97 RA
gen : awake , alert , NAD
heent : perrl , eomi , mmm
cv : RRR , / r / g
pulm : CTAB
abd : soft , NT / ND
ext : 1 + dp pulse , edema
neuro : a+ox4 . CN ii - xii intact , move extremity well .
pertinent result :
[ * * 2147 - 6 - 8 * * ] - Admission lab
WBC-5.5 RBC-5.39 Hgb-17.0 Hct-50.8 MCV-94 MCH-31.5 mchc-33.4
RDW-13.5 Plt Ct-186
glucose-360 * UreaN-12 Creat-1.8 * Na-129 * K-6.6 * Cl-95 * HCO3 - 11 *
AnGap-30 *
Albumin-4.7 Calcium-9.4 phos-2.9 Mg-2.6
% HbA1c-13.7 *
tox screen : ASA - NEG Ethanol - NEG Acetmnp - NEG Bnzodzp - NEG
Barbitr - NEG Tricycl - NEG .
.
[ * * 2147 - 6 - 9 * * ]
Triglyc-176 * HDL-34 CHOL / HD-7.3 LDLcalc-179 * Homocys-7.1
.
[ * * 2147 - 6 - 12 * * ]
WBC-4.2 RBC-4.10 * Hgb-13.3 * Hct-37.2 * MCV-91 MCH-32.4 *
MCHC-35.7 * RDW-14.0 Plt Ct-118 *
Glucose-219 * UreaN-4 * creat-1.2 na-136 K-3.4 Cl-102 HCO3 - 21 *
AnGap-16
Phos-2.4 * mg-2.3
.
[ * * 2147 - 6 - 8 * * ] CT head without CONTRAST : intracranial mass
lesion , hydrocephalus , shift normally midline structure ,
minor major vascular territorial infarct apparent . density
value brain parenchyma within normal limit .
surround osseous soft tissue structure unremarkable .
Falx calcification note . visualized paranasal sinus
unremarkable .
IMPRESSION : acute intracranial pathology , include sign
intracranial hemorrhage .
.
[ * * 2147 - 6 - 8 * * ] PA LATERAL VIEWS CHEST : cardiac
silhouette , mediastinal hilar contour normal .
8 - mm nodule right lung base . otherwise , lung
clear . evidence pleural effusion . evidence
pneumothorax . pulmonary vasculature normal .
IMPRESSION : 8 - mm lung nodule right lung base . Comparison
prior outside study , feasible , follow - study
recommend assess stability .
.
[ * * 2147 - 6 - 9 * * ] CT CHEST W / CONTRAST
finding : Linear scarring atelectasis present within
right low lobe , evidence suspicious lung
nodule mass region . suspicious endobronchial
lesion identify . small bulla present right
upper lobe , minimal area emphysema
extreme lung apex .
suspicious lytic blastic skeletal lesion identify .
degenerative change present spine .
leave lobe thyroid gland enlarge measure 3.7 cm .
enlarge mediastinal hilar lymph node present . heart
size normal . pericardial pleural effusion .
image portion upper abdoman , probable
mild fatty infiltration liver , relative sparing
around gallbladder . image portion adrenal gland
remain portion upper abdoman unremarkable ,
please note examination specifically tailor
evaluate abdominal structure .
IMPRESSION :
1 . Linear scar versus atelectasis right low lobe
evidence discrete lung nodule mass .
2 . probable fatty infiltration liver .
3 . Enlarged leave lobe thyroid gland , probably represent
asymmetric goiter , thyroid ultrasound may consider
complete assessment warrant clinically .
Brief Hospital Course :
59 AA HTN , glaucoma present dka ARF ,
without prior diagnosis diabetes . presentation
consistent " flatbush " type 1b diabete .
.
1 . acute renal failure :
cr 1.8 admission . discharge , decrease 1.2
IVF . unclear baseline . likely prerenal setting DKA .
.
2 . DKA :
newly diagnose DM2 ; give age race may represent Flatbush
Phenomenon give mild dka presentation .
evidence cause anion gap acidosis , patient
negative tox screen lactate significantly
elevated . initially admit ICU Insulin gtt ;
transition glargine 25 unit daily Humalog SS .
receive diabete education [ * * last Name ( un ) * * ] consultant nurse
educator , train administer home insulin outpatient
follup [ * * last Name ( un ) * * ] . BS well control regimen
AG close normal . hga1c level send 13.9 % . ASA
start admission give multiple
cardiac risk factor CAD equivalent .
.
3 . HTN :
give new onset DMII , start ACE . bp
normal range . titrate need outpatient . Patient
evidence LVH ekg , likely hypertensive etiology .
need pcp f / u.
.
4 . lung nodule :
incidental lung nodule note CXR follow Chest
CT reveal Linear scar versus atelectasis right low
lobe evidence discrete lung nodule mass .
.
5 . high Cholesterol
cholesterol panel show elevated level ( tc 248 , LDL 179 ) .
start simvastatin 20 mg daily .
.
6 . Glaucoma
continue pilocarpine 0.5 % 1 gtt eye q6h
.
7 . Incidental L Thyroid Lobe enlargement
probably represent asymmetric goiter , thyroid ultrasound
may consider complete outpatient assessment
warrant clinically .
.
8 . Altered Taste
Neurology consult , feel necessary
inpatient assessment time . suggest Diamox cause ,
know appetite loss alter sensation
taste . follow outpatient .
.
FEN : diabetic diet
.
Proph : heparin SC
.
access : piv
.
full code
Medications admission :
1 . pilocarpine
2 . Diamox
3 . kossup
Discharge medication :
1 . pilocarpine HCl 0.5 % drop Sig : one ( 1 ) Drop Ophthalmic Q6H
( every 6 hour ) .
2 . aspirin 81 mg Tablet , Chewable Sig : one ( 1 ) Tablet , Chewable
po DAILY ( Daily ) .
3 . Simvastatin 10 mg Tablet Sig : two ( 2 ) Tablet po QHS (
day ( bedtime ) ) .
disp:*30 Tablet(s ) * Refills:*0 *
4 . lisinopril 10 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*0 *
5 . Insulin Glargine 100 unit / mL Solution Sig : one ( 1 ) 25
Subcutaneous every morning breakfast .
Disp:*1 vial * Refills:*2 *
6 . humalog 100 unit / mL Solution Sig : one ( 1 ) see slide scale
subcutaneous qac HS .
Disp:*1 vial * Refills:*2 *
7 . syringe Needle , safety 1 ml 28 X [ * * 12 - 20 * * ] Syringe Sig : four
( 4 ) Miscellaneous day .
disp:*120 syrinx * Refills:*2 *
8 . sharps box
Discharge Disposition :
home
discharge Diagnosis :
primary : diabete Mellitus II ketoacidosis
.
secondary :
Hypertension
Glaucoma
discharge condition :
improve , stable
Discharge instruction :
please take medication , include insulin , prescribe .
please check blood sugar home instruct .
experience symptom concern , include
dizziness / lightheadedness , fatigue / lethargy , excessive
urination / thirst , please call PCP go near
Emergency Room .
Followup Instructions :
please follow PCP [ * * last Name ( namepattern4 ) * * ] [ * * 12 - 20 * * ] week . also , please call
[ * * last Name ( un ) * * ] center make appointment diabetes care
management .
|
[
"5849",
"4019"
] |
Admission Date : [ * * 2129 - 3 - 4 * * ] Discharge Date : [ * * 2129 - 3 - 6 * * ]
Date Birth : [ * * 2053 - 6 - 30 * * ] sex : F
Service : MEDICINE
allergy :
Iodine - Iodine Containing / Ace Inhibitors
attending:[**first Name3 ( LF ) 443 * * ]
Chief Complaint :
RCA dissection
Major Surgical Invasive Procedure :
Cardiac Catheterization placement 4 bare metal stent
intra - operative ( catheterization ) trans - esophageal
echocardiogram
history Present Illness :
75 / hypertension , HL exertional angina
initially present elective cardiac catheterization c / b RCA
dissection , transfer CCU management .
.
Briefly , patient complain exertional angina several
week . describe chest discomfort radiate jaw
walk treadmill ride exercise bike vigorously . also
experiance dyspnea chest discomfort walk 1
flight stair . symptom always resolve rest . exercise
stress test [ * * 2129 - 2 - 14 * * ] concern ischemia : 8
minute [ * * Doctor First Name * * ] protocol , peak hr 116 ( 80 % predict
age ) , patient develop recurrent angina EKG show 0.5 mm
st depression infero - lateral lead . give positive stress
test , patient refer elective coronary
catheterization .
.
morning , undergo coronary catheterization show
calcification coronary artery diffuse disease RCA
proximal 90 % stenosis distal 60 - 80 % stenosis .
catheterization complicate RCA dissection
retrograde extention right sinus valsalva .
receive four bare metal stent RCA : 2 overlap distal ,
1 non - overlapping proximal , 1 ostial integrity stent .
follow ostial stent depolyment , contrast long see
flow sinus . post - catheterization TEE show
unchanged AI , function leaflet pericadial effusion .
transfered CCU stable condition .
.
arrival CCU , endorse mild left side chest
jaw pain significantly improve compare
experience cath lab . endorse comfortably
breathing deny complaint .
.
review system , deny prior history stroke ,
tia , deep venous thrombosis , pulmonary embolism , bleed
time surgery , myalgias , joint pain , cough , hemoptysis , black
stool red stool . deny recent fever , chill
rigor . deny exertional buttock calf pain .
review system negative .
.
Cardiac review system notable chest pain per HPI ;
deny paroxysmal nocturnal dyspnea , orthopnea , ankle edema ,
palpitation , syncope presyncope .
Past Medical History :
1 . CARDIAC risk factors : - Diabetes , + dyslipidemia , +
Hypertension
2 . cardiac history :
- moderate AI , moderate MR
3 . PAST MEDICAL history :
- leave Breast Cancer / p Mastectomy [ * * 2103 * * ]
- GERD
- Hemorrhoids
- Pneumonia x2 ( [ * * 2097 * * ] 's )
- Hiatial Hernia
- / p Hysterectomy
- Osteopenia
- / p Tonsillectomy
- / p Adenoidectomy
- / p Appendectomy
Social History :
retire , live husband . [ * * Name ( NI ) * * ] active lifestyle , go
gym daily
- tobacco history :
- etoh : drink approx 4 oz red wine daily
- Illicit drug : deny
Family history :
- family history early mi , arrhythmia , cardiomyopathy ,
sudden cardiac death ; otherwise non - contributory .
- Mother : die age 83 CHF
- Father : die 80 CVA
Physical Exam :
Admission exam :
VS : t=98.4 BP=127/80 HR=93 RR=14 O2 sat=100 % 2L
GENERAL : NAD . orient x3 . mood , affect appropriate .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
neck : supple JVP 8 cm .
CARDIAC : PMI locate 5th intercostal space , midclavicular
line . rr , systolic murmur loudest apex . thrill , lift .
lung : leave mastectomy scar note . Resp unlabored ,
accessory muscle use . CTAB , crackle , wheeze rhonchus .
ABDOMEN : soft , NTND . HSM tenderness . abd aorta
enlarge palpation . abdominial bruit .
extremitie : c / c / e. femoral bruit .
skin : stasis dermatitis , ulcer , scar , xanthomas .
pulse :
right : Carotid 2 + Femoral 2 + popliteal 2 + dp 2 + PT 2 +
leave : Carotid 2 + Femoral 2 + popliteal 2 + dp 2 + PT 2 +
Discharge Exam :
tc 98.0 , Tm 98.4 , BP 128 - 146/49 - 68 , hr 58 - 88 , RR 16 - 18 , sat
95 - 99 % RA
GENERAL : NAD . orient x3 . mood , affect appropriate .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
neck : supple JVP 8 cm .
CARDIAC : PMI locate 5th intercostal space , midclavicular
line . rr , systolic murmur loudest apex . thrill , lift .
lung : CTAB
ABDOMEN : soft , NTND . HSM tenderness .
extremitie : c / c / e. femoral bruit . 2 + pulse radial / dp
pertinent result :
Admission Labs ( [ * * 2129 - 3 - 4 * * ] ):
Hct-32.2 *
glucose-218 * UreaN-17 Creat-0.6 na-134 K-3.8 Cl-99 HCO3 - 23
AnGap-16
Calcium-9.5 Phos-3.7 mg-2.1
[ * * 2129 - 3 - 4 * * ] 04:09pm blood ck(cpk)-69
[ * * 2129 - 3 - 5 * * ] 06:00AM blood ck(cpk)-98
[ * * 2129 - 3 - 4 * * ] 04:09pm blood CK - MB-4 cTropnT-<0.01
[ * * 2129 - 3 - 5 * * ] 06:00AM blood CK - MB-5 cTropnT - LESS
.
Imaging :
intra - operative TEE ( [ * * 2129 - 3 - 4 * * ] ):
conclusion
atrial septal defect see 2D color Doppler . left
ventricle well see overall left ventricular systolic
function normal ( lvef>55 % ) . simple atheroma
aortic arch . mobile density see aortic sinus
right coronary cusp consistent intimal flap / aortic
dissection.the flap extend minimally sinus
Valsalva . aortic valve leaflet ( 3 ) mildly thicken .
mild moderate ( [ * * 12 - 12**]+ ) aortic regurgitation see . moderate
( 2 + ) mitral regurgitation see . pericardial
effusion .
IMPRESSION : dissection flap right coronary sinus , largely
contain within sinus Valsalva . preserve global LV
systolic function mild moderate aortic regurgitation
moderate mitral regurgitation .
.
CTA chest ( [ * * 2129 - 3 - 4 * * ] ):
finding : trace pericardial sluid note . multivessel
coronary
arterial calcification mitral annular calcification .
Density right coronary artery compatible know
stent . proximal RCA appear low attenuation centrally ,
assessment limit overlie stent non - gated study .
close origin RCA , minimal linear mural
irregularity
proximal aorta see ( 4,58 ) , likely represent small
focal
dissection note time coronary angiogram . distal
propagation see .
calcification left anterolateral papillary muscle
note
( 6,61 ) . likely due prior ischemia .
pulmonary arterial tree opacifie without evidence
pulmonary
embolism .
mediastinal , hilar , axillary lymphadenopathy
CT size
criterion . exception trace bibasilar dependent
atelectase , lung clear . central airway remain
patent .
limited subdiaphragmatic evaluation demonstrate hyperdense
material within gallbladder , compatible vicarious
excretion contrast status post recent cardiac
catheterization . tiny hiatal hernia may present . left
adrenal gland mildly prominent , without focal nodularity .
small non - specific 7 mm hypodensity see dome
right hepatic lobe ( 4,68 ) , small characterize .
BONE WINDOW : focal concern lesion . mild multilevel
thoracic
spondylosis present . mild levoconvex thoracic curvature
note .
IMPRESSION :
1 . tiny linear irregularity aortic root adjacent
RCA origin
compatible know tiny dissection . propagation see .
2 . apparent opacification RCA proximally may
artifactual relate stent non - gated study , clinical
correlation advise .
3 . coronary calcification small area calcification
tip
anterolateral papillary muscle .
.
Cardiac Cath ( [ * * 2129 - 3 - 4 * * ] ): Report yet finalize
.
Discharge Labs :
[ * * 2129 - 3 - 6 * * ] 08:35AM blood wbc-7.2 rbc-3.77 * hgb-11.8 * Hct-32.7 *
MCV-87 MCH-31.2 mchc-36.0 * RDW-12.6 Plt Ct-299
[ * * 2129 - 3 - 6 * * ] 08:35AM blood Glucose-119 * UreaN-17 Creat-0.6 na-137
K-4.0 Cl-102 HCO3 - 24 angap-15
[ * * 2129 - 3 - 6 * * ] 08:35AM blood Calcium-9.5 Phos-3.6 Mg-2.0
Brief Hospital Course :
assessment PLAN
Mrs. [ * * know lastname * * ] 75 year - old woman HTN , HLD exertional
angina / p elective cardiac catheterization c / b RCA dissection
placement 4 bms RCA .
# coronary : Patient know CAD identify cardiac cath
[ * * 3 - 4 * * ] / p RCA dissection cardiac catheterization
placement 4 BMS RCA . Patient receive integrillin
procedure . chest pain significantly improve . discuss
patient importance avoid valsalva manuver
increase intra - thoracic pressure . CTA report finalize
per radiology wet read significant dissection still note
post - proceedure although contrast time sub - optimal
evaluation . CTA pt receive premedication benadryl ,
prednisone , mucomyst / IV hydration . Nitro gtt wean
cardiac enzyme stable . Pt continue ASA
indefinitely need take plavix 75 mg daily
least 1 month . plan repeat CTA 2 - 3 week
discharge - evaluate RCA dissection . Pt follow -
Dr. [ * * last Name ( STitle ) * * ] outpatient setting .
# Pump : Patient know CHF symptom . LVEF obtain
durre TEE perform cath lab . Patient remain
hemodynamically stable hospitalization .
# RHYTHM : Patient sinus rhythm . known
dysrhythmia . monitor Tele CCU
floor signficiant arrhythmias note .
# HTN : patient Hx HTN metoprolol home BP me .
Day cath pt start 25 mg daily losartan
well BP control metoprolol increase 50 mg po tid
200 mg po daily .
# HLD : Patient take rosuvastatin 20 mg daily home
atorvastatin 80 mg admit . discharge home
regiman rosuvastatin 20 mg po daily .
# code : full ( confirm patient )
medication admission :
- ciprofloxacin 250 mg [ * * hospital1 * * ] prn UTI
- hydrocortisone acetate - 25 mg suppository - 1 rectally
tid
prn irritation pressure
- metoprolol tartrate 50 mg [ * * hospital1 * * ]
- omeprazole 20 mg Capsule , Delayed Release(E.C. ) daily
- rosuvostatin 20 mg daily
- vitamin c 500 mg daily
- ASA 81 mg daily
- calcium carbonate- vitamin D3 500 mg ( 1,250 mg)-400 U Tablet
daily
- geriatric MVI w / iron 1tab daily
- magnesium 250 mg 4 tab daily
Discharge medication :
1 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*1 *
2 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
3 . metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig : one ( 1 ) Tablet Extended Release 24 hr po day .
disp:*30 Tablet Extended Release 24 hr(s ) * Refills:*2 *
4 . omeprazole 20 mg Capsule , Delayed Release(E.C. ) Sig : one ( 1 )
Capsule , Delayed Release(E.C. ) PO DAILY ( Daily ) .
5 . losartan 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
6 . rosuvastatin 20 mg Tablet Sig : one ( 1 ) Tablet po day .
7 . vitamin c 500 mg Tablet Sig : one ( 1 ) Tablet po day .
8 . calcium carbonate - vitamin D3 500 mg(1,250 mg ) -400 unit Tablet
Sig : one ( 1 ) Tablet po day .
9 . geriatric multivit w / iron - min Tablet Sig : one ( 1 ) Tablet
po day .
10 . magnesium 250 mg Tablet Sig : four ( 4 ) Tablet po day .
11 . hydrocortisone acetate 25 mg Suppository Sig : one ( 1 )
rectal day need irritation pressure .
discharge Disposition :
home
discharge Diagnosis :
Primary Diagnosis :
Coronary artery disease
Coronary artery dissection
secondary :
Hypertension
Discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
admit hospital small tear one
coronary artery occur cardiac
catheterization . help stabilize artery open
coronary find narrowing , 4 bare
metal stent place coronary artery . chest
pain improve significantly next day CT scan
chest show worsening tear artery .
start plavix 75 mg daily Aspirin 325 mg daily .
must take plavix every day least next month
take aspirin daily indefinitely order help keep
stent clot . important take
medication every day otherwise risk clot
form stent . also increase metoprolol dose
start new blood pressure medication call losartan
help keep blood pressure good range .
follow - Dr. [ * * last Name ( STitle ) * * ] likely get repeat CT scan
heart [ * * 1 - 13 * * ] week .
follow change make medication :
- Metoprolol dose increase metoprolol XL 200 mg mouth
daily
- add Losartan 25 mg mouth daily blood pressure
- add clopidogrel ( Plavix ) 75 mg mouth daily least
next month - important miss [ * * First Name ( Titles ) 691 * * ] [ * * last Name ( Titles ) 11014**]s medication . please talk Dr. [ * * last Name ( STitle ) * * ]
ok stop take medication .
- increase Aspirin dose 81 mg daily 325 mg mouth
daily
- continue home medication
refrain lift weight great 20 pound
1 month hospital discharge .
Followup Instructions :
follow - Dr. [ * * last Name ( STitle ) * * ] [ * * 12 - 12 * * ] week . please call office
make sure appointment . number call
[ * * telephone / Fax ( 1 ) 4105 * * ] . likely repeat CT scan
heart [ * * 1 - 13 * * ] week .
refrain lift weight great 20 pound
1 month hospital discharge .
|
[
"4019",
"2720"
] |
Admission Date : [ * * 2192 - 1 - 5 * * ] Discharge Date : [ * * 2192 - 1 - 20 * * ]
Date Birth : [ * * 2117 - 9 - 11 * * ] sex : F
Service : CARDIOTHORACIC
allergy :
Hydralazine / Opioid Analgesics / Compazine
attending:[**first Name3 ( LF ) 922 * * ]
Chief Complaint :
chest pain / epigastric pain
Major Surgical Invasive Procedure :
Coronary artery bypass graft x 4 ( LIMA - LAD , SV - DG , SV - OM , SV - PDA )
[ * * 1 - 13 * * ]
leave heart catheterization , coronary angiography
history Present Illness :
patient 74 year - old female significant PMH
recent NSTEMI ( [ * * 2191 - 11 - 5 * * ] ) , CAD , hyperlipidemia ,
hypertension , dm-2 , ESRD hemodialysis present
several hour epigastric pain evolve predominant
complaint [ * * 2193 - 8 - 13 * * ] chest pressure . similar
presentation [ * * 2191 - 11 - 22 * * ] diagnose NSTEMI
positive cardiac enzyme note new LBBB EKG .
undergo cardiac catheterization time show LAD
lesion 90 % totally occlude mid LAD lesion , RCA lesion
90 % , circumflex show minimal disease . unfortunately ,
unsuccessful PCI , CT Surgery consult arrange
future CABG plan .
Past Medical history :
-hypothyroidism ( thyroidectomy [ * * 2173 * * ] benign growth )
-diabete type ii > 10yrs
-End - Stage Renal Disease : hemodialysis leave forearm av graft
[ * * 2187 * * ] , use Tunelled HD Line
-CVA [ * * 2186 * * ] : leave caudate infarct ; several mini - stroke
-gait disorder / shaky unsteady walk
-splenectomy [ * * 2145 * * ] ( trauma related )
-SVC stenosis
-cataract surgery ( bilateral )
-Hypertension
-hyperlipidemia
-Coronary Artery Disease ( recent cath [ * * 11/2191 * * ] show 90 %
proximal LAD totally occlude mid LAD 90 % RCA minimal
disease circumflex )
Social History :
Patient live alone home daughter [ * * Name ( NI ) * * ] ( [ * * telephone / Fax ( 1 ) 108910 * * ] )
extensively involve care . 7 child .
use walker baseline , wheelchair bind
1 year per daughter patient afraid
fall . deny current past tobacco , alcohol illicit
drug use .
Family history :
mother : die 5 year ago ( cause unknown pt )
Father : die pt 17 ( cause unknown pt )
child major medical problem
Physical Exam :
admission
VS -T 98.6F , BP 153/100 , hr 80 , RR 20 , 96 % 3L oxygen
Gen : appear fatigued , middle aged female NAD , Oriented x3 .
Affect somewhat flatten .
HEENT : NC / . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
Neck : supple JVP 7 - 8 cm . leave EJ place ( clean / intact )
leave IJ HD catheter place non - erythematous
surround skin .
CV : S1 / S2 appreciate , RRR , II - III / VI systolic murmur note @
LUSB , murmur , rub , gallop . thrill , lift . S3 / S4 .
Chest : chest wall deformity scoliosis , + mild
kyphosis . respiration unlabore , accessory muscle use .
decrease aeration basis bilaterally ( r > l ) . wheeze
rhonchus .
Abd : soft , mild upper epigastric tenderness , moderate
distension . hsm tenderness RUQ . due distension ,
unable ausculate well abdominial bruit -but 4
quadrant + normoactive bs .
Ext : [ * * Name Prefix ( Prefixes ) * * ] [ * * last Name ( Prefixes ) * * ] cool , 1 + dp PT pulse left 2 + dp 1 +
PT pulse right . femoral bruit / femoral pulse 2 +
bilaterally .
skin : LE calve scaling skin , sore / lesion / rash .
pulse : right : Carotid 2 + Femoral 2 + popliteal 2 + dp 2 + PT 1 +
leave : Carotid 2 + Femoral 2 + popliteal 2 + dp 1 + PT 1 +
.
discharge
VS 98.4 BP 144/71 HR 80 SR RR 20 o2sat 97%-2LNP
Gen NAD , sit chair
Neuro A&O x3 , nonfocal exam
Pulm CTA bilat
CV RRR , sternum stable , incision CDI
Abdm soft , nt/+bs
Ext Warm , trace pedal edema bilat .
skin staple l groin thigh . leave subclav HD catheter
pertinent result :
ADMISSION labs :
[ * * 2192 - 1 - 5 * * ] 03:57PM PT-41.6 * PTT-37.8 * INR(PT)-4.6 *
[ * * 2192 - 1 - 5 * * ] 03:03pm glucose-381 * NA+-138 K+-4.4 CL--91 * TCO2 - 27
[ * * 2192 - 1 - 5 * * ] 03:03PM HGB-14.3 calcHCT-43
[ * * 2192 - 1 - 5 * * ] 02:45PM GLUCOSE-385 * UREA N-33 * CREAT-4.2 * SODIUM-137
POTASSIUM-5.0 chloride-92 * total CO2 - 27 anion gap-23 *
[ * * 2192 - 1 - 5 * * ] 02:45PM ALT(SGPT)-150 * ast(sgot)-104 * CK(CPK)-46 ALK
PHOS-205 * TOT BILI-0.3
[ * * 2192 - 1 - 5 * * ] 02:45PM lipase-50
[ * * 2192 - 1 - 5 * * ] 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2
[ * * 2192 - 1 - 5 * * ] 02:45PM WBC-14.1 * RBC-4.46 HGB-13.8 HCT-44.2 MCV-99 *
MCH-31.0 MCHC-31.3 RDW-17.4 *
[ * * 2192 - 1 - 5 * * ] 02:45PM blood ctropnt-0.21 *
[ * * 2192 - 1 - 6 * * ] 01:10PM blood CK - MB - NotDone cTropnT-0.29 *
[ * * 2192 - 1 - 6 * * ] 12:19am blood ck(cpk)-77
[ * * 2192 - 1 - 5 * * ] 02:45PM blood ck(cpk)-46
[ * * 2192 - 1 - 19 * * ] 09:30AM blood WBC-17.8 * RBC-3.11 * hgb-9.6 * hct-30.0 *
MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8 * Plt Ct-280
[ * * 2192 - 1 - 19 * * ] 09:30AM blood Plt Ct-280
[ * * 2192 - 1 - 17 * * ] 04:00am blood pt-15.0 * PTT-29.6 inr(pt)-1.3 *
[ * * 2192 - 1 - 19 * * ] 09:30AM blood glucose-233 * urean-43 * Creat-5.2 * # na-137
K-5.1 Cl-99 HCO3 - 28 angap-15
[ * * 2192 - 1 - 12 * * ] 09:00AM blood % HbA1c-7.0 *
[ * * 2192 - 1 - 6 * * ] 01:10PM blood tsh-2.9
.
additional study :
[ * * 2192 - 1 - 10 * * ] Cardiac MD / Thallium Viability study : impression : 1 .
moderate Anterior wall / apical defect completely
reversible 24 h. 2 . moderate septal defect partially
reversible 24 h.
.
[ * * 2192 - 1 - 8 * * ] CTA Chest / Pelvis / Abdomen : impression : 1 .
opacification SMA , without evidence ischemic bowel . 2 .
extensive atherosclerotic disease , without aortic aneurysm
dissection see . 3 . extensive colonic diverticulosis ,
minimal stranding surround descending colon , suggest
mild uncomplicated diverticulitis . 4 . incompletely characterize
hypodense lesion kidney note . 5 . soft tissue
nodule arise medial limb left adrenal gland
incompletely characterize . 6 . increase number
mediastinal retroperitoneal lymph node , without size
enlargement .
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
[ * * know lastname * * ] , [ * * known firstname 108974 * * ] [ * * Medical Record Number 108975 * * ] F 74 [ * * 2117 - 9 - 11 * * ]
Radiology Report CHEST ( PA & LAT ) Study Date [ * * 2192 - 1 - 19 * * ] 4:15 pm
[ * * Hospital 93 * * ] MEDICAL condition :
74 year old woman / p CABG x4
reason examination :
atelectasis
Final Report
history : status post CABG atelectasis .
finding : comparison study [ * * 1 - 17 * * ] , little
overall change .
extensive opacification left base persist , possibly
increase
pleural fluid . central catheter remain place .
right axillary
catheter remain outside hemithorax .
DR . [ * * First Name8 ( NamePattern2 ) 1569 * * ] [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 11006 * * ]
approve : [ * * first Name8 ( NamePattern2 ) * * ] [ * * 2192 - 1 - 19 * * ] 6:21 pm
=
=
=
=
=
=
=
=
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
[ * * know lastname * * ] , [ * * known firstname 108974 * * ] [ * * Medical Record Number 108975 * * ] F 74 [ * * 2117 - 9 - 11 * * ]
Radiology Report [ * * Numeric Identifier * * ] PICC W / port Study Date [ * * 2192 - 1 - 17 * * ]
12:30 pm
[ * * last Name ( LF ) * * ] , [ * * first Name7 ( NamePattern1 ) 177 * * ] [ * * initial ( NamePattern1 ) * * ] [ * * last Name ( namepattern4 ) 5204 * * ] CSRU [ * * 2192 - 1 - 17 * * ] SCHED
PICC line PLACMENT SCH Clip # [ * * Clip Number ( Radiology ) 108976 * * ]
Reason : ESRD HD . LT scv Permacath , / p mult RIJ cath . unable
[ * * Hospital 93 * * ] MEDICAL condition :
74 year old woman / p cabg
reason examination :
ESRD HD . LT scv Permacath , / p mult RIJ cath . unable
pass wire ij
time recent CABG . RT femoral Cordis . IV unable
thread wire
PICC bedside . please place midline * * * * *
Final Report
INDICATION : 74 year old woman require IV access . request right
mid - line due
presence left HD catheter SVC . procedure
explain
patient . timeout perform .
RADIOLOGIST : Dr. [ * * last Name ( STitle ) 3012 * * ] Dr. [ * * First Name ( STitle ) * * ] perform procedure .
Dr. [ * * last Name ( STitle ) 2492 * * ] , attend radiologist , present
supervise
procedure .
TECHNIQUE : use sterile technique local anesthesia ,
right brachial
vein puncture direct ultrasound guidance use
micropuncture set .
Ultrasound image obtain immediately
establish
intravenous access . guidewire advance right
subclavian vein fluoroscopic guidance . peel- away sheath
place guidewire double - lumen PICC
measure 20 cm length place peel- away
sheath tip position axillary vein
fluoroscopic guidance . position catheter confirm
fluoroscopic spot film chest . peel - away sheath
guidewire remove . catheter secure
skin , flushed , sterile dressing apply . patient
tolerate procedure well . immediate
complication .
IMPRESSION : uncomplicated ultrasound fluoroscopically guide
double - lumen PICC placement via right brachial venous approach .
final internal length 20 cm , tip position
right axillary vein . line ready use .
study report review staff radiologist .
DR . [ * * First Name ( STitle ) 2671 * * ] [ * * Doctor Last Name * * ]
DR . [ * * First Name8 ( NamePattern2 ) 95 * * ] [ * * last Name ( NamePattern1 ) * * ]
DR . [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ]
approve : WED [ * * 2192 - 1 - 18 * * ] 9:17
=
=
=
=
=
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
[ * * Hospital1 18 * * ] echocardiography REPORT
[ * * know lastname * * ] , [ * * known firstname 108974 * * ] [ * * Hospital1 18 * * ] [ * * Numeric Identifier 108977 * * ] ( Complete )
do [ * * 2192 - 1 - 13 * * ] 6:17:28 pm FINAL
refer Physician [ * * Name9 ( PRE ) * * ] Information
[ * * Name9 ( PRE ) * * ] , [ * * first Name3 ( LF ) 177 * * ] C.
[ * * Hospital Unit Name 927 * * ]
[ * * Location ( un ) 86 * * ] , [ * * Numeric Identifier 718 * * ] status : Inpatient DOB : [ * * 2117 - 9 - 11 * * ]
Age ( year ): 74 F Hgt ( ): 60
BP ( mm hg ): / Wgt ( lb ): 140
hr ( bpm ): BSA ( m2 ): 1.61 m2
Indication : intraop cabg evaluate LV function , valvular
function , Aortic contour
ICD-9 Codes : 410.92 , 440.0 , 424.0
Test Information
Date / Time : [ * * 2192 - 1 - 13 * * ] 18:17 Interpret MD : [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , MD
Test Type : TEE ( Complete ) son[**name ( NI ) 930 * * ] : [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 3319 * * ] , MD
Doppler : full Doppler color Doppler Test Location :
Anesthesia West cardiac
contrast : None Tech Quality : Adequate
tape # : 2009aw1- : machine : [ * * Doctor Last Name * * ]
Echocardiographic measurement
result measurement Normal Range
Left Atrium - Four Chamber Length : * 6.3 cm < = 5.2 cm
leave Ventricle - Inferolateral Thickness : * 1.4 cm 0.6 - 1.1 cm
leave Ventricle - Diastolic Dimension : 5.3 cm < = 5.6 cm
leave Ventricle - Ejection Fraction : 25 % 30 % > = 55 %
Aorta - Ascending : * 3.5 cm < = 3.4 cm
finding
LEFT ATRIUM : Marked LA enlargement . mass / thrombus [ * * Name Prefix ( Prefixes ) * * ]
[ * * last Name ( Prefixes ) * * ] LAA .
right ATRIUM / INTERATRIAL SEPTUM : mildly dilate RA . normal
interatrial septum . ASD 2d color Doppler .
LEFT VENTRICLE : mild symmetric LVH . top normal / borderline
dilate LV cavity size . severe regional LV systolic dysfunction .
right VENTRICLE : moderately dilate RV cavity . borderline normal
RV systolic function .
AORTA : mildly dilate ascending aorta . focal calcification
ascend aorta . normal aortic arch diameter . complex ( > 4 mm )
atheroma aortic arch . mildly dilate descend aorta .
Complex ( > 4 mm ) atheroma descending thoracic aorta .
AORTIC VALVE : mildly thicken aortic valve leaflet ( 3 ) . .
Trace AR .
MITRAL VALVE : mildly thicken mitral valve leaflet . MS .
moderate severe ( 3 + ) MR . [ * * First Name ( Titles ) * * ] vena contracta > = 0.7 cm
TRICUSPID VALVE : normal tricuspid valve leaflet . mild [ 1 + ] TR .
PULMONIC VALVE / PULMONARY ARTERY : pulmonic valve well see .
Physiologic ( normal ) pr . dilate main pa .
PERICARDIUM : small pericardial effusion .
GENERAL comment : tee perform location list
. certify present compliance HCFA
regulation . TEE relate complication .
REGIONAL LEFT VENTRICULAR WALL MOTION :
N = Normal , H = Hypokinetic , = akinetic , = Dyskinetic
Conclusions
Pre Bypass : left atrium markedly dilate .
mass / thrombus see left atrium leave atrial
appendage . atrial septal defect see 2D color
Doppler . mild symmetric left ventricular hypertrophy .
left ventricular cavity size top normal / borderline
dilate . severe regional left ventricular systolic
dysfunction septal hypokinesis base akinesis
mid apical level , hypokinesis anteroseptal
anterior wall .. right ventricular cavity moderately
dilate borderline normal free wall function . ascending
aorta mildly dilate . complex ( > 4 mm ) atheroma
aortic arch . descending thoracic aorta mildly
dilate . complex ( > 4 mm ) atheroma descending
thoracic aorta . aortic valve leaflet ( 3 ) mildly
thicken . aortic valve stenosis . Trace aortic
regurgitation see . mitral valve leaflet mildly
thicken . moderate severe ( 3 + ) central mitral regurgitation
see . mitral regurgitation vena contracta > = 0.7 cm .
small pericardial effusion . TEE use hemodynamic
monitoring throughout . estimate PASP 43 pre bypass . frequent
cardiac output measurement obtain . CO 2.0 start case ,
increase 2.7 , later 3.9 prior bypass .
Post Bypass : Patient epinepherine infusion ( .08 )
phenylepherine ( 2 ) , AV pace .
Biventricular function slightly improve ionotrope . LVEF
30 - 35 % . anterior wall motion improve . septum
pace paradoxical movement fully evaluate .
mitral reguritation [ * * 1 - 6**]+ . aortic contour intact . remaing
exam unchanged . cardiac output post bypass initally [ * * 2 - 7 * * ] ,
improve end case 4.1 ionotrope volume .
finiding discuss surgeon time exam .
certify present procedure compliance
HCFA regulation .
Electronically sign [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , MD , interpreting
physician [ * * last Name ( namepattern4 ) * * ] [ * * 2192 - 1 - 16 * * ] 14:34
Brief Hospital course :
Ms. [ * * know lastname 108904 * * ] 74 year old female past medical history
recent NSTEMI ( [ * * 11/2191 * * ] ) , extensive coronary artery disease ,
hyperatension , diabete mellitis type II , end stage renal
disease hemodialysis , present emergency
department several hour epigastric pain chest
pressure . rule acute coronary syndrome / myocardial
infarction . workup mesenteric ischemia negative
schedule coronary artey bypass .
[ * * 2192 - 1 - 13 * * ] undergo coronary artery bypass grafting time
four . procedure perform Dr. [ * * last Name ( STitle ) 914 * * ] .
tolerate procedure well transfer critical
stable condition surgical intensive care unit .
post - operative day one dialyze , extubate , wean
pressor . Dialysis resume following day .
chest tube epicardial wire remove . see
consultation physical therapy service . next
several day hospital course uneventful , progress
slowly physical activity POD7 decide
ready discharge rehabilitation [ * * hospital1 * * ] .
medication Admission :
-Vitamin B Complex / vitamin c
-Folic Acid 1 mg daily
-Renagel 800 mg tablet three time day .
-Levothyroxine 100 mcg tablet daily
-Atorvastatin 80 mg Tablet PO daily
-Heparin ( Porcine ) 5,000 unit / mL Solution [ * * hospital1 * * ] : 4,000 - 11,000
unit dwell Injection PRN ( need ) need line flush :
* * use dialysis .
-prevacid 30 mg Capsule , ( e.c.)daily .
-Lorazepam 0.5 mg tablet PO Q6H need Anxiety .
-Acetaminophen 325 mg , 1 - 2 tablet po Q6H PRN
-warfarin 7.5 mg tablet PO daily 4 pm .
-aspirin 81 mg tablet day .
-Lisinopril 40 mg tablet daily .
-Toprol XL 100 mg daily .
.
Discharge medication :
1 . Docusate Sodium 100 mg Capsule [ * * hospital1 * * ] : one ( 1 ) Capsule po BID ( 2
time day ) .
2 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) [ * * hospital1 * * ] : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
3 . Acetaminophen 325 mg Tablet [ * * hospital1 * * ] : two ( 2 ) Tablet po Q4H ( every
4 hour ) need .
4 . Bisacodyl 10 mg Suppository [ * * hospital1 * * ] : one ( 1 ) Suppository Rectal
DAILY ( Daily ) need constipation .
5 . Polyvinyl Alcohol - Povidone 1.4 - 0.6 % Dropperette [ * * hospital1 * * ] : [ * * 1 - 6 * * ]
drop Ophthalmic PRN ( need ) .
6 . Heparin ( Porcine ) 5,000 unit / mL Solution [ * * Month / Day ( 2 ) * * ] : 5000 ( 5000 )
unit Injection TID ( 3 time day ) .
7 . Sevelamer Carbonate 800 mg Tablet [ * * Month / Day ( 2 ) * * ] : two ( 2 ) Tablet PO TID
W / MEALS ( 3 time DAY MEALS ) .
8 . Lansoprazole 30 mg Tablet , Rapid Dissolve , DR [ * * last Name ( STitle ) * * ] : one ( 1 )
Tablet , Rapid Dissolve , DR [ * * last Name ( STitle ) * * ] DAILY ( Daily ) .
9 . Atorvastatin 80 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet PO DAILY
( Daily ) .
10 . b Complex - vitamin C - Folic Acid 1 mg Capsule [ * * last Name ( STitle ) * * ] : one ( 1 ) Cap
po DAILY ( Daily ) .
11 . Folic Acid 1 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet PO DAILY ( Daily ) .
12 . lisinopril 20 mg Tablet [ * * last Name ( STitle ) * * ] : two ( 2 ) Tablet PO DAILY
( Daily ) .
13 . Levothyroxine 50 mcg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet PO DAILY
( Daily ) .
14 . senna 8.6 mg Tablet [ * * last Name ( STitle ) * * ] : two ( 2 ) Tablet po BID ( 2 time
day ) need .
15 . ibuprofen 600 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need pain .
16 . Pramoxine - Mineral Oil - Zinc 1 - 12.5 % ointment [ * * last Name ( STitle ) * * ] : one ( 1 )
Appl Rectal QID ( 4 time day ) need .
17 . Metoprolol Tartrate 25 mg Tablet [ * * last Name ( STitle ) * * ] : 1.5 tablet po TID ( 3
time day ) .
18 . Glipizide 10 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet po BID ( 2 time
day ) .
19 . Insulin Lispro 100 unit / mL Solution [ * * last Name ( STitle ) * * ] : slide scale
Subcutaneous Q AC&HS .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 7 * * ] & Rehab Center - [ * * hospital1 8 * * ]
discharge diagnosis :
unsatble angina
/ p coronary artery bypass graft
end stage renal disease
hypertension
cerebrovascular disease
noninsulin dependent diabete mellitus
hypothyroidism
/ p thyroidectomy
/ p hysterectomy
/ p splenectomy
discharge condition :
good
Discharge instruction :
shower daily , bath swimming
lotion , cream powder incision
driving 4 week narcotic
lifting 10 pound 10 week
report fever great 100.5
report redness , drainage incision
report weight gain great 2 pound day 5 pound
week
take medication direct
Followup Instructions :
Dr. [ * * last Name ( STitle ) 914 * * ] 4 week ( [ * * telephone / Fax ( 1 ) 170 * * ] )
Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] [ * * 1 - 6 * * ] week ( [ * * telephone / Fax ( 1 ) 250 * * ] )
complete by:[**2192 - 1 - 20 * * ]
|
[
"5856",
"4111",
"9971",
"4280",
"2724"
] |
Admission Date : [ * * 2160 - 3 - 26 * * ] Discharge Date : [ * * 2160 - 3 - 30 * * ]
Date Birth : [ * * 2103 - 6 - 21 * * ] sex : F
Service : MEDICINE
allergy :
Penicillins / Iodine ; Iodine Containing / Egg / Fish product
Derivatives / Milk
attending:[**first Name3 ( LF ) 1974 * * ]
Chief Complaint :
Dyspnea
Major Surgical Invasive Procedure :
none .
history Present Illness :
56 yo F severe asthma present difficutly breathing
prominent wheeze . Patient recently see
outpatient pulmonologist Dr. [ * * last Name ( STitle ) * * ] [ * * 3 - 3 * * ] place
steroid taper . feel much well
week ago apartment flood . result
report mold grow trigger asthma . also
neighbor smoke also trigger . 2 day
prior admission patient nebulizer break since
symptom quite severe . unable eat
secondary cough .
.
ED patient give nebs , azithromycin , solumedrol ,
magnesium effect . however still require continuous
nebs .
.
arrival unit patient still extremely wheezy
short breath . deny symptom . Denies HA , neck
stiffness , CP , abd pain , dysuria , hematuria , N / V , diarrhea .
.
Past Medical History :
- Asthma ( [ * * 3 - 3 * * ] PFT FVC 1.7(56 % ) ; FEV1 1.1(50 % )
decrease prior . Mult admission include ICU , however
never intubate . peak flow generally 200 - 250 feel well .
- GERD
- chronic r hemiparesis
- blind r eye cataract
.
Social History :
live home , disability . divorced . many
family member disperse throughout country - 4 child , 5
grandchild . deny tobacco , EtOH , illicit .
sexually active many year . prior h / std HIV .
Family history :
h / asthma , degenerative eye disease , CAD , CVA . h /
cancer , HTN , NIDDM , bleeding / clot disorder .
Physical Exam :
VS 98.6 134 148/60 25 95 nebs
Gen - A+Ox3 , dyspnic
HEENT - op clear
Neck - supple , LAD
Cor - RRR tachy
Chest - diffuse severe wheeze , prolong expiration
Abd - / nt / nd + BS
Ext - edema
.
pertinent result :
admit :
[ * * 2160 - 3 - 26 * * ] 11:25pm GLUCOSE-305 * UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.1 * chloride-105 TOTAL CO2 - 21 * ANION GAP-20
[ * * 2160 - 3 - 26 * * ] 11:25PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.8 *
[ * * 2160 - 3 - 26 * * ] 06:45PM GLUCOSE-116 * urea N-11 CREAT-0.8 sodium-145
POTASSIUM-4.0 chloride-106 total CO2 - 25 anion GAP-18
.
[ * * 2160 - 3 - 26 * * ] 06:45PM WBC-12.8 * RBC-4.34 HGB-13.6 HCT-38.8 MCV-89
MCH-31.3 mchc-35.0 RDW-14.5
[ * * 2160 - 3 - 26 * * ] 06:45PM neuts-72.8 * lymphs-13.4 * MONOS-3.3 EOS-10.3 *
BASOS-0.2
[ * * 2160 - 3 - 26 * * ] 06:45PM PLT count-253
.
transfer MICU :
[ * * 2160 - 3 - 28 * * ] 03:49AM blood WBC-30.8 * # rbc-3.91 * Hgb-11.9 * Hct-34.9 *
MCV-89 MCH-30.4 mchc-34.2 RDW-14.5 Plt Ct-254
[ * * 2160 - 3 - 28 * * ] 03:49AM blood Plt Ct-254
[ * * 2160 - 3 - 28 * * ] 03:49AM blood glucose-207 * UreaN-19 Creat-0.8 Na-138
K-4.4 Cl-105 HCO3 - 21 * AnGap-16
[ * * 2160 - 3 - 28 * * ] 03:49AM blood Calcium-9.4 Phos-3.4 mg-2.3
.
report :
CXR:[**3 - 7 * * ] : acute pulmonary process
[ * * 3 - 28 * * ] : acute pulmonary process
.
ekg - sinus tach , poor baseline , sig change prior
.
PFT [ * * 3 - 3 * * ] :
FVC 1.68 ; 56 %
FEV1 1.11 ; 50 %
Brief Hospital Course :
1 ) ASTHMA FLARE :
HD#2 , patient take continuous nebs ,
increase q4 hour interval switch po steroid .
develop anion gap acidosis / elevate lactate
think attributable respiratory muscle breakdown .
HD#3 , patient transfer floor , neb treatment
decrease q4 hour . transfer floor
report feel much improved . continue PO
prednisone 60 mg . also continue z - pak
start ICU due productive cough depsite clear CXR .
nebs space 6hours . dyspnea resolve almost
completely though still wheeze exam .
complete 2 week steroid taper , Z - pak .
2 ) eosinophilia :
[ * * Month ( ) 116 * * ] relate asthma allergy . also think
abpa work outpt .
medication admission :
med :
Flonase
advair 500/50
nebs
claritin 10
protonix 40
singulair 10
finish prednisone tape [ * * 3 - 7 * * ]
.
Discharge medication :
1 . Fluticasone - Salmeterol 500 - 50 mcg / Dose Disk Device Sig :
one ( 1 ) puff Inhalation [ * * hospital1 * * ] ( 2 time day ) .
2 . Azithromycin 250 mg Capsule Sig : one ( 1 ) Capsule po Q24H
( every 24 hour ) 3 day .
Disp:*3 capsule(s ) * Refills:*0 *
3 . montelukast 10 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
4 . prednisone 10 mg Tablet Sig : taper direct Tablet PO
day 2 week : 4 tablet [ * * Date range ( 1 ) 9236 * * ]
3 tablet [ * * Date range ( 1 ) 9237 * * ]
2 tab [ * * date range ( 1 ) 9238 * * ]
1 tab [ * * date range ( 1 ) 9239 * * ]
half tab [ * * 4 - 11 * * ] .
disp:*15 Tablet(s ) * Refills:*0 *
5 . nebulizer Device Sig : one ( 1 ) device miscellaneous
DIRECTED .
Disp:*1 device * Refills:*0 *
6 . fluticasone 50 mcg / Actuation Aerosol , Spray Sig : two ( 2 )
Spray Nasal DAILY ( Daily ) .
7 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
8 . Albuterol Sulfate 0.083 % solution Sig : one ( 1 ) neb
Inhalation every six ( 6 ) hour need shortness breath
wheezing .
9 . claritin Oral
10 . albuterol 90 mcg / Actuation Aerosol Sig : [ * * 2 - 5 * * ] puff Inhalation
every six ( 6 ) hour need shortness breath
wheezing .
Disp:*1 aersol * Refills:*2 *
discharge disposition :
home
discharge Diagnosis :
Asthma exacerbation
discharge condition :
good .
Discharge instruction :
please take medication prescribe .
please call Dr. [ * * last Name ( STitle ) * * ] fever , increase shortness
breath wheezing , worsen cough , chest pain ,
symptom concern .
Followup Instructions :
please make appointment see Dr. [ * * last Name ( STitle ) 2185**]/[**doctor last Name * * ] Dr.
[ * * last Name ( STitle ) * * ] next 7 - 10 day follow .
also follow appointment already schedule :
Provider : [ * * Name10 ( NameIs ) 1571 * * ] breathing test phone:[**telephone / fax ( 1 ) 612 * * ]
Date / Time:[**2160 - 6 - 11 * * ] 3:20
Provider : [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , [ * * Name Initial ( NameIs ) * * ] .D. Phone:[**Telephone / fax ( 1 ) 612 * * ]
Date / Time:[**2160 - 6 - 11 * * ] 3:40
|
[
"2762"
] |
Admission Date : [ * * 2176 - 4 - 9 * * ] Discharge Date : [ * * 2176 - 4 - 12 * * ]
Date Birth : [ * * 2121 - 4 - 8 * * ] sex : F
Service : SURGERY
allergy :
Ovral-21 / Codeine / Sulfonamides
attending:[**doctor First Name 5188 * * ]
Chief Complaint :
bruise mild abdominal pain
Major Surgical Invasive Procedure :
exploratory laparotomy , debridement abdominal
wall , small large bowel resection , closure
[ * * Location ( un ) 5701 * * ] bag .
exploratory laparotomy .
history Present Illness :
INDICATIONS SURGERY : 55 - year - old woman
note bruising mild abdominal pain large
incisional hernia site . come emergency room
develop profound sepsis CT scan show
intraperitoneal air . also find crepitance
expand hematoma bruise incisional
hernia .
patient take emergently operating room .
Past Medical History :
/ p MVC ( ' [ * * 61 * * ] ) , / p R AKA , ventral hernia repair w/ component
seperation ( ' [ * * 66 * * ] ) , anxiety
Social History :
Mother son patient 's support system
family history :
noncontributory
Physical Exam :
gen : intubated , secate
CV : + s1s2
Pulm : coarse BS diffusely
Abd : large [ * * Location ( un ) 5701 * * ] bag place
Ext : + edema
pertinent result :
[ * * 4 - 9 * * ] CT : 1 . large ventral abdominal wall hernia two discrete
defect . inferior hernia defect ( small defect )
contain several loop necrotic- appear bowel
evidence pneumatosis possible perforation , suggest
strangulate ventral hernia . large amount subcutaneous free
air within ventral hernia sac inferiorly track
retroperitoneally mesentery , necrotize
fascitis consider .
2 . likely aspiration lung basis , bad right side .
[ * * 4 - 10 * * ] pathology : ) ventral hernial sac ( - b ):
Hernial sac acute inflammation serositis .
II ) abdominal wall ( C - ):
skin subcutaneous tissue extensive necrosis abscess
formation .
III : distal ileum ascend colon , resection ( e - L ):
extensive hemorrhagic necrosis transmural infarction
small large intestine :
a. Transmural necrosis present proximal ( ileal )
resection margin .
b. viable distal ( colonic ) resection margin serositis ;
acute inflammation focally extend subserosa
muscularis .
[ * * 2176 - 4 - 9 * * ] 06:00PM blood WBC-19.2 * RBC-3.46 * Hgb-11.0 * # Hct-33.3 *
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.5 Plt ct-163
[ * * 2176 - 4 - 11 * * ] 02:39am blood WBC-63.3 * # RBC-2.66 * hgb-8.0 * hct-25.5 *
MCV-96 MCH-30.2 MCHC-31.4 RDW-17.1 * Plt ct-47 * #
[ * * 2176 - 4 - 11 * * ] 08:09PM blood WBC-50.3 * RBC-3.14 * Hgb-9.5 * Hct-27.5 *
MCV-88 MCH-30.1 MCHC-34.4 RDW-18.5 * Plt ct-25 *
[ * * 2176 - 4 - 9 * * ] 06:00PM blood Neuts-65 Bands-12 * Lymphs-6 * Monos-10
Eos-1 baso-1 Atyps-0 Metas-2 * Myelos-3 *
[ * * 2176 - 4 - 10 * * ] 01:40AM blood Neuts-79 * Bands-3 Lymphs-11 * Monos-0
Eos-0 baso-0 Atyps-0 Metas-6 * Myelos-1 *
[ * * 2176 - 4 - 9 * * ] 06:00PM blood alt-62 * AST-212 * LD(LDH)-359 *
AlkPhos-139 * Amylase-17 TotBili-3.8 *
[ * * 2176 - 4 - 10 * * ] 09:50am blood ALT-33 AST-98 * LD(LDH)-245 alkphos-94
Amylase-42 TotBili-6.4 *
[ * * 2176 - 4 - 11 * * ] 08:12am blood ALT-88 * AST-406 * AlkPhos-158 * Amylase-27
TotBili-7.4 *
[ * * 2176 - 4 - 12 * * ] 03:09AM blood ALT-160 * AST-576 * AlkPhos-297 *
TotBili-8.1 *
[ * * 2176 - 4 - 9 * * ] 06:00PM blood Lipase-22
[ * * 2176 - 4 - 10 * * ] 09:50am blood Lipase-63 *
[ * * 2176 - 4 - 11 * * ] 08:12AM blood Lipase-17
[ * * 2176 - 4 - 11 * * ] 03:54PM blood Cortsol-30.6 *
[ * * 2176 - 4 - 11 * * ] 03:54PM blood cortsol-34.2 *
[ * * 2176 - 4 - 9 * * ] 06:06PM blood Lactate-3.2 * K-3.6
[ * * 2176 - 4 - 10 * * ] 10:03am blood Glucose-78 Lactate-4.3 * Na-126 * K-3.9
Cl-102
[ * * 2176 - 4 - 11 * * ] 02:51am blood Glucose-93 Lactate-5.9 * Na-124 * K-4.3
Cl-109
[ * * 2176 - 4 - 11 * * ] 11:46AM blood Lactate-7.7 *
[ * * 2176 - 4 - 12 * * ] 06:11AM blood Glucose-146 * Lactate-5.1 * K-3.7
Brief Hospital course :
patient admit , undergo aforementione
surgical procedure ; detail , please see operative note .
patient return SICU intubate sedate
care . [ * * 4 - 12 * * ] , family decide make patient CMO
two exploratory laparotomy .
Neuro : patient sedate receive paralytic time
keep comfortable ventilate . receive pain
medication IV appropriate .
CV : patient 's vital sign routinely monitor ,
put vasopressin , norepinephrine epinephrine
stay maintain appropriate hemodynamic .
Pulmonary : vital sign routinely monitor .
intubated sedate throughout admission ,
ventilation setting adjust base ABG value . serial
chest x - ray perform .
bronchoscopy perform [ * * 4 - 10 * * ] , aspiration feculant
material right bronchus intermedius , blood clot
adherent left main bronchus .
GI / GU / FEN :
Post operatively , patient make NPO IVF .
unable extubate receive nutrition .
[ * * 4 - 12 * * ] , patient make CMO .
patient 's intake output closely monitor , IVF
adjust necessary . patient 's electrolyte
routinely follow hospitalization , replete
necessary .
ID : patient 's white blood count fever curve
closely watch sign infection . white blood count
continue rise throughout admission ; trend , please
see result section . patient septic shock
multiorgan failure . vancomycin , fluconazole
Zosyn stay , culture datum routinely monitor .
Endocrine : patient 's blood sugar monitor throughout
stay ; insulin dosing adjust accordingly ,
put drip necessary .
receive cosyntropin cortisol stimulation test .
Hematology : patient 's complete blood count examine
routinely ; multiple ( 6 unit ) transfusion require
stay .
Prophylaxis : patient receive subcutaneous heparin
stay .
patient make CMO [ * * 4 - 12 * * ] , pass away .
medication admission :
serax 15 '' ' , amitryptiline
discharge Disposition :
expire
discharge diagnosis :
perforate viscus , dead bowel ,
deep tissue infection .
discharge condition :
decease
Discharge instruction :
none
Followup Instructions :
none
[ * * Name6 ( MD ) * * ] [ * * last Name ( namepattern4 ) * * ] MD , [ * * MD Number(3 ) 5190 * * ]
|
[
"0389",
"5715"
] |
Admission Date : [ * * 2186 - 2 - 1 * * ] Discharge Date : [ * * 2186 - 2 - 10 * * ]
Date Birth : [ * * 2163 - 2 - 7 * * ] sex :
Service : NEUROLOGY
allergy :
Codeine / Depakote
attending:[**first Name3 ( LF ) 7567 * * ]
Chief Complaint :
elective admission depth electrode placement invasive
EEG monitoring possible temporal lobectomy
Major Surgical Invasive Procedure :
Craniotomy depth electrode placement
history Present Illness :
patient 22 year old right handed man history
refractory complex partial epilepsy admit
invasive electroencephalographic monitoring .
transfer Neurosurgery service placement
depth electrode strip . history seizure begin
age
16 . history febrile seizure , meningo - encephalitic
infection early childhood , head trauma . precede
first
witness seizure month , note
intermittent staire spell unknown duration
significance
note retrospect . unwitnessed event
drive car , lead motor vehicle accident possibly
head concussion . hospitalize injury ,
witness generalized convulsion hospital one day later .
initially start Phenytoin leave temporal
slowing
find routine EEG . medication compliance poor ,
result generalized convulsion approximately every six
month .
seizure multiple semiology . generalize
convulsion ( secondary generalized tonic - clonic ) usually
nocturnal , include loss consciousness tongue biting ,
precede aura . sometimes
show appearance experience ictal fear .
different type episode ( complex partial ) would
pupillary dilation , stare , behavioral arrest .
sometimes precede feeling [ * * last Name ( un ) 5083 * * ] vu . event
typically
last second minute ( per omr 5 second 3.5 minute ) .
also third type episode ( simple partial )
include feeling [ * * last Name ( un ) 5083 * * ] vu .
report feeling jamais vu well along
[ * * last Name ( un ) 5083 * * ] vu prior stare spell . aura ,
sometimes feel thing appear unreal strange , almost
though body . deny
micropsia / macropsia , tableau visual distortion , strange taste
smell , epigastric rise sensation .
approximately three work - reate minor head injury
initial onset seizure . try
Dilantin / phenytoin ( ineffective vs noncompliance ) ,
Depakote / valproic acid ( weight gain , tremor ) ,
Trileptal / oxcarbazepine ( headache ) . subsequently
switch
Keppra / levetiracetam Lamictal / lamotrigine Epilepsy
service diminishment seizure frequency per
patient mother .
Past Medical History :
1 . Epilepsy include generalized tonic - clonic " absence
seizure " likely complex partial seizure
2 . Headache / relate ( pre / post ) seizure
3 . h / right hand fracture punch wall
4 . h / right UE trauma - relate thrombosis MVC [ * * 11/2179 * * ]
place Lovenox two month ( unreveale
hypercoagulable workup ) .
Social History :
+ tobacco ( occasional cigar , cigarette ) . + ETOH
( weekend , social ) . illicit drug use . bear full - term without
perinatal complication . reportedly achieve developmental
milestone early . complete college level education ,
complete due concentration difficulty . currently
unemployed . currently drive .
Family history :
seizure ( maternal aunt , possibly drug use ) .
seizure history .
Mother - hypothyroidism .
Father - die PE ( @bed rest sciatic pain ) .
Physical Exam :
admission exam :
General : NAD , lie bed comfortably . / Head : NC / ,
conjunctival icterus , oropharyngeal lesion / Neck : Supple ,
nuchal rigidity / Cardiovascular : RRR , / r / G / Pulmonary :
equal air entry bilaterally , crackle wheeze / Abdomen :
Soft , NT , ND , + BS , guarding / extremity : Warm , edema ,
palpable radial / dorsalis pedis pulse / skin : rash
lesion
Neurologic Examination :
- Mental Status - awake , alert , orient x 3 . recall coherent
history . registration [ * * 3 - 18 * * ] recall [ * * 3 - 18 * * ] . concentration
maintain recall month backwards . follow two step
command , midline appendicular . language fluent intact
repetition verbal comprehension . normal prosody .
paraphasic error . high low frequency name intact .
dysarthria . apraxia neglect .
- Cranial Nerves - [ II ] perrl 3->2 brisk . vf full number
counting . funduscopy show crisp disc margin , papilledema .
[ III , IV , VI ] EOMI , nystagmus , slightly droopy eyelid
leave slightly low right notably tired / exhaust ,
hold eyelid volitionally . [ v ] v1 - V3 without
deficit
light touch bilaterally . [ vii ] facial asymmetry . [ viii ]
hear intact finger rub bilaterally . [ IX , X ] palate
elevation symmetric . [ [ * * Doctor First Name 81 * * ] ] SCM / Trapezius strength 5/5
bilaterally .
[ xii ] Tongue midline .
- Motor - normal bulk tone . pronation , drift .
tremor
asterixis .
=[ Delt ] [ bic ] [ tri ] [ ECR ] [ io ] [ ip ] [ quad ] [ ham ] [ ta ] [ gas ]
[ [ * * last Name ( un ) 938 * * ] ]
[ C5 ] [ C5 ] [ c7 ] [ c6 ] [ t1 ] [ l2 ] [ l3 ] [ l5 ] [ L4 ] [ s1 ] [ l5 ]
L 5 5 5 5 5 5 5 5 5 5 5
r 5 5 5 5 5 5 5 5 5 5 5
- sensory - deficit light touch bilaterally .
- Reflexes
=[ Bic ] [ tri ] [ [ * * last Name ( un ) 1035 * * ] ] [ quad ] [ gastroc ]
L 2 2 2 2 2
r 2 2 2 2 2
Plantar response flexor bilaterally .
- Coordination - dysmetria finger nose testing .
slight
change cadence right hand [ * * Doctor First Name * * ] , less impair leave
hand
[ * * Doctor First Name * * ] .
- Gait - unable assess time examination ,
restraint / p electrode placement .
----
pertinent result :
WBC 14.7 , Hgb 14.1 , Plt 297 , Na 145 , Cr 1 , Glu 158
NCHCT [ * * 2 - 1 * * ] - hemorhage , depth electrode place ,
pneumocephalus
MRI Head [ * * 2 - 2 * * ]
finding :
interval placement electrode , posterior
parietal
approach , one side . right - sided electrode , course
parietal temporal lobe , hippocampus ,
tip
extend slightly beyond margin hippocampus antral
medially
inferiorly right temporal lobe . left - sided lead
tip within
left hippocampus .
focus slow diffusion suggest acute infarction .
ventricle extra - axial CSF space normal . focal area
alter
signal intensity note brain parenchyma
non - contrast image .
major intracranial arterial flow void note . image
portion
paranasal sinus mastoid air cell clear .
post - procedural
change note soft tissue scalp bone
adjacent
soft tissue posterior temporal region .
NCHCT ` [ * * 2 - 9 * * ]
finding : previously visualize bitemporal depth electrode
well
bilateral temporal grid since remove . five burr
hole
note temporal lobe , posterior aspect parietal
lobe ,
right lateral aspect frontal bone . mild right frontal
bitemporal
pneumocephalus note , well focus gas
subgaleal tissue
overlie right temporal bone . , however ,
evidence
hemorrhage , edema , large vessel territorial infarction , shift
normally
midline structure . ventricle sulci remain normal
size
configuration . visualized paranasal sinus mastoid air
cell
clear .
IMPRESSION : interval removal previously place depth
electrode grid .
evidence post - procedural complication .
EEG [ * * 2 - 2 * * ]
impression : abnormal video intracranial EEG
monitoring
session left temporal clinical focal seizure ,
describe
. arise regionally antero - mesial temporal
region
( subdural strip anterior temporal strip hippocampus ) ,
exact
ictal onset zone record . clinical
manifestation
brief eye opening . ictal activity briefly spread
right
subtemporal strip , repetitive spike spike - wave
activity
20 second , spread right temporal
electrode .
abundant bilateral hippocampal depth electrode
spike ,
describe . spike frequent right anterior
hippocampus also see frequently left anterior
hippocampus .
EEG [ * * 2 - 3 * * ]
impression : abnormal video intracranial EEG
monitoring
session two leave temporal complex partial seizure
describe . appear arise regionally
antero - mesial temporal region ( subdural strip anterior temporal
strip
hippocampus ) , exact ictal onset zone record .
ictal activity spread briefly right subdural strip
electrode ,
repetitive spike RST2 - 3 RST3 - 4 , involve
right
temporal electrode . abundant bilateral hippocampal
depth
electrode spike , describe . spike frequent
right anterior hippocampus also see frequently
left
anterior hippocampus . compare prior day 's recording ,
significant change interictal activity , two complex
partial
seizure record .
EEG [ * * 2 - 4 * * ]
impression : abnormal video intracranial EEG
monitoring
session abundant bilateral hippocampal depth
electrode spike
describe . spike frequent right
anterior
hippocampus also see frequently left anterior
hippocampus . electrographic seizure present . compare
prior day 's recording , significant change
interictal
activity , seizure record .
EEG [ * * 2 - 5 * * ]
impression : abnormal video intracranial EEG
monitoring
session abundant bilateral hippocampal depth
electrode spike
describe . spike frequent right
anterior
hippocampus also see frequently left anterior
hippocampus . electrographic seizure present . compare
prior day 's recording , significant change
interictal
activity , seizure record .
Brief Hospital Course :
22yow h / epilepsy , depression electively admit depth
electrode placement , continuous EEG , localization
temporal lobe seizure focus anticipation surgical
resection .
[ ] Depth Electrodes Placement Invasive EEG Monitoring -
depth electrode place Dr. [ * * last Name ( STitle ) * * ] /Neurosurgery without
major perioperative complication , remove
similarly without major complication . persistent new
neurologic deficit either procedure . cover
antibiotic include 7 day cephalexin discharge
( vancomycin gentamicin - house ) .
[ ] Epilepsy - patient monitor invasive EEG
monitoring medication downtitrate reveal
bilateral temporal lobe seizure . medication restart
lamotrigine uptitrated 200 qam 300 qpm .
[ ] depression - Sertraline increase 100 mg daily .
display sign worsen depression , new
finding bilateral temporal seizure inability get
temporal lobectomy could major trigger worsen
depression .
pende study :
EEG final report
TRANSITIONAL CARE ISSUES :
[ ] please assess seizure frequency new dose
lamotrigine .
[ ] please follow emotional state / depression high
dose Sertraline .
medication admission :
Keppra 1500 mg [ * * hospital1 * * ] , Lamictal 200 mg [ * * hospital1 * * ] , Sertraline
50 mg Daily
Discharge medication :
1 . lamotrigine 200 mg Tablet Sig : one ( 1 ) Tablet PO QAM .
disp:*30 Tablet(s ) * Refills:*2 *
2 . levetiracetam 500 mg Tablet Sig : three ( 3 ) Tablet po twice
day .
3 . sumatriptan succinate 50 mg Tablet Sig : one ( 1 ) Tablet PO PRN
need headache .
4 . Keflex 500 mg Capsule Sig : one ( 1 ) Capsule po four time
day 7 day : prevention infection
operation .
Disp:*28 Capsule(s ) * Refills:*0 *
5 . oxycodone 5 mg Tablet Sig : 1 - 2 tablet po three time day
need pain 3 day : take prescribed
amount . drive operate heavy machinery make
drowsy .
disp:*18 Tablet(s ) * Refills:*0 *
6 . lamotrigine 200 mg Tablet Sig : 1.5 Tablets po QPM .
Disp:*45 Tablet(s ) * Refills:*2 *
7 . docusate sodium 100 mg Tablet Sig : one ( 1 ) Tablet po twice
day 7 day .
Disp:*14 Tablet(s ) * Refills:*0 *
8 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po twice day 7
day .
Disp:*14 Tablet(s ) * Refills:*0 *
9 . sertraline 100 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
discharge disposition :
home
discharge Diagnosis :
Primary Diagnosis : Epilepsy / Seizures
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Neurologic : deficit .
Discharge instruction :
[ NEUROLOGY discharge instruction ]
Mr. [ * * know lastname 88790 * * ] ,
admit hospital invasive
electroencephalographic monitoring seizure disorder
( temporal lobe epilepsy ) . depth electrode strip
place neurosurgical team without major
complication . monitor Epilepsy Monitoring Unit
able record several seizure . electrode
subsequently remove . Dr. [ * * First Name ( STitle ) * * ] use datum
continue guide management epilepsy .
time , make change medication
regiman . please take anticonvulsant previously
prescribe .
changingthe follow medication :
1 . please increase evening dose lamictal / lamotrigine
300 MG per night . take lamictal 200 mg morning
300 MG evening .
2 . please take KEFLEX / cephalexin 500 MG four time per day
( every 6 hour ) 7 day prevention infection
surgery .
3 . Sertraline increase 100 MG per day .
prescribe new tablet .
4 . please take Docusate Sodium Senna prescribe
prevent constipation whiel take Oxycodone pain .
5 . take Oxycodone 5 mg every 8 hour need pain
next day . operate heavy machinery
use medication make drowsy . also
take Acetaminophen 650 MG three four time daily need
headache day ( take frequently
long term ) .
please continue take schedule medication .
would like followup Dr. [ * * First Name ( STitle ) * * ] list .
follow symptom , please seek medical
attention .
pleasure provide medical care
hospitalization .
[ NEUROSURGERY DISCHARGE instruction ]
? ? ? ? ? ? friend / family member check incision daily
sign infection .
? ? ? ? ? ? take pain medicine prescribe .
? ? ? ? ? ? Exercise limit walk ; lifting , strain ,
excessive bending .
? ? ? ? ? ? dressing may remove Day 2 surgery .
? ? ? ? ? ? dissolvable suture may wash hair get
incision wet day 3 surgery . may shower
time use show cap cover head .
? ? ? ? ? ? wound close staple non - dissolvable
suture must wait remove wash
hair . may shower time use show cap
cover head .
? ? ? ? ? ? increase intake fluid fiber , narcotic pain
medicine cause constipation . generally recommend take
counter stool softener , Docusate ( Colace )
take narcotic pain medication .
? ? ? ? ? ? unless direct doctor , take
anti - inflammatory medicine Motrin , Aspirin , Advil ,
Ibuprofen etc .
call SURGEON IMMEDIATELY experience
following
? ? ? ? ? ? new onset tremor seizure .
? ? ? ? ? ? confusion change mental status .
? ? ? ? ? ? numbness , tingling , weakness extremity .
? ? ? ? ? ? pain headache continually increase ,
relieve pain medication .
? ? ? ? ? ? sign infection wound site : redness , swell ,
tenderness , drainage .
? ? ? ? ? ? fever great equal 101 ? ? ? ? ? ? F.
Followup Instructions :
NEUROLOGY Provider : [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 7025 * * ] , MD Phone : [ * * telephone / Fax ( 1 ) 3294 * * ]
Date / time : [ * * 2186 - 3 - 3 * * ] 1:00
neurosurgery : please call [ * * telephone / Fax ( 1 ) 1669 * * ] set time
staple remove . occur 1 week . (
Neurosurgeons provide information
instruction . )
|
[
"3051",
"311"
] |
Admission Date : [ * * 2140 - 2 - 29 * * ] Discharge Date : [ * * 2140 - 3 - 4 * * ]
Date Birth : [ * * 2069 - 7 - 18 * * ] sex : F
Service : NEUROSURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 1835 * * ]
Chief Complaint :
C2 type II den fracture / p HALO placement
Major Surgical Invasive Procedure :
[ * * 2140 - 2 - 29 * * ] :
open reduction internal fixation type II C2 den
fracture .
history Present Illness :
Pt 79 year old woman know C2 fracture sustain
fall [ * * 2139 - 10 - 22 * * ] . place halo
time , discharge [ * * Hospital 100 * * ] Rehab , today
follow . yet discharge rehabilitation .
complain pain relate halo time , feel
decrease mobility especially get
bed chair . additional complaint . HA ,
numbness / tingling .
Past Medical History :
CAD
Hiatal hernia
SVD
vaginal hysterectomy
Post colporrhaphy bladder neck suspension ,
r breast lumpectomy
L mastectomy Breast Ca
C2 type II den fracture .
Social History :
widow
Family history :
Father - CAD , [ * * Name ( NI ) * * ] Ca . Mother - PE
Physical Exam :
GENERAL : alert orient x 3 , pleasant ,
acute distress .
NEUROLOGIC : halo intact . able
rise seat , tentative , use arm
additional strength . full strength throughout , [ * * 3 - 25 * * ] . Deep tendon
reflexe 2 + throughout . sensation intact . halo pin site ,
erythema , edema , drainage .
c - spine CT [ * * 2 - 2 * * ] - see oblique fracture
involve base odontoid process ( type 2 ) .
Fracture
fragment appear unchanged alignment . multiple small
osseous
fragment , also unchanged appearance , note .
slight cortication still - evident fracture line margin .
however , lack change alignment suggest development
fibrous [ * * hospital1 * * ] .
pertinent result :
[ * * 2140 - 3 - 3 * * ] 06:45AM blood wbc-8.9 rbc-4.32 Hgb-12.9 hct-38.4 MCV-89
MCH-29.9 MCHC-33.6 RDW-14.0 Plt ct-99 *
[ * * 2140 - 3 - 3 * * ] 06:45am blood Glucose-87 UreaN-11 creat-0.6 na-145
K-4.3 Cl-105 HCO3 - 32 AnGap-12
[ * * 2140 - 3 - 3 * * ] 06:45am blood Calcium-8.5 phos-2.8 # Mg-1.8 RADIOLOGY
Final Report
CT C - spine W / contrast [ * * 2140 - 3 - 1 * * ] 12:03 pm
CT C - spine W / CONTRAST
Reason : please evaluate post op 0800 [ * * 2140 - 3 - 1 * * ] . thank .
[ * * Hospital 93 * * ] MEDICAL condition :
70 year old woman / p ORIF C2 type II den fx .
reason examination :
please evaluate post op 0800 [ * * 2140 - 3 - 1 * * ] . thank .
contraindication IV CONTRAST : none .
CT scan cervical spine multiplanar reformatte
image .
Exam compare previous examination [ * * 2140 - 2 - 2 * * ] .
finding : intramedullary fixation fracture
C2 odontoid metallic device extend
body C2 odontoid process . evidence
abnormal calcification within spinal canal .
retropharyngeal mass demonstrate unchanged
prior study . alteration alignment .
IMPRESSION : status post internal fixation odontoid fracture .
stable appearance retropharyngeal mass .
DR . [ * * First Name ( STitle ) 23303 * * ] [ * * Doctor Last Name * * ]
approve : TUE [ * * 2140 - 3 - 1 * * ] 3:57 pm
Brief Hospital course :
Pt admit neurosurgery service / p ORIF type II C2 den
fracture .
Pt keep PACU overnight q1 hr neurocheck . Post
operatively awake , alert orientate X3 move upper
extremetie good strength .
post op CT scan : finding :
intramedullary fixation fracture C2 odontoid
metallic device extend body C2
odontoid process . evidence abnormal calcification
within spinal canal . retropharyngeal mass
demonstrate unchanged prior study .
alteration alignment .
see PT find hypotensive
observe additional day . social work also involve
discharge planning Ms [ * * know lastname 98305 * * ] agree return rehab .
medication admission :
protonix 40 mg qd
triethanolamine / water ( shampoo ) Th@10 scalp .
neosporin triple antibiotic ointment pin site
tylenol 650 q4h prn
tylenol 650 [ * * hospital1 * * ]
fosamax 70 mg qSat
lipitor 80 mg qpm
dulcolax 10 mg pr prn
calcium / vit 500 tid
celexa 40 qhs
colace 250 qAM
[ * * Doctor First Name 130 * * ] 30 qd prn
robitussin syrup 5ml q6prn
MOM 30ml qd prn
MVI
oxycodone hcl 5 q4 prn
senna 2 tab qhs
trazodone 25 daily prn
lasix 40 qod
Discharge medication :
1 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : 1 - 2 tablet po
q4 - 6h ( every 4 6 hour ) need pain .
Disp:*60 Tablet(s ) * Refills:*0 *
2 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ): Use
Percocet .
disp:*30 Tablet(s ) * Refills:*1 *
3 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet po EVERY
DAY ( every Day ) .
4 . Alendronate 70 mg Tablet Sig : one ( 1 ) Tablet po QSAT ( every
Saturday ) .
5 . citalopram 20 mg Tablet Sig : two ( 2 ) Tablet PO HS (
bedtime ) .
6 . calcium Carbonate 500 mg Tablet , Chewable Sig : one ( 1 )
Tablet , Chewable PO TID ( 3 time day ) .
7 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q4 - 6h
( every 4 6 hour ) need pain / fever .
8 . Atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO HS (
bedtime ) .
9 . Colace 100 mg Capsule Sig : one ( 1 ) Capsule po twice day :
Use Percocet .
Disp:*60 Capsule(s ) * Refills:*2 *
10 . Multivitamin Capsule Sig : one ( 1 ) Cap po DAILY ( Daily ) .
11 . Cephalexin 500 mg Capsule Sig : one ( 1 ) Capsule PO Q6H ( every
6 hour ) 8 day .
Disp:*32 Capsule(s ) * Refills:*0 *
12 . Bacitracin Zinc 500 unit / g Ointment Sig : one ( 1 ) Appl
Topical [ * * hospital1 * * ] ( 2 time day ): pin site .
Disp:*1 500unit / g * Refills:*2 *
13 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 459 * * ] Aged - [ * * Location ( un ) 550 * * ]
discharge diagnosis :
C2 type II den fracture .
discharge condition :
neurologically stable .
Discharge instruction :
restart home medication usual . please take newly
prescribe medication instruct .
must wear collar time except bathe
heavy lifting
Diet low cholesterol high fiber .
get steristrip wet tomorrow , may shower start
tomorrow .
watch incision redness , drainage , bleeding , swelling ,
develop fever great 101.5 call Dr [ * * last Name ( STitle ) 17511 * * ] office
may shower please keep incision cover tegaderm
shower .
please keep incision clean , dry , intact till see Dr. [ * * last Name ( STitle ) * * ]
clinic .
* increase pain
* Fever ( > 101.5 F ) Vomiting
* inability eat drink
* Reddness / swelling / discharge wound
* anything concern .
Followup Instructions :
please follow - Dr. [ * * last Name ( STitle ) * * ] 8 week . please call
[ * * telephone / Fax ( 1 ) 1669 * * ] make appointment .
please keep follow appointment :
Provider : [ * * Name10 ( NameIs ) 326 * * ] [ * * Name11 ( NameIs ) * * ] DX RM2 RADIOLOGY phone:[**telephone / Fax ( 1 ) 327 * * ]
Date / time:[**2140 - 3 - 4 * * ] 1:30
Provider : [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 98306 * * ] , [ * * Name12 ( NameIs ) 16569 * * ] RNC Date / time:[**2140 - 4 - 4 * * ] 1:20
Provider : [ * * First Name11 ( Name Pattern1 ) 20 * * ] [ * * last Name ( NamePattern1 ) 21 * * ] , M.D. Date / Time:[**2140 - 4 - 11 * * ] 3:30
|
[
"2724"
] |
Admission Date : [ * * 2126 - 2 - 27 * * ] Discharge Date : [ * * 2126 - 3 - 5 * * ]
Date Birth : [ * * 2050 - 6 - 17 * * ] sex : F
Service : CCU
history PRESENT ILLNESS : 75 year - old woman
past medical history hypertension , hypercholesterolemia
transfer [ * * hospital6 33 * * ] emergent
cardiac catheterization since present hospital
early evening admission complaint 6
10 abdominal indigestion . patient note back pain ,
deny nausea vomiting . Electrocardiogram show ST
segment elevation 6 mm lead V2 , V3 5 mm
change V5 , 3 mm V6 3 mm change lead 2
AVL . patient old right bundle branch block
reciprocal change inferior lead . patient
give Lopressor , nitroglycerin Integrilin outside
hospital chest pain decrease 1.5 10 .
note patient similar complaint Sunday . time
complaint associate nausea vomiting
well . catheterization laboratory patient
underwent stenting mid left anterior descend
coronary artery lesion due 50 % proximal 50 % first
septal 100 % mid occlusion . patient also underwent
percutaneous transluminal coronary angioplasty left
anterior descend coronary artery beyond flow stent .
patient multiple infusion intracoronary
nitroglycerin Diltiazem improve flow . Hemodynamically
patient 's right atrium pressure 10 , PA 42/21 ,
wedge pressure 26 , cardiac output 3.24 , cardiac index
1.95 , FVR 2100 . patient give 10 mg intravenous
Lasix transfer Coronary Care Unit .
PAST MEDICAL history :
1 . Hypertension .
2 . Hypercholesterolemia .
3 . Status post appendectomy .
allergy : Penicillin cause rash .
medication :
1 . Atenolol 50 day .
2 . lipitor 10 day .
FAMILY history : Negative coronary artery disease .
Father aortic aneurysm . Mother stroke .
social history : former tobacco smoker half pack per
day five yea . Alcohol dinner occasionally .
drug . live home old sister .
PHYSICAL EXAMINATION admission : blood pressure 150/80 .
Pulse 78 . O2 sit 96 % 2 liter . general ,
pleasant elderly woman acute distress . HEENT
normocephalic , atraumatic . pupil equal , round
reactive light . extraocular movement intact . mucous
membrane moist . clear oropharynx . cardiovascular
regular rate rhythm . Normal S1 S2 . 1 6 systolic
ejection murmur . jvp 8 cm . lung clear
auscultation anteriorly . Abdomen soft , nontender ,
nondistended . positive bowel sound . extremities
club , cyanosis edema . good dorsalis pedi pulse
posterior tibial pulse 2 + bilaterally . right groin arterial
sheath Swan place . skin rash lesion .
LABORATORY DATA : white blood cell count 11.4 , hematocrit
38.9 , platelet 319 , sodium 138 , K 4.2 , chloride 103 , bicarb
26 , BUN 23 , creatinine 1.0 , albumin 4.1 , troponin 0.79 .
Electrocardiogram describe previously .
HOSPITAL COURSE : 75 year - old woman history
hypertension , hypercholesterolemia status post large
anterior myocardial infarction placement stent
mid left anterior descend coronary artery .
catheterization patient note elevated
wedge pressure residual lesion left circumflex ,
intervene .
1 . Coronary artery disease : patient large
anterior myocardial infarction catheterization result
note . patient continue aspirin , Plavix ,
Integrilin 18 hour discontinue . also
continue heparin beta - blocker continue
tolerate . patient continue lipitor 80 mg
wean nitro drip . otherwise patient
remain mostly ch pain free throughout course
stay . start beta - blocker titrate
tolerate patient evaluate EP team
possible risk stratification future secondary
anterior myocardial infarction decrease ejection
fraction . continue episode
telemetry tachycardia exertion plan make
outpatient Holter monitor outpatient stress
six week time wave alternan time
follow Dr. [ * * last Name ( STitle ) * * ] follow study
reassess obtuse marginal right coronary artery
lesion possible reintervention . patient also
start low level Coumadin three four month
anticoagulation anterior myocardial infarction
hypokinesis anterior wall decrease ejection
fraction . also start Lovenox
bridge wait Coumadin become therapeutic
follow outpatient . Goal inr 1.5
time discontinued Lovenox . patient
give teaching Lovenox stay understand
injection . otherwise patient also start ace
inhibitor improve cardiac function decrease
ejection fraction .
2 . Congestive heart failure : patient ejection
fraction 35 % anterior myocardial infarction .
akinesis mid distal anterior septum ,
distal anterior wall apical akinesis patient
continue ace inhibitor load reduction
start low dose Coumadin . patient 's Os
monitor receive Lasix prn basis .
transfuse one unit blood hematocrit less
30 follow dose Lasix
bibasilar crackle follow blood .
3 . Hematuria : patient hematuria ,
likely secondary traumatic Foley placement
admission , however , patient recommend
outpatient cystoscopy urology follow get
evaluate acute process resolve .
4 . Nutrition : patient continue cardiac diet
electrolyte follow closely . patient
see evaluate physical therapy acute need
rehab physical therapy . patient ambulate
without difficulty without desaturation orthostasis .
discharge condition : good . discharge service
Lovenox teaching . patient ambulate without difficulty
require oxygen .
discharge diagnosis :
1 . anterior wall myocardial infarction .
2 . Congestive heart failure .
3 . Hypertension .
4 . Hypercholesterolemia .
5 . Hematuria .
discharge medication :
1 . Lovenox 100 mg subq q day INR great 1.5 .
2 . Coumadin 5 mg po q day three four month goal
INR 1.5 .
3 . Toprol XL 100 mg one po q day .
4 . Lisinopril 10 mg one po q day .
5 . sublingual nitroglycerin prn .
6 . Atorvastatin 80 mg po q day .
7 . Plavix 75 mg one po q day .
8 . Aspirin 325 mg one po q day .
discharge follow : patient follow
primary care physician [ * * Name9 ( PRE ) 2974 * * ] . patient
INR check time adjust accordingly .
patient follow outpatient neurologist
establish local cardiologist see
local primary care physician . [ * * Name10 ( NameIs ) * * ] follow
Dr. [ * * last Name ( STitle ) * * ] [ * * 2126 - 4 - 17 * * ] . patient
Holter monitor place [ * * 4 - 8 * * ] return
stress test wave alternan [ * * 4 - 9 * * ] .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) * * ] , M.D. [ * * MD Number(1 ) 8227 * * ]
Dictated By:[**Name8 ( MD ) 264 * * ]
medquist36
: [ * * 2126 - 3 - 5 * * ] 04:24
: [ * * 2126 - 3 - 6 * * ] 08:50
JOB # : [ * * Job Number 54527 * * ]
|
[
"4280",
"2720",
"4019"
] |
Admission Date : [ * * 2156 - 11 - 17 * * ] Discharge Date : [ * * 2156 - 11 - 19 * * ]
Date Birth : [ * * 2156 - 11 - 17 * * ] Sex : F
Service : NB
history : Baby Girl [ * * first Name4 ( NamePattern1 ) 47506 * * ] [ * * know lastname * * ] , twin # 1 , deliver 35-
4/7 week gestation , admit newborn intensive
care nursery management prematurity . birth weight 2215
gm ( 25th 50th percentile ) , length 47 cm ( 50th percentile ) ,
head circumference 32 cm ( 50th percentile ) .
Mother 38 - year - old gravida 1 mother estimate date
delivery [ * * 2156 - 12 - 18 * * ] . prenatal screen include
blood type positive , antibody screen negative , hepatitis B
surface antigen negative , rubella immune , RPR nonreactive ,
group B strep unknown . pregnancy conceive
[ * * last Name ( un ) 5153 * * ] fertilization result dichorionic diamnionic twin
gestation . pregnancy complicate advanced maternal
age , twin gestation , gestational hypertension treat
Aldomet . present day delivery pre - term
premature rupture membrane pre - term labor .
deliver cesarean section spinal anesthesia
secondary multiple gestation . amniotic fluid
clear . maternal fever . interpartem antibiotic .
twin emerge cry , dry , bulb suction . apgar
score 9 one minute 9 five minute .
PHYSICAL EXAMINATION discharge : Weight 2205 gm . awake
alert infant . anterior fontanelle open , soft , flat .
cleft . red reflex defer . breath sound clear equal
bilaterally easy work breathing . murmur . normal
pulse perfusion . Abdomen soft , nondistended , positive
bowel sound , cord dry . spine intact . hip stable . normal pre-
term female genitalia . active normal tone activity
gestational age .
SUMMARY HOSPITAL COURSE systems : Respiratory -
room air since admission comfortable work
breathing , respiratory rate remain 30 40 ,
apnea .
Cardiovascular - murmur , heart rate range 130s 140s ;
blood pressure 62/29 mean 41 .
Fluids , electrolyte , nutrition - baby initially
IV admission start ad lib feed . IV fluid
discontinue [ * * 2156 - 11 - 18 * * ] ; take Enfamil 20 ad
lib , take around 18 - 35 cc every 3 - 4 hour , void
stool appropriately .
Gastrointestinal - mild facial jaundice , bili
draw yet , plan draw day life 3 .
Hematology - hematocrit admission 51 % .
infectious disease - CBC blood culture draw
admission start ampicillin gentamicin
rule infection [ * * 2156 - 11 - 19 * * ] . CBC show
white count 8.9 21 poly , band , platelet
331,000 , hematocrit 51 % . blood culture growth date .
Sensory - hearing screening perform yet ,
need prior discharge .
condition discharge : stable pre - term infant .
discharge disposition : transfer newborn nursery .
NAME PRIMARY PEDIATRICIAN : [ * * first Name4 ( NamePattern1 ) 3742 * * ] [ * * last Name ( NamePattern1 ) 74887 * * ] , M.D. , [ * * Location ( un ) 74888 * * ] , [ * * apartment address(1 ) 50442 * * ] , [ * * Location ( un ) * * ] , [ * * Numeric Identifier 1415 * * ] , telephone
# [ * * telephone / Fax ( 1 ) 43701 * * ] .
CARE recommendation : Feeds - Enfamil 20 iron ad lib ,
monitor weight , may need 24 calorie per ounce .
medication - currently medication , iron vitamin
supplementation , iron recommend pre - term low
birth weight infant 12 month correct age .
infant feed predominantly breast milk receive vitamin
supplementation 200 international unit , may provide
multivitamin preparation , daily 12 month
correct age .
car seat position screen test perform ,
need prior discharge .
state newborn screen draw , plan draw
[ * * 2156 - 11 - 20 * * ] , draw bilirubin .
IMMUNIZATIONS RECEIVED : receive hepatitis b
immunization yet .
IMMUNIZATIONS RECOMMENDED : Synagis RSV prophylaxis
consider [ * * Month ( ) * * ] [ * * Month ( ) 958 * * ] infant meet
follow 4 criterion - 1 ) bear less 32
week , 2 ) bear 32 35 week 2
follow - day care RSV season , smoker
household , neuromuscular disease , airway abnormality ,
school - age sibling , 3 ) chronic lung disease , 4 )
hemodynamically significant congenital heart disease .
Influenza immunization recommend annually fall
infant reach 6 month age .
age first 24 month child 's life
immunization influenza recommend household
contact home caregiver .
infant receive rotavirus vaccine . American
Academy Pediatrics recommend initial vaccination pre-
term infant follow discharge hospital
clinically stable least 6 week few
12 week age .
FOLLOW - appointment : recommend followup per
pediatrician .
discharge diagnosis :
1 . appropriate gestational age , pre - term female 35-
4/7 week .
2 . twin # 1 .
3 . rule sepsis .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 48738 * * ] , MD [ * * MD Number(2 ) 55708 * * ]
dictate by:[**last Name ( NamePattern1 ) * * ]
medquist36
: [ * * 2156 - 11 - 19 * * ] 02:26:25
: [ * * 2156 - 11 - 19 * * ] 03:52:12
Job # : [ * * Job number 74889 * * ]
|
[
"V290"
] |
Admission Date : [ * * 2126 - 8 - 30 * * ] Discharge Date : [ * * 2126 - 9 - 8 * * ]
Date Birth : [ * * 2054 - 2 - 16 * * ] sex : F
Service : CARDIOTHORACIC
allergy :
Relafen
attending:[**first Name3 ( LF ) 4679 * * ]
Chief Complaint :
Recurrence lung cancer
Major Surgical Invasive Procedure :
[ * * 2126 - 8 - 30 * * ] : Redo right thoracotomy , Lysis adhesion
decortication lung , wedge resection right low lobe lung
cancer .
history Present Illness :
Ms. [ * * know lastname 6610 * * ] 72 year - old woman perform
right thoracotomy , right lower lobe superior segmentectomy
[ * * 2125 - 7 - 27 * * ] . pathology reveal 2.5 cm , moderately
differentiate , adenocarcinoma negative margin . lymph
node negative . pt1bn0mx , stage IA . see clinic
[ * * 2126 - 7 - 16 * * ] local recurrence note CT . [ * * 2126 - 7 - 19 * * ] PET
show FDG - avid subpleural nodule right low lobe ,
compatible recurrence well chest wall
region right 5th 6th rib new [ * * 2125 - 7 - 3 * * ]
also concern recurrence . undergo core biopsy
[ * * 2126 - 8 - 2 * * ] path reveal recurrent adenocarcinoma . deny
symptom time .
Past Medical history :
Hypertension
Hyperlipidemia
breast CA / p lumpectomy [ * * 2118 * * ] nodal negative adjuvant
chemorad
renal angiomyolipoma
Emphysema
PSH : RLL superior segmentectomy [ * * 2125 - 7 - 27 * * ] , Recurrent PTX require
partial resection via thoracotomy
Social History :
quit smoking [ * * 2109 * * ] smoke 40 year 2 pack day .
deny alcohol use . unfortunately , husband terminal gastric
cancer , hospitalize VA greatly upset patient .
Family history :
two daughter healthy . history
allergy emphysema family .
Physical Exam :
Gen : NAD , anxious
Neck : [ * * Doctor First Name * * ]
chest : clear ausc , incision c , ,
Cor : RRR murmur
Ext : CCE
Pertinent result :
ADMISSION labs
[ * * 2126 - 8 - 30 * * ] 11:30am blood WBC-10.5 RBC-3.27 * Hgb-10.1 * Hct-29.9 *
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt ct-333
[ * * 2126 - 8 - 30 * * ] 03:30PM blood Glucose-167 * UreaN-20 Creat-0.9 na-140
k-4.1 cl-106 HCO3 - 22 AnGap-16
[ * * 2126 - 8 - 30 * * ] 03:30PM blood Calcium-8.1 * Phos-3.9 Mg-1.5 *
DISCHARGE labs
[ * * 2126 - 9 - 7 * * ] 07:05am blood wbc-8.7 RBC-2.65 * hgb-8.0 * Hct-24.2 *
MCV-92 MCH-30.0 mchc-32.8 RDW-14.9 Plt Ct-455 *
[ * * 2126 - 9 - 7 * * ] 07:05am blood Glucose-127 * UreaN-12 creat-0.7 na-136
K-3.9 Cl-96 HCO3 - 30 angap-14
[ * * 2126 - 9 - 7 * * ] 07:05am blood Calcium-8.8 phos-4.6 * Mg-1.8
[ * * 8 - 30 * * ] CXR post op
right pneumothorax post surgery three chest tube place
[ * * 9 - 7 * * ] CXR
Interval removal right basilar chest tube .
continue
subcutaneous emphysema within right lateral chest wall
soft tissue . post - surgical change right hemithorax
lung stable . stable right lateral pleural thickening
right basilar pleural thickening could post - operative
represent pleural fluid . however , appearance
stable . pneumothorax see . left lung remain well
inflated clear . Cardiac mediastinal contour
stable . clip right upper quadrant consistent
cholecystectomy . pulmonary edema .
Brief Hospital course :
Patient admit [ * * 2126 - 8 - 30 * * ] thoracic surgery service
plan right thoracotomy , right low lobe wedge
resection decortication . tolerate procedure well ,
extubate recover PACU prior
transfer ICU stable condition . full detail
please see operative report . three chest tube place
procedure postoperative chest x - ray showed
expect right pneumothorax post surgery three chest tube
place . Pathology reveal 1.8 cm poorly differentiate
adenocarcinoma negative margin positive node .
start clear liquid diet , pain control
epidural start home medication . POD
1 diet advanced regular transfer
surgical floor ICU . POD 2 note
increase somnolence think relate pain
medication epidural turn narcotic
breakthrough pain discontinue . give unit
PRBC Hct 20.3 appropriate increase 24.4
improve somnolence . POD 3 metoprolol start
elevate systolic blood pressure . continue air
leak three chest tube . epidural discontinue
foley catheter remove . start oxycodone
tramadol pain . POD 4 air leak stop
anterior chest tube remove . posterior chest tube
remove POD 6 . POD 7 note feel dizzy
get bed find atrial
fibrillation RVR . give metoprolol without
effect give IV diltiazem return sinus
rhythm . cardiac enzyme negative monitor
telemetry without recurrence . POD 8 air leak resolve
basilar chest tube remove . post pull chest
xray show PTX . pain well control ,
tolerate diet ambulate without assistance ,
discharge home POD 9 instruction follow
dr.[**name ( NI ) 5067 * * ] clinic chest x - ray .
medication admission :
1 . Fluticasone Propionate 110mcg 2 puff ih [ * * hospital1 * * ]
twice day Rinse mouth use
2 . nortriptyline 30 mg PO HS
3 . pravastatin 40 mg PO DAILY
4 . Tiotropium Bromide 1 CAP IH DAILY
5 . triamterene - Hydrochlorothiazide 1 CAP PO DAILY
Discharge medication :
1 . Acetaminophen 650 mg PO Q6H
RX * acetaminophen 650 mg 1 tablet(s ) mouth every 6 hour disp
# * 60 Tablet refills:*0
2 . Docusate Sodium 100 mg PO BID
RX * docusate sodium [ Colace ] 100 mg 1 capsule(s ) mouth twice
day Disp # * 30 Capsule refills:*0
3 . Fluticasone Propionate 110mcg 2 puff ih [ * * hospital1 * * ]
twice day Rinse mouth use
4 . nortriptyline 30 mg PO HS
5 . oxycodone ( Immediate Release ) 5 - 10 mg po Q4H : PRN pain
rx * oxycodone 5 mg [ * * 12 - 10 * * ] tablet(s ) mouth every 4 hour disp
# * 50 Tablet refills:*0
6 . pravastatin 40 mg PO DAILY
7 . senna 1 tab po BID
RX * sennoside [ senna ] 8.6 mg 1 tablet mouth twice day disp
# * 30 Tablet Refills:*0
8 . Tiotropium Bromide 1 CAP IH DAILY
9 . triamterene - Hydrochlorothiazide 1 CAP po DAILY
10 . Metoprolol Tartrate 12.5 mg po BID HTN
hold SBP < 100 hr < 60
RX * metoprolol tartrate 25 mg Half tablet(s ) mouth twice
day Disp # * 15 Tablet refills:*0
Discharge Disposition :
Home Service
Facility :
[ * * Hospital 119 * * ] Homecare
Discharge Diagnosis :
recurrent lung cancer
Discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
admit hospital surgery lung .
do well procedure may return home
continue recovery .
dressing site chest tube- may
remove 24 hour . leave incision open air
. may shower dressing place .
please take prescribed pain medication need .
constipation problem narcotic use , therefore drink
plenty fluid stay well hydrated use stool softener
take narcotic . drive take narcotic pain
medication .
hospital , notice heart rhythm
call atrial fibrillation . able convert rhythm
back normal using medication ; please ask primary care
doctor need test treatment . also start
new medication call Metoprolol high blood
pressure new dysrhythmia , please ask primary care
doctor need continue .
develop chest pain , shortness breath
symptom concern , please call surgeon go
near Emergency Room .
thank allow we participate care .
Followup Instructions :
please follow Dr. [ * * First Name ( STitle ) * * ] 2 week . please call
[ * * telephone / Fax ( 1 ) 2348 * * ] schedule follow appointment 2 week
chest x ray .
please report [ * * Location ( un ) * * ] [ * * Hospital Ward Name 23 * * ] center 30 min
prior appointment chest x - ray .
please follow primary care doctor within week
discharge .
|
[
"4019",
"2724"
] |
Admission Date : [ * * 2126 - 11 - 1 * * ] Discharge Date : [ * * 2126 - 11 - 6 * * ]
Date Birth : [ * * 2069 - 11 - 6 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 7333 * * ]
Chief Complaint :
/ p PEA arrest
Major Surgical Invasive Procedure :
none
history Present Illness :
58 year old male history atrial fibrillation , DM2 , prior
MI present / p PEA arrest OSH vat .
.
Patient intubated unresponsive arrival , history
obtain outside record .
.
early [ * * Month ( ) 359 * * ] , sore throat feel poorly . go
PCP treat 10 day ammoxicillin .
treat penicillin dental extraction . shortly
, become progressively short breath . see
PCP refer Cardiology ( Dr. [ * * last Name ( STitle ) 77919 * * ] .
time CXR perform show opacification right
low [ * * 12 - 9 * * ] [ * * 12 - 8 * * ] hemithorax , interpret infiltrate + pleural
effusion . also stress echocardiogram cardiac
catheterization plan . chest x - ray repeat
[ * * 2126 - 10 - 28 * * ] , unchanged . cath defer
schedule undergo vat possible pleural decortication .
.
admit [ * * hospital3 26615 * * ] [ * * 2126 - 10 - 30 * * ] VATS
bronchoscopy . 2600 cc straw color pleural fluid
remove , pleural biopsy take . end
procedure , prior extubation , patient drop blood
pressure suffer PEA arrest . patient receive
defibrillation , epinephrine , chest compresion 17
minute . return [ * * Location 213 * * ] sinus rhythm , transfer
ICU . put lasix drip . echo
demonstrate pericardial effusion , CT PA demonstrate
PE . lab significant WBC 12 . cardiac
enzyme flat . treat levaquin unasyn
presume PNA . wean sedation respond
noxious stimulus . evaluate neurology
recommend MRI EEG . transfer [ * * Hospital1 18 * * ]
cardiology neurology evaluation . transfer ,
heparin drip , midazolam / fentanyl sedation mechanical
ventilation ( AC ) .
Past Medical History :
- Atrial Fibrillation
- Diabetes Type II
- h / mi
Social History :
-Tobacco history : Quit smoke three year ago , 1 ppd x 20 year
previously
-etoh : 12 pack weekend
-illicit drug :
family history :
NC
Physical Exam :
VS : T= 99.7 BP= 126/81 hr= 78 rr= 16 O2 sat= 100/ AC FiO2 100 ,
Tv 550 , RR 16 , PEEP 5
GENERAL : intubate , sedate , responsive command .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
neck : supple JVP 10 cm .
CARDIAC : PMI locate 5th intercostal space , midclavicular
line . rr , normal S1 , S2 . / r / g. thrill , lift . S3
S4 .
lung : chest wall deformity , scoliosis kyphosis . Resp
unlabore , accessory muscle use . CTAB , crackle ,
wheeze rhonchus .
ABDOMEN : soft , NTND . HSM tenderness . abd aorta
enlarge palpation . abdominial bruit .
extremitie : c / c / e. femoral bruit .
skin : stasis dermatitis , ulcer , scar , xanthomas .
pulse :
right : dp 2 + PT 2 +
leave : dp 2 + PT 2 +
NEURO : unresponsive command . pupil reactive light ,
corneal relfex intact . Babinski go . spontaneous
movement observe .
.
time death : extubate
pertinent result :
[ * * 2126 - 11 - 1 * * ] 06:22pm blood WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90
MCH-31.8 mchc-35.4 * RDW-13.5 Plt ct-222
[ * * 2126 - 11 - 1 * * ] 06:22pm blood Neuts-74.9 * Lymphs-17.0 * Monos-5.7
Eos-0.7 Baso-1.8
[ * * 2126 - 11 - 1 * * ] 06:22pm blood pt-15.6 * PTT-32.2 INR(PT)-1.4 *
[ * * 2126 - 11 - 2 * * ] 04:11am blood ESR-30 *
[ * * 2126 - 11 - 1 * * ] 06:22pm blood Glucose-143 * UreaN-16 Creat-1.0 Na-136
K-3.7 Cl-98 HCO3 - 29 angap-13
[ * * 2126 - 11 - 1 * * ] 06:22pm blood ALT-24 AST-51 * CK(CPK)-100 AlkPhos-75
TotBili-2.1 *
[ * * 2126 - 11 - 2 * * ] 04:11am blood alt-22 ast-50 * alkphos-69 TotBili-2.0 *
[ * * 2126 - 11 - 3 * * ] 04:26AM blood alt-22 ast-54 * alkphos-69 totbili-2.4 *
[ * * 2126 - 11 - 1 * * ] 06:22pm blood CK - mb-1 cTropnT-<0.01
[ * * 2126 - 11 - 1 * * ] 06:22pm blood calcium-8.6 phos-2.9 mg-2.1
[ * * 2126 - 11 - 2 * * ] 04:11am blood CRP-41.7 *
[ * * 2126 - 11 - 2 * * ] 04:11am blood [ * * Doctor First Name * * ] -NEGATIVE dsDNA - NEGATIVE
[ * * 2126 - 11 - 1 * * ] 06:27PM blood Type - ART pO2 - 386 * pco2 - 39 pH-7.48 *
calTCO2 - 30 Base XS-6
[ * * 2126 - 11 - 3 * * ] 05:12AM BLOOD Type - ART pO2 - 143 * pco2 - 39 ph-7.47 *
calTCO2 - 29 Base xs-5
[ * * 2126 - 11 - 1 * * ] 06:27PM blood Lactate-1.6
.
EEG : abnormal routine eeg due presence
low - voltage background invariant nonreactive
external
stimulation . finding suggest diffuse severe
encephalopathy ,
cause hypoxic - ischemic injury , toxic - metabolic
change ,
medication effect , among thing . focal
abnormality epileptiform feature note .
.
PCXR : ET tube tip 5.2 cm carina . NG tube
tip pass diaphragm tip
stomach .
Diffuse pericardial calcification note , circumferential .
Mediastinum minimally widen might relate
portable technique study . minimal vascular
congestion overt edema . leave retrocardiac opacity might
represent area atelectasis , aspiration infectious process
closely monitor .
.
TTE : left atrium elongate . right atrium
moderately dilate . estimate right atrial pressure
10 - 20mmhg . mild moderate regional left ventricular
systolic dysfunction basal mid inferior , inferolateral ,
anterolateral hypokinesis . due suboptimal technical
quality , additional focal wall motion abnormality
fully exclude . overall leave ventricular systolic function
mildly depressed ( lvef= 40 % ) . unable assess leave ventricular
diastolic function . right ventricular chamber size free wall
motion normal . abnormal septal motion / position .
ascending aorta mildly dilate . aortic valve leaflet
mildly thicken ( ? # ) . aortic valve stenosis . Trace
aortic regurgitation see . mitral valve leaflet
mildly thicken . mitral regurgitation see .
pericardial effusion . anterior space
likely represent prominent fat pad .
.
MR HEAD W/ W / CON :
1 . extensive confluent area decrease diffusion
bilateral parietal occipital [ * * Month / Day / Year 3630 * * ] part frontal
lobe likely relate cortical infarction degree
cortical swelling . spread temporal lobe , basal
ganglia right cerebellar hemisphere probably
leave cerebellar hemisphere . correlate clinically consider
followup / correlation brain scan .
2 . area increase signal intensity T2 FLAIR
sequence
right frontal [ * * last Name ( LF ) 3630 * * ] , [ * * first Name3 ( LF ) * * ] relate change parenchyma
surround small developmental venous anomaly . however , give
lack prior study extent flair hyperintense
area , measure 2.1 x 2.6 cm , consider followup assess
stability / progression exclude associated low - grade
neoplasm .
3 . mucosal thickening mastoid air cell side ,
right leave .
.
Brief Hospital Course :
# . / p PEA arrest . post - op / peri anesthesia hypotension
likely precipitant PEA . possible contribution hypoxia
give lung collapse see CT . CT PA negative PE , echo
negative tamponade . lab essentially normal , cardiac enzyme
negative . neurology consult EEG MRI head do ,
consistent poor neurologic prognosis . neurology team
explain prognosis patient 's family agree
would within wish exist without meaningful
interaction . NEOB initially contact[**name ( NI ) * * ] pt . long
possible donor extubate .
.
# Respiratory Failure / Pleural Effusion : Patient never
extubate post - thoracentesis . continue levaquin unasyn
give concern aspiration / oral flora give unilateral PNA ,
recent tooth extraction alcohol history . pleural fluid
analysis empyema , suggestive exudate . fluid
cytology negative . Patient overbreathe vent excellent
RSBI prior extubation . make DNR / DNI prior
extubation . successfully extubate [ * * 11 - 4 * * ] morphine
drip give scopolamine patch comfort measure .
expire morning [ * * 11 - 6 * * ] . Autopsy request
family .
medication admission :
HOME medication :
Metformin 1000 mg po bid
ASA 325 mg PO daily
glyburide 5 mg po bid
Imdur 30 mg PO daily
.
medication TRANSFER :
Combivent
Heparin gtt 900 U / hr
Unasyn 3gm IV q6
Levaquin 750 mg q24
Lasix 40 mg IV q daily
Discharge Disposition :
expire
discharge Diagnosis :
/ p PEA arrest
death
discharge condition :
expire
|
[
"9971",
"486",
"5180",
"5119",
"412",
"4019",
"4275",
"4280"
] |
Admission Date : [ * * 2176 - 5 - 31 * * ] Discharge Date : [ * * 2176 - 6 - 14 * * ]
Date Birth : [ * * 2101 - 7 - 5 * * ] sex : F
Service : SURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 4111 * * ]
Chief Complaint :
Constipation , fatigue , weight loss
Major Surgical Invasive Procedure :
Resection transverse colon splenic
flexure , colocolostomy , resection small bowel ( en bloc )
enteroenterostomy feed jejunostomy .
history Present Illness :
Mrs [ * * know lastname 1391 * * ] 74f present several month history
constipation , diarrhea , occasional nausea / vomiting ,
weight loss approx 25lbs past 6 month . first
seek medical attention 3 week admission ,
workup , include colonoscopy CT scan , show mass
transverse colon . Biopsy show moderately differentiate
adenocarcinoma . deny black bloody stool , dysuria .
Past Medical History :
CAD CABG [ * * 9-/2172 * * ]
Hypothyroidism
Recent onset heartburn symptom , formal dx GERD
Social History :
30 - 40py smoking history
widow 6 year
3 Children
Family history :
Mother die pancreatic cancer , father prostate cancer
Physical Exam :
physical exam discharge :
VS :
rrr
CTAB
Abd soft , non - tender jejunostomy tube place . j - tube site
free erythema induration .
Brief Hospital course :
Ms [ * * know lastname 1391 * * ] admit [ * * 2176 - 5 - 31 * * ] begin nutritional
optimization preparation surgery . pre - operative
cardiology clearance obtain cardiac intervention
require . central line place [ * * 6 - 1 * * ] total parenteral
nutrition initiate , although pt continue attempt
self - support oral intake . CT scan [ * * 6 - 5 * * ]
pre - operative planning encouraging , show
metastatic lesion invade mesentery likely involvement
celiac mesenteric vessel . undergo [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ]
prep fleet # 1 prep [ * * 6 - 5 * * ] , take operating
room [ * * 6 - 6 * * ] . please refer operative report Dr [ * * last Name ( STitle ) 957 * * ]
detail procedure . Post - operatively
note markedly bradycardic , heart rate low 29
blood pressure prove difficult measure
either machine direct auscultation . thus place
MICU overnight advice cardiology service ,
feel unlikely event hr drop low
unable support blood pressure , would essential
close monitoring . fluid resuscitation continue ,
patient 's hr gradually normalize . electrophysiology
consult , recommend pacemaker time ,
rhythm Wenckebach constitute indication
pacemaker . although continue TPN post - operatively ,
functional level improve return oral
intake , tubefeed supplement . [ * * 6 - 11 * * ] begin
complain suprapubic burn pain , urinalysis
negative UTI , pain deem post - surgical .
improve , TPN stop , tubefeed oral intake
increase , central line remove .
discharge home service [ * * 6 - 14 * * ] .
follow Heme / Onc arrange , pt express wish
follow Dr [ * * last Name ( STitle ) * * ] [ * * hospital3 * * ] . also
recommend seek care [ * * Hospital3 35292 * * ] service
[ * * Hospital1 18 * * ] , modality may well suited tumor .
medication admission :
Atenolol 25
Fosamax 35 q week
Levoxyl 88mcg
81 mg ASA
Ambien prn
Vicodin prn , MVI
discharge medication :
1 . Metoprolol Tartrate 25 mg Tablet Sig : 0.5 Tablet po BID ( 2
time day ) .
disp:*30 Tablet(s ) * Refills:*2 *
2 . Hydrocodone - Acetaminophen 5 - 500 mg Tablet Sig : 1 - 2 tablet po
q4 - 6h ( every 4 6 hour ) need .
Disp:*40 Tablet(s ) * Refills:*0 *
3 . Levothyroxine Sodium 88 mcg Tablet Sig : one ( 1 ) Tablet PO
DAILY ( Daily ) .
4 . Sodium Chloride 1 g Tablet Sig : one ( 1 ) Tablet PO TID ( 3
time day ) 2 week .
Disp:*42 Tablet(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
[ * * Hospital3 7571**]Nursing Assc .
discharge diagnosis :
colon cancer
discharge condition :
good
Discharge instruction :
take medication prescribe . drive take
narcotic pain medication percocet vicodin . please
follow VNA 's instruction tubefeed . develop
fever , chill , nausea / vomiting , cessation bowel movement
flatus , difficulty flush J - tube , severe abdominal pain ,
concern symptom , please contact office
local emergency room . please call Dr[**Name ( NI ) 6275 * * ] office
schedule follow appoitnment . also able
put contact [ * * Name ( NI ) 35292 * * ] office , help arrange
chemotherapy treatment . Dr[**Name ( NI ) 35293 * * ] office
contact Dr [ * * last Name ( STitle ) * * ] followup well , not
hear within one week please call office .
Followup Instructions :
please call Dr[**Name ( NI ) 6275 * * ] office schedule follow
appoitnment . also able put contact
[ * * Name ( NI ) 35292 * * ] office , help arrange chemotherapy
treatment . Dr[**Name ( NI ) 35293 * * ] office contact Dr
[ * * last Name ( STitle ) * * ] followup well , not hear within
one week please call office .
|
[
"9971",
"2449"
] |
Admission Date : [ * * 2162 - 6 - 3 * * ] Discharge Date : [ * * 2162 - 6 - 9 * * ]
service : MEDICINE
allergy :
Known Allergies / Adverse Drug Reactions
attending:[**doctor First Name 1402 * * ]
Chief Complaint :
lethargy , bradycardia , fever
Major Surgical Invasive Procedure :
none
history Present Illness :
89 w/ COPD , Afib coumadin , moderate dementia urinary
retention indwelling foley , admit altered mental
status , admit MICU fever , new complete heart block
question sepsis . morning admission , patient note
fatigue unable walk . baseline , live [ * * Hospital1 100 * * ]
generally orient self answer basic
question , walk walker . exam rehab ,
bradycardia 40 , BP 154/64 , O2 sit 94 % RA , temp 99.3 . EKG
show complete heart block . transfer ED
evaluation .
ED , initial VS : 101.3 44 155/37 32 87 % RA . Hypoxia
improve 2L nasal cannula . UA sig UTI ( > 182 WBC , lrg
leuk , pos nitrate , many bacteria ) . CXR concern ?
infiltrate . pressure stable sbp 120s-130s . get 2L IVF ,
ceftriaxone azithro . confirmed 3rd degree heartblock EKG .
Labs show acute renal failure ( Cr 1.6 , baseline 1.0 ) , lactate
2.7 , concern mild sepsis . 18 g 20 g
place . a&o&1 . Patient confirm DNR , would consider PPM .
foley catheter replace .
arrival MICU , patient rest comfortably .
questioning daughter deny pain . feel
appear well morning . discussion ,
would like temporary pacing necessary . would like
father DNR / DNI , would okay reverse
status pacemaker placement .
Past Medical History :
- Bacteremia [ * * 11/2161 * * ] VRE [ * * Female First Name ( un ) * * ]
- COPD ( unclear history , always nonsmoker )
- HTN med
- AF coumadin
- colon cancer [ * * 2152 * * ]
- dementia ( recognize child orient place
able converse normally orient place time ) ,
significant behavioral component
- history TB , find 10 mm PPD [ * * 2153 * * ] , negative
CXR treat [ * * 2153 * * ] 9 month latent TB . CXR repeat
[ * * 2156 * * ] look increase density basis
- BPH chronic indwelling foley , h / [ * * Year ( 4 digit ) 40097 * * ] E.Coli urine
infection
- gerd
- anemia
- intermittent complete heart block . asymptomatic , discussion
family , PPM clear benefit .
Social History :
live [ * * Hospital 100 * * ] Rehab . never smoker . able walk
walker assist . Diet pureed / nectar thicken
several month , recently switch back thin liquid .
Family history :
daughter know significant family history .
Physical Exam :
Admission exam :
VS : 101.3 44 155/37 32 87 % RA
General : Alert , orient self , acute distress
HEENT : Sclera anicteric , MMM , oropharynx clear , EOMI , PERRL
Neck : supple , JVP mildly elevate 8 - 10 cm , LAD
CV : distant heart sound , marked bradycardia , normal S1 + S2 ,
audible murmur , rub , gallop
lung : clear auscultation anteriorly , wheeze , rale ,
ronchi
Abdomen : soft , non - tender , non - distended , bowel sound present ,
organomegaly
GU : foley place
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
Neuro : CNII - XII intact , move four extremity , unable
cooperate .
discharge Exam :
vital : afebrile x2.5days , Tc 98.5 , 150/85 , 51 , 18 , 99%ra
General : rest comfortably bed , acute distress ,
interactive , smile
HEENT : Sclera anicteric , drymm
Neck : supple , JVP elevate , LAD
CV : bradycardiain 50 , normal S1 + S2 , audible murmur ,
rub , gallop
lung : + mild rale bilaterally basis , rhonchi / wheeze .
Abdomen : soft , non - tender , non - distended , bowel sound present ,
organomegaly
GU : indwelling foley place
Ext : room temperature , improve cap refill , 2 + pulse ,
club , cyanosis edema
Dementia : speak sensical Russian currently , orient
self . baseline .
pertinent result :
Admission Labs :
[ * * 2162 - 6 - 3 * * ] 02:20pm blood WBC-14.0 * # rbc-5.66 # hgb-13.2 * # hct-44.6 #
MCV-79 * MCH-23.3 * MCHC-29.6 * RDW-15.8 * Plt ct-221
[ * * 2162 - 6 - 3 * * ] 02:20PM BLOOD Neuts-89.0 * Lymphs-6.7 * Monos-3.7 eos-0.6
Baso-0.2
[ * * 2162 - 6 - 3 * * ] 02:20pm blood PT-32.5 * PTT-39.6 * INR(PT)-3.2 *
[ * * 2162 - 6 - 3 * * ] 02:20pm blood Glucose-145 * UreaN-27 * Creat-1.6 * Na-138
K-7.4 * Cl-106 HCO3 - 21 * angap-18
[ * * 2162 - 6 - 3 * * ] 02:20pm blood ALT-49 * AST-76 * alkphos-81 totbili-0.5
[ * * 2162 - 6 - 3 * * ] 02:20pm blood Lipase-40
[ * * 2162 - 6 - 3 * * ] 02:20pm blood cTropnT-0.06 *
[ * * 2162 - 6 - 3 * * ] 02:20pm blood albumin-3.8 calcium-8.8 Phos-2.6 * mg-2.4
[ * * 2162 - 6 - 3 * * ] 02:28PM blood lactate-2.7 * K-5.7 *
Admission UA :
[ * * 2162 - 6 - 3 * * ] 02:30pm URINE Color - Yellow Appear - Cloudy Sp [ * * last Name ( un ) * * ] -1.020
[ * * 2162 - 6 - 3 * * ] 02:30pm URINE Blood - MOD Nitrite - POS Protein-100
Glucose - NEG Ketone - TR Bilirub - NEG Urobiln - NEG ph-5.5 Leuks - LG
[ * * 2162 - 6 - 3 * * ] 02:30PM URINE RBC-9 * WBC->182 * Bacteri - MANY yeast - NONE
Epi-0
Repeat UA :
[ * * 2162 - 6 - 5 * * ] 09:00PM URINE Color - Yellow Appear - Hazy Sp [ * * last Name ( un ) * * ] -1.019
[ * * 2162 - 6 - 5 * * ] 09:00PM URINE Blood - MOD Nitrite - NEG Protein-100
Glucose - NEG Ketone - TR Bilirub - NEG Urobiln - NEG ph-5.5 Leuks - TR
[ * * 2162 - 6 - 5 * * ] 09:00PM URINE RBC-7 * WBC-5 Bacteri - NONE yeast - NONE
Epi-0
Lactate trend :
[ * * 2162 - 6 - 3 * * ] 02:28PM blood lactate-2.7 * K-5.7 *
[ * * 2162 - 6 - 4 * * ] 12:33AM blood lactate-1.4
[ * * 2162 - 6 - 5 * * ] 07:51PM blood lactate-3.4 *
[ * * 2162 - 6 - 5 * * ] 08:14PM blood Lactate-1.4
Troponin Trend :
[ * * 2162 - 6 - 3 * * ] 02:20pm blood cTropnT-0.06 *
[ * * 2162 - 6 - 3 * * ] 10:10PM blood CK - MB-3 cTropnT-0.06 *
[ * * 2162 - 6 - 5 * * ] 04:06AM blood CK - MB-3 cTropnT-0.05 *
WBC trend : 14.0->11.7->10.1->9.2->7.9->8.2->7.8->6.9
Discharge Labs :
[ * * 2162 - 6 - 9 * * ] 06:49am blood WBC-6.9 rbc-5.05 Hgb-11.9 * Hct-39.7 *
MCV-79 * MCH-23.6 * MCHC-30.0 * RDW-16.1 * Plt Ct-257
[ * * 2162 - 6 - 9 * * ] 06:49am blood pt-22.8 * PTT-32.0 INR(PT)-2.2 *
[ * * 2162 - 6 - 9 * * ] 06:49am blood Glucose-77 UreaN-22 * Creat-0.9 Na-146 *
K-4.4 cl-114 * HCO3 - 24 AnGap-12
[ * * 2162 - 6 - 9 * * ] 06:49am blood calcium-8.6 Phos-3.0 Mg-2.2
MICRO :
[ * * 2162 - 6 - 3 * * ] MRSA SCREEN MRSA SCREEN - negative
[ * * 2162 - 6 - 3 * * ] URINE URINE culture- Mixed Flora
[ * * 2162 - 6 - 3 * * ] blood CULTURE Blood Culture ,
Routine - PENDING [ * * 2162 - 6 - 3 * * ] blood CULTURE Blood
Culture , Routine - pending
[ * * 2162 - 6 - 8 * * ] STOOL C. difficile dna amplification
assay - negative
[ * * 2162 - 6 - 5 * * ] blood CULTURE Blood Culture ,
Routine - PENDING [ * * 2162 - 6 - 5 * * ] blood CULTURE Blood
Culture , Routine - PENDING [ * * 2162 - 6 - 5 * * ] URINE URINE
CULTURE - mix flora
IMAGING :
[ * * 2162 - 6 - 3 * * ] EKG : sinus rhythm high grade - v block . baseline
artifact obscure interpretation appear complete
heart block present junctional escape approximately
40 beat per minute . compare previous tracing [ * * 2161 - 5 - 29 * * ]
heart block new . high grade - v block new . trace # 1
[ * * 2162 - 6 - 4 * * ] EKG : high grade - v dissociation junctional escape
approximately 34 beat per minute . appear
conduct p wave likely isorhythmic dissociation .
variation p - p interval may due ventriculophasic
affect . compare previous tracing [ * * 2161 - 5 - 29 * * ] heart block
persist . trace # 2
[ * * 2162 - 6 - 3 * * ] CXR : Low lung volume . probable bibasilar atelectasis
aspiration difficult exclude . possible trace
bilateral pleural effusion .
[ * * 2162 - 6 - 4 * * ] echo : left atrium mildly dilate . atrial septal
defect see 2D color Doppler . mild symmetric
leave ventricular hypertrophy normal cavity size
regional / global systolic function ( lvef>55 % ) .
ventricular septal defect . right ventricular chamber size
free wall motion normal . diameter aorta
sinus , ascending arch level normal . aortic valve
leaflet ( 3 ) mildly thicken aortic stenosis
present . mild ( 1 + ) aortic regurgitation see . aortic
regurgitation jet eccentric , direct toward anterior
mitral leaflet . mitral valve leaflet mildly thicken .
mitral valve prolapse . mild ( 1 + ) mitral
regurgitation see . tricuspid valve leaflet mildly
thicken . mild pulmonary artery systolic hypertension .
pericardial effusion . compare prior study
( image review ) [ * * 2161 - 11 - 18 * * ] , clear change .
[ * * 2162 - 6 - 5 * * ] CXR : heart moderately enlarge .
moderate - sized left effusion increase compare
prior . pulmonary vascular redistribution alveolar
infiltrate suggest element fluid overload ; however ,
addition , dense alveolar infiltrate involve
leave low lobe . unclear due infectious
process . Chronic right upper lobe low lobe lung change
visualize .
IMPRESSION :
1 . new infiltrate left low lobe .
2 . increase fluid overload .
Brief Hospital Course :
89 w/ COPD , Afib coumadin , moderate dementia urinary
retention indwelling foley , admit altered mental
status , new complete heart block infection unclear
source .
Acute Issues :
# complete heart block : Patient previously pr interval
218 , suggest progressive nodal disease . narrow qrs ,
slow escape rhythm . trial atropine suggestive infranodal
disease , telemetry also show multiple foci disease .
course hospital stay , heart block resolve
intermittently heart rate time discharge
persistently 50 - 60 . result family discussion
risk benefit PPM elderly patient
end stage dementia intermittent asymptomatic complete
heart block coumadin afib , potential (
guarantee ) benefit PPM placement would outweight
potential risk .
# Fever / UTI / Infection unclear source : Patient present
fever 101.3f grossly positive UA . likely source
urinary , give positive UA . Indwelling foley
replace ED . CXR similar prior . history
resistant bacteria ( VRE [ * * Month / Day / Year 40097 * * ] e.coli ) ,
iniatially cover broadly Meropenem Linezolid
[ * * last Name ( un ) * * ] Daptomycin . Urine culture finalize mixed flora
evidence VRE [ * * last Name ( LF ) 40097 * * ] , [ * * first Name3 ( LF ) * * ] pt narrow ceftriaxone .
10 hour last dose meropenem , become febrile
102.9f , venous lactate 2.4 . UTI cause high
fever , ddx include prostatitis , pyelonephritis , PNA . Repeat UA
without bacteria repeat urine culture mixed
flora . CXR show fluid overload possible infiltrate / PNA ,
sypmtom . C. diff PCR negative . blood culture NGTD .
rebroadene Meropenem ( Daptomycin restart ,
suspicion gram positive infection ) WBC continue
trend without subsequent fever . Patient lose IV access
( pull iv EKG lead ) replacement iv
successfully place . give source infection
unknown , fail trial narrowing antibiotic ,
continue [ * * first Name3 ( LF ) * * ] 1gm IM daily remainder
antibiotic course . continue [ * * first Name3 ( LF ) 49799 * * ] 2 day
inhouse afebrile normal WBC , continue course
[ * * 2162 - 6 - 12 * * ] .
# Respiratory Alkalosis / Hypoxia / dchf : transfer MICU ,
note tachypneic decrease O2 saturation . ABG
show respiratory alkalosis , likely due hyperventilation 2/2
hypoxia : ph 7.53 , pco2 23 , pO2 62 . place O2 repeat ABG
show ph 7.40 , pco2 40 , pO2 68 . CXR show acute congestive
heart failure posible infiltrate LLL . Echo show
mild pulmonary hypertension ( increase TR gradient ) nml EF .
CHB likely decrease CO cause mild chf . give 10 mg
IV lasix gentle diuresis good urine output
improvement O2 sat . Patient without symptom cough .
WBC continue trend current meropenem/[**Last Name ( LF ) 49799 * * ] , [ * * first Name3 ( LF ) * * ]
pneumonia treatment initiate .
# Hypertension ( Occult Hypoperfusion ): Patient carry
diagnosis HTN , though note
antihypertensive outpatient . since CHB , patient
note high bp ( sbp 150s-180s ) .
low hrs ( 30 - 40s ) , patient dry cool , suggest
vascularly constrict , likely effort maintain perfusion
tissue CHB . venous lactate 3.4 , arterial lactate
1.4 , support likely occult hypoperfusion [ * * 2 - 4 * * ] CHB .
several day admission , heart rate improve
50 - 60 , rarely complete heart block . elevated
blood pressure never rise SBP 200 ,
tolerate effort maintain perfusion tissue .
Chronic Issues :
# Dementia : Patient end stage dementia , orient
self able communicate sensically . initially
find fatigue able walk around . family
concerned baseline term mental status
time , however treatment infection return
baseline MS . may element decrease MS heart
rate 30 , however infection improve , heart rate
improve , difficult assess . Patient
continue home mirtazipine zyprexa rare dose
zydis agitation ( family report baseline ) .
# [ * * last Name ( un ) * * ] : Patient present [ * * last Name ( un ) * * ] ( Cr 1.6 , baseline note
1.0 ) . likely due hypoperfusion infection compound
complete heart block . Cr trend since admission ,
discharge 0.9 .
# afib : CHADS score 2 , coumadin goal [ * * 2 - 5 * * ] . present
INR 3.2 . Coumadin initially hold , restart remain
therapeutic home dose 3 mg daily except Mondays
take 3.5 mg daily .
# COPD : write albuterol ipratropium nebs need
wheezing .
# BPH : continue finasteride chronic foley ,
exchange ED [ * * 2162 - 6 - 3 * * ] .
Transitional issue :
DNR / DNI
give patient intermittently complete heart
block , anticoagulate end stage dementia , give
appear baseline mental status currently ,
decide risk outweight benefit pacemaker
placement .
long blood pressure < 200 , elevate blood pressure
tolerate patient bradycardic . high
blood pressure natural compensation maintain blood
perfusion body cardiac output decrease
slow heart rate .
medication admission :
- mirtazapine 30 mg QHS
- trazodone 50 mg QHS PRN insomnia
- Senna 17.2 mg qhs
- Miralax 17gm daily
- Bacitracin 1 application [ * * hospital1 * * ]
- finasteride 5 mg daily
- tylenol 650 mg Q6hrs PRN
- olanzapine 2.5 mg daily
- warfarin 3 mg daily TuWeThFrSaSu
- warfarin 3.5 mg daily Mo
Discharge medication :
1 . mirtazapine 30 mg Tablet Sig : one ( 1 ) Tablet po bedtime .
2 . trazodone 50 mg Tablet Sig : one ( 1 ) Tablet po bedtime
need insomnia .
3 . senna 8.6 mg Tablet Sig : two ( 2 ) Tablet PO HS ( bedtime ) .
4 . polyethylene glycol 3350 17 gram Powder Packet Sig : one
( 1 ) Powder Packet PO DAILY ( Daily ) .
5 . bacitracin Topical
6 . finasteride 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
7 . acetaminophen 650 mg Tablet Sig : one ( 1 ) Tablet po every six
( 6 ) hour need pain .
8 . olanzapine 2.5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
9 . warfarin 3 mg Tablet Sig : one ( 1 ) Tablet PO daily except
3.5 mg Mondays .
10 . warfarin 1 mg Tablet Sig : 3.5 tablet po 1X / WEEK ( MO ): 3 mg
daily , except 3.5 mg Mondays .
11 . [ * * Hospital1 49799 * * ] 1 gram Recon Soln Sig : one ( 1 ) gram Injection
day 4 day : give 2 pm daily 4 dose , last dose
[ * * 2162 - 6 - 12 * * ] 2 pm . mix injection lidocaine lessen pain
injection .
Disp:*4 gram * Refills:*0 *
12 . miconazole nitrate 2 % Aerosol Powder Sig : one ( 1 )
application Topical four time day : fungal rash buttock .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 459 * * ] Aged - MACU
Discharge Diagnosis :
Primary Diagnosis : Complete Heart Block , Urinary Tract infection
secondary Diagnosis :
Hypertension
Dementia
Acute Kidney Injury
Atrial Fibrillation
COPD
BPH
discharge condition :
Mental Status : confused - always .
level consciousness : alert interactive .
Activity Status : ambulatory - require assistance aid ( walker
cane ) .
discharge instruction :
dear Mr. [ * * know lastname 55195 * * ] ,
pleasure take care fo [ * * hospital1 827 * * ] . admit extreme fatigue
irregular heart beat . admission find
urinary tract infection , treat .
additionally , note irregularly slow heart
rhythm call Complete Heart Block , however improve
admission . decide risk
outweight possible benefit place pacemaker
problem . [ * * Name ( NI ) * * ] improve treatment infection
safe discharge .
please make follow change outpatient medication
regiman :
START [ * * Name ( NI ) * * ] 1 mg intramuscular injection daily 4
day .
start miconazole powder apply 4 time daily fungal
rash buttock . keep area dry clean .
change make outpatient medication .
continue medication previously prescribe .
weigh every morning , [ * * Name8 ( MD ) 138 * * ] MD weight go
3 lbs .
Followup Instructions :
follow doctor [ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) 100 * * ] Rehab .
|
[
"5990",
"5849",
"4280",
"496"
] |
Admission Date : [ * * 2109 - 6 - 6 * * ] Discharge Date : [ * * 2109 - 6 - 7 * * ]
Date Birth : [ * * 2051 - 9 - 7 * * ] sex : F
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 443 * * ]
Chief Complaint :
afib w/ RVR
Major Surgical Invasive Procedure :
none
history Present Illness :
Ms. [ * * know lastname 85533 * * ] 57 year old woman hard control HTN
hypothyroidism , transfer OSH [ * * Hospital1 18 * * ]
find atrial fibrillation TEE / DCCV .
.
Ms. [ * * know lastname 85533 * * ] state past week
mild chest pain , last several minute . also
shortness breath evening keep
sleep . question state chest pain
addition palpitation feeling skip beat
go two year . throughout time think
" nerve . " go PCP , [ * * Name10 ( NameIs ) * * ]
see physician [ * * last Name ( namepattern4 ) * * ] 2 year , ECG do office .
find atrial fibrillation send ED .
.
OSH , give metoprolol po iv without
improvement heart rate . initially labetalol increase
stop switch toprol XL . heart rate
range 120s-130s . start coumadin lovenox .
echo show mildly decrease EF . lab :
- dimer negative , hct 41.9 , cr 0.8 , trop < 0.01 .
.
note , poorly control hypertension sbp<200s
dbp>100s . report compliant medication
state infrequently go PCP . [ * * Name10 ( NameIs ) * * ] last time
see prior visit two year ago .
.
currently , deny shortness breath chest pain .
review system , deny prior history stroke ,
tia , deep venous thrombosis , pulmonary embolism , bleed
time surgery , myalgias , joint pain , cough , hemoptysis , black
stool red stool . deny recent fever , chill
rigor . / deny exertional buttock calf pain .
review system negative .
.
Cardiac review system notable absence dyspnea
exertion , paroxysmal nocturnal dyspnea , orthopnea , syncope
presyncope .
.
ROS positive back / neck pain , chronic headache , weight
gain three week , chronic stable LE edema past 10
year .
.
Past Medical History :
1 . CARDIAC risk factor : -diabete , -Dyslipidemia , + Hypertension
2 . cardiac history :
-cabg :
-percutaneous CORONARY intervention :
-PACING / ICD :
3 . PAST MEDICAL history :
- HTN poorly control
- Afib new , ? go 2 year give funny
feeling chest
- Hypothyroidism
- / p ? thyroid parathyroid surgery
Social History :
- Cigs : 3 py 50
- etOH : deny
- illicit : denie
- Works CNA
- Kids [ * * country 19639 * * ]
family history :
- Father : MI age 63
- mother : CVA age 64
Physical Exam :
vital sign : BP 150/90 hr 90 rr 16 98%ra
GEN : sit bed NAD
Cardiac : nl JVP , irregular rhythm , murmurs
Resp : clear lung
Abd : soft , NT ND
Ext : edema note
pertinent result :
[ * * 2109 - 6 - 6 * * ] 01:42PM % HbA1c-5.5 eAG-111
[ * * 2109 - 6 - 6 * * ] 12:20pm GLUCOSE-88 UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-3.9 chloride-104 total CO2 - 29 anion GAP-13
[ * * 2109 - 6 - 6 * * ] 12:20pm estGFR - use
[ * * 2109 - 6 - 6 * * ] 12:20pm CALCIUM-9.3 phosphate-3.5 magnesium-2.3
[ * * 2109 - 6 - 6 * * ] 12:20pm TSH-2.5
[ * * 2109 - 6 - 6 * * ] 12:20pm TSH-2.5
[ * * 2109 - 6 - 6 * * ] 12:20pm NEUTS-78.2 * LYMPHS-15.2 * MONOS-3.6 eos-2.4
basos-0.6
[ * * 2109 - 6 - 6 * * ] 12:20pm PLT COUNT-259
[ * * 2109 - 6 - 6 * * ] 12:20pm pt-16.9 * PTT-27.5 INR(PT)-1.5 *
Brief Hospital Course :
57 yo female atrial fibrillation , severe hypertension
diastolic heart failure . initial plan TEE / cardioversion .
TEE perform show clot . initially
attempt DC cardioversion X 3 however attempt
bring sinus . initiate sotalol
good rate control establish HRs < 100 however
remain sinus rhythm . continue coumadin
anticoagulation . hypertensive hypokalemic
work - hypertension initiate ; renal artery ultrasound
pende . Valsartan increase 80 160 daily
improve BP control ; spirinolactone discontinue . Labetalol
discontinue give initiation sotalol . Plasma
renin / angiotensin order pende . give
symptomatic improvement rate control , transfer
floor management . evaluate [ * * Doctor Last Name * * ]
heart monitor discharge ; follow Dr [ * * last Name ( STitle ) 171 * * ]
schedule . also appointment PCP schedule
Wednesday [ * * 6 - 12 * * ] follow - along lab check [ * * Month ( ) 766 * * ]
[ * * 6 - 10 * * ] [ * * hospital3 * * ] INR potassium .
medication admission :
Benecar 40 + HCTZ 12.5 QD
Labetolol 100 mg PO BID
Levothyroxine 100mcg po daily
Tylenol PRN
Hx " water pill "
Discharge medication :
1 . warfarin 2 mg Tablet Sig : 1.5 tablet po Daily 4 pm .
Disp:*45 Tablet(s ) * Refills:*2 *
2 . aspirin 81 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
3 . Levothyroxine 100 mcg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
4 . Diovan HCT 160 - 12.5 mg Tablet Sig : one ( 1 ) Tablet po
day .
disp:*30 Tablet(s ) * Refills:*0 *
5 . Sotalol 80 mg Tablet Sig : 1.5 tablet po BID ( 2 time day ) .
Disp:*90 Tablet(s ) * Refills:*0 *
6 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q6H ( every
6 hour ) need pain .
7 . amlodipine 5 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*0 *
8 . outpatient lab work
please get INR , Potassium , Magnesium , calcium , phosphate
check [ * * last Name ( LF ) 766 * * ] , [ * * 6 - 10 * * ] .
9 . spironolactone 25 mg Tablet Sig : one ( 1 ) Tablet po
day .
disp:*30 Tablet(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
[ * * hospital1 * * ] Family & [ * * Hospital1 1926 * * ] service
discharge Diagnosis :
( 1 ) atrial fibrillation
( 2 ) Hypertension
( 3 ) Hypothyroidism
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
Dear Ms [ * * know lastname 85533 * * ] ,
admit heart rate fast
rhythm " atrial fibrillation " also high blood
pressure . try convert rhythm use
electrical shock , however keep normal
rhythm long . reason , start new
medication hospital help control heart
rate . also make medication change help
control blood pressure . change medication
schedule . need follow
cardiologist Dr [ * * last Name ( STitle ) 171 * * ] outpatient , may try additional
therapy try convert atrial fibrillation .
.
medication change make hospitalization :
( 1 ) start warfarin , blood thinning medication ,
take every day . need take 3 mg daily .
important medicine prevent heart form
blood clot atrial fibrillation . need
see [ * * hospital3 * * ] [ * * Hospital3 766 * * ] morning get lab
check medicine . instruction attend
clinic list .
( 2 ) start Diovan HCT 160 - 12.5 mg medicine help
low blood pressure .
( 3 ) start sotalol 120 mg twice day . medicine help
prevent heart rate go fast .
( 4 ) start amlodipine 10 mg daily - another medicine help
control blood pressure .
( 5 ) start spirinolactone 25 mg daily blood pressure .
( 6 ) stop benicar - HCTZ combination pill .
( 7 ) stop labetolol .
( 8) go [ * * hospital3 * * ] [ * * hospital1 * * ] [ * * Location ( un ) 620 * * ]
[ * * Location ( un ) 766 * * ] [ * * 6 - 10 * * ] get INR ( coumadin level ) check .
[ * * Hospital3 271 * * ] call [ * * Hospital3 766 * * ] morning
confirm .
Followup Instructions :
Primary Care : [ * * last Name ( LF ) * * ] , [ * * first Name3 ( LF ) * * ]
-You need get blood check [ * * first Name3 ( LF ) 766 * * ] hospital :
prescription get labwork do
outpatient .
-You appointment Dr [ * * last Name ( STitle ) 5419 * * ] : 16th 430 pm
phone : [ * * telephone / Fax ( 1 ) 31235 * * ]
FAX [ * * telephone / Fax ( 1 ) 85534 * * ]
.
[ * * Hospital3 271 * * ] [ * * hospital1 * * ] [ * * Location ( un ) 620 * * ] : [ * * telephone / Fax ( 1 ) 41860 * * ] . please go
hospital registration ask direction [ * * telephone / Fax ( 1 ) 766 * * ]
INR check .
.
appointment cardiology :
[ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , MD phone:[**telephone / fax ( 1 ) 62 * * ] Date / Time:[**2109 - 6 - 17 * * ] 12:40
|
[
"4019",
"2449"
] |
Admission Date : [ * * 2108 - 9 - 26 * * ] Discharge Date : [ * * 2108 - 10 - 5 * * ]
service : MEDICINE
allergy :
Aspirin / Sulfa ( Sulfonamides ) / Codeine
attending:[**first Name3 ( LF ) 2297 * * ]
Chief Complaint :
transfer MWH cardiac catheterization CP trop
elevation 0.79 , likely NSTEMI ( non st elevation myocardial
infarction )
Major Surgical Invasive Procedure :
cardiac catheterization
history Present Illness :
84yo male cad - CABG x5 [ * * 2094 * * ] ( LIM LAD , SVG DA , SVG
[ * * Female First Name ( un ) * * ] , SVG PDA , SVG lt ventr branch ) , MI [ * * 2070 * * ] , / p
AAA repair , / p fem-[**doctor last Name * * ] bypass , CRF HD transfer
MWH cath ? dx MI .
Patient initially present MWH ED [ * * 2108 - 9 - 24 * * ] c /
continuous 7 10 shoulder shoulder chest pain
radiation . deny SOB diaphoresis . take nitro home x2
relief . ED , + Trop 0.79 , EKG 100 % pace ,
receive iv nitro morphine ,
plavix heparin . aspirin give ( per GI )
h / severe gi bleed aspitrin . Pt 2 subsequent episode
CP overnight relieve Morphine . [ * * 9 - 26 * * ] , pt transfer
[ * * Hospital1 18 * * ] cath .
Past Medical History :
CAD - MI [ * * 2070 * * ] , CABG x5 [ * * 2094 * * ] [ * * Hospital1 336 * * ]
/ p AAA repair [ * * 2082 * * ]
PPM [ * * 2105 * * ]
bilateral fem-[**doctor last Name * * ] Bypass
CRF - HD - Th - Sat ( last dialysis [ * * 9 - 25 * * ] , tolerate well )
severe duodenal ulcer bleed [ * * 2105 * * ] - receive 11 PRBC
Chrone 's Dx
diverticulosis
Social History :
past tobacco
Family history :
.
Physical Exam :
PE : pt bed , look comfortable , acute distress
98.7 BP 130/72 , HR 60 , RR 18 , 96 % r /
HEENT : symm neck , mouth clear , LN , flat JBP
CHest : limit exam , clear , GAEB
CVS : rrr , N S1S2 , syst gr II - III / VI murm precordium
[ * * last Name ( un ) * * ] : soft , N BS , NT
Extrem : edema , varicose vein
pulse : normal carotid , radial , doplerable pedal
Neuro : alert , orient x3 , grossly N
Lt Groin : hematoma ( 4 pm )
pertinent result :
[ * * 2108 - 9 - 26 * * ] 06:55pm CK - MB-30 * MB indx-13.8 * cTropnT-0.89 *
[ * * 2108 - 9 - 27 * * ] 03:00AM CK - MB-129 * mb Indx-20.4 *
[ * * 2108 - 9 - 27 * * ] 06:40AM CK - MB-155 * mb Indx-20.9 * cTropnT-2.54 *
[ * * 2108 - 9 - 26 * * ] 06:55pm WBC-7.1 RBC-3.25 * HGB-11.4 * HCT-33.7 *
MCV-104 * MCH-35.0 * mchc-33.7 RDW-15.8 *
[ * * 2108 - 9 - 26 * * ] 06:55pm PLT SMR - NORMAL PLT COUNT-178
[ * * 2108 - 9 - 26 * * ] 06:55pm glucose-74 UREA N-52 * CREAT-6.4 * SODIUM-135
POTASSIUM-5.3 * chloride-92 * total CO2 - 21 * ANION GAP-27 *
Cardiac cath:1 . Coronary grft angiography show previous
right
dominant system . LMCA diffusely disese focal
critical lesion . LAD taper mid segment
large
s2 totally occlude . d1 D2 small vessel
diffusely diseased . D3 recive SVG see
LMCA injection . Mid distal LAD receive LIMA .
Cx
vessel self lesion . give lengthy collateral .
OM1
arise close LMCA small . om2 arise close
LMCA large . proximal lesion 80 % . OM3
recive SVG see LMCA injection .
OM4 / postero
latateral branch arise distally small vessel . RCA
occlude proximally . distal rca include PDA
PLV
collateralise left system . PDA poorly fill
mid 60 % lesion . LIMA , LIMA - LAD anastomosis
distal LAD
free disease . LIMA fill LAD retrogradely
supply
proximal LAD D3 . D3 ostial 70 % lesion
TIMI III
flow . SV graft RCA PLB occlude
completely
see stump aorta . graft Diagonal could
locate , likely occlude give
angiogaphic
finding . SVG OM3 show diffuse disease mid
lengthy
lesion 99 % whole vessel show TIMI II flow .
collateral OM .
2 . left ventriculography perform .
3 . predilation use 1.5 x 15 Maverick balloon , stente use
3.0 x 28
3.0 x 33 OTW Cypher stent thrombus extraction use
export
catheter gradual deterioration flow SVG
OM3 .
flow deteriorate TIMI TIMI 0 .
FINAL DIAGNOSIS :
1 . three vessel native coronary artery disease function
LIMA
LAD .
2 . acute occlusion SVG OM chronically occlude
SV
graft PDA , PLB Diagonal .
3 . unable restore flow SVG om despite stente ,
pharmacotherapy thrombus aspiration . .
Echo : . left atrium mildly dilate .
2 . left ventricular cavity size normal . overall left
ventricular
systolic function mildly depressed . basal inferior
hypokinesis present .
3 . aortic valve leaflet severely thicken / deform .
moderate aortic valve stenosis .
4 . mitral valve leaflet mildly thicken .
5 . mild pulmonary artery systolic hypertension .
.
ct scan :
1 . evidence intrahepatic gas suggest prior
ultrasound . repeat ultrasound suggest give change
appearance .
2 . bibasilar dependent atelectatic change / consolidation
associate effusion .
3 . gas distend loop bowel air - fluid level
without transition suggest ileus . Stool distend rectum .
4 . small infrarenal abdominal aortic aneurysm .
Brief Hospital course :
admit unstable angina , total occlusion
svg graft patent LIMA LAD , receive 2 cypher
stent . catheterization compicte fail thrombus
extractuib abd TIMI 0 . catherization persistent
CP evidence NSTEMI . initially treat
ASA past gi bleed , persistent ischemia ,
add plavix . require significant morphine
controll pain . discussion MICU team
family pain control determined option
. code status change DNR / DNI/. due
ongoing ischemia , persistent hypotension require
multiple pressor . HD change CVVH
low blood presssure . also intermittent nsvt .
transfer [ * * Hospital Unit Name 196 * * ] team MICU team due
hypotension HD cardiac catheterization
concern possible sepsis . concern
acute abdoman appear impact stool .
disimpacte receive aggresive bowel regimen .
distension pain improve . low grade temperature
initially treat pneumonia hypoxic .
source infection identify . likely
cardiogenic shock fluid overload . repeat bedside
echo reveal worsen ventricular function . require
blood transfusion persistently drop HCT setting
frequent blood draw . also coagulopathy
appear DIC . require vitamin k
supplementation . expire 6:45am [ * * 2108 - 10 - 5 * * ]
episode severe chest pain .
medication admission :
Plavix 300 mg x2 [ * * 2078 - 9 - 24 * * ] mg [ * * hospital1 * * ] start [ * * 2108 - 9 - 26 * * ]
Lopressor 12.5 mg [ * * hospital1 * * ]
Foslo 667 mg x4 TID
Quinine 324 mg daily
Pentasa 250 mg x4 QID
MVI
Mirtazapine 15 mg qhs
Colace 100 mg [ * * hospital1 * * ]
Protonix 40 mg daily
Morphine prn
Nitro prn
Discharge medication :
none
discharge disposition :
expire
discharge diagnosis :
sinus tachycardia
nsvt
cardiogenic shock
coagulopathy
obstipation
nstemi
esrd
Discharge condition :
expire
Discharge instruction :
.
Followup Instructions :
.
complete by:[**2108 - 12 - 21 * * ]
|
[
"4280",
"486",
"5856",
"4241"
] |
Admission Date : [ * * 2156 - 7 - 21 * * ] Discharge Date : [ * * 2156 - 9 - 3 * * ]
Date Birth : [ * * 2156 - 7 - 21 * * ] sex : F
Service : neonatolog
history PRESENT ILLNESS : [ * * know lastname * * ] [ * * know lastname 1071**]-[**known lastname 29608 * * ] former
961 gram product 31 - 5/7 week gestation pregnancy bear
28 - year - old G1 , P0 , woman . prenatal screen : blood type
positive , antibody negative , rpr nonreactive , Rubella immune ,
hepatitis B surface antigen negative , Group beta Strep status
unknown . estimate date confinement [ * * 2156 - 9 - 17 * * ] ,
base last menstrual period first trimester
ultrasound . pregnancy uncomplicated [ * * 2156 - 7 - 6 * * ] , intrauterine growth restriction note
fetal ultrasound . extensive laboratory evaluation
workup etiology growth restriction
identify . follow closely fetal biophysical
profile [ * * 9 - 3 * * ] normal amniotic fluid volume .
day delivery amniotic fluid volume drop
fetus note two heart rate deceleration .
undergo elective induction take cesarean
section concern fetal distress . infant emerge
spontaneous cry , require blow - oxygen , apgar
8 one minute 8 five minute . transfer
Neonatal Intensive Care Unit treatment
prematurity .
PHYSICAL EXAMINATION admission NEONATAL intensive CARE
UNIT : Weight 961 gram , less 10th percentile . Length
38 cm , 58th percentile . Head circumference 25.5 cm , less
10th percentile . General : Nondysmorphic ,
well - appear , pre - term infant . Head , eye , ear , nose
throat : anterior fontanelle soft level . red reflex
present bilaterally . palate intact . symmetric facial
feature . Chest : Breath sound clear equal . Minimal
retraction . Cardiovascular : regular rate rhythm
without murmur . two plus peripheral pulse include
femoral . Abdomen benign without hepatosplenomegaly . small
umbilical cord note . Genitourinary : normal female external
genitalia consistent gestational age . spine normal
normal sacrum . hip stable . skin pink brisk capillary
refill . Neuro : normal tone responsiveness . Alert
acute distress .
HOSPITAL COURSE systems including pertinent LABORATORY
datum :
1 . Respiratory : retraction tachypnea note upon
admission resolve within first eight hour life .
[ * * know lastname * * ] always remain room air throughout Neonatal
Intensive Care Unit admission . infrequent episode
apnea bradycardia , last occur [ * * 2156 - 8 - 9 * * ] .
2 . Cardiovascular : [ * * know lastname * * ] maintain normal heart
rate blood pressure admission . soft murmur
note intermittently remain audible time
discharge . feel consistent peripheral
pulmonic stenosis benign nature .
3 . Fluids , Electrolytes Nutrition : initial glucose
45 . [ * * know lastname * * ] require several dextrose bolus
hypoglycemia resolve within 24 hour birth .
initially npo maintain intravenous fluid .
Parenteral feed start day life number two
gradually advanced full volume . maximum caloric
intake 30 calorie per ounce . currently take
150 / cc / kg / day breast milk Enfamil fortify 26
calorie per ounce . formula four calorie
concentration two calorie corn oil breast
milk four calorie Enfamil powder two calorie
corn oil . Serum electrolyte check first week
life within normal limit . discharge weight
1.875 kilogram 4 pound , 2.1 ounce , length 47
cm head circumference 30.5 cm .
4 . infectious Disease : due prematurity , [ * * know lastname * * ]
evaluate sepsis . white blood cell count 7,900
33 % poly , 0 % band . blood culture obtain
treat antibiotic . blood culture
growth 48 hour .
5 . Hematological : initial hematocrit birth 66.3 %
platelet 43,000 . [ * * know lastname * * ] blood type positive
Coombs negative . Platelet count fall 24,000 day
life one [ * * know lastname * * ] transfuse platelet
also receive intravenous gamma globulin . day life
number four day life number seven
require transfusion platelet count less
60,000 . day third platelet transfusion
platelet count 104,000 within 72 hour
255,000 . repeat count day life 17 694,000 .
etiology thrombocytopenia consistent
intrauterine growth restriction . platelet antibody
send mother negative . [ * * know lastname * * ] low
hematocrit occur [ * * 2156 - 8 - 25 * * ] , 22.1 % . Reticulocyte
count time 7.9 % . repeat hematocrit [ * * 2156 - 8 - 1 * * ] , 25.7 % .
6 . Gastrointestinal : [ * * know lastname * * ] require treatment
unconjugated hyperbilirubinemia phototherapy . peak
serum bilirubin occur day life number one
total 5.9 mg / dl . treat phototherapy
approximately five day . rebound bilirubin day
life nine 2.6 total 0.6 mg / dl direct .
7 . Endocrine : state screen send [ * * 2156 - 8 - 5 * * ] ,
thyroid stimulate hormone level 45.7 reference
range less 15 microunit per mL. Endocrine
consult [ * * hospital3 1810 * * ] obtain . repeat
thyroid function test show definite clinical
hypothyroidism treatment Synthroid start
[ * * 2156 - 8 - 13 * * ] . significant part history
mother treat wound dehiscence betadine packing
theorize hypothyroidism may
induce infant 's exposure iodine
mother 's milk . breast milk hold one week
breast feeding - initiate . thyroid function test
follow weekly slowly normalizing .
recent thyroid stimulate hormone 9.1
12 normal range 0.27 4.2 . t3 167
140 free T4 1.8 1.4 normal range
0.93 1.7 . [ * * know lastname * * ] discharge home
Synthroid Endocrine follow four week Dr.
[ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 51137 * * ] [ * * hospital3 1810 * * ] , phone number
[ * * telephone / Fax ( 1 ) 37116 * * ] . thyroid function test check
time .
8 . Neurology : head ultrasound obtain [ * * 7 - 23 * * ]
[ * * 2156 - 8 - 18 * * ] , study within normal limit .
neurological concern time discharge .
9 . Sensory : Audiology : hearing screening perform
automate auditory brainstem response . [ * * know lastname * * ]
pass ear . ophthalmology : retinal examination
perform [ * * 2156 - 8 - 12 * * ] , show mature retina
bilaterally . recommend follow eight month age .
condition discharge : good .
discharge disposition : home parent .
PRIMARY PEDIATRICIAN : Dr. [ * * last Name ( STitle ) 51138 * * ] [ * * Name ( STitle ) 19419 * * ] , [ * * Location ( un ) 246 * * ] Pediatric
Associates , [ * * Location ( un ) 51139 * * ] , [ * * last Name ( NamePattern1 ) 51140 * * ] , [ * * Location ( un ) 246 * * ] , [ * * Numeric Identifier 51141 * * ] , phone number [ * * telephone / Fax ( 1 ) 37501 * * ] , fax number [ * * telephone / Fax ( 1 ) 51142 * * ] .
appointment schedule [ * * last Name ( LF ) 766 * * ] , [ * * 9 - 6 * * ]
1:30 p.m.
recommendation discharge :
1 . feed : Enfamil 26 calorie per ounce concentration
two corn oil express mother 's milk fortify 26
calorie four Enfamil powder plus two corn oil .
2 . medication : ferrous sulfate 25 mg per ml dilution 0.3
cc p.o . q. day ; levothyroxine 12.5 mcg p.o . q. day .
3 . car seat position screening perform . infant
observe 90 minute without episode oxygen
desaturation bradycardia .
4 . State newborn screen send [ * * 7 - 25 * * ] , [ * * 8 - 4 * * ]
[ * * 2156 - 8 - 21 * * ] . except hypothyroidism previously
mention , result within normal limit . state
screen send [ * * 2156 - 8 - 21 * * ] , show normal TSH T4
level .
5 . immunization administer date .
receive hepatitis B meet weight criterion
yet .
IMMUNIZATIONS RECOMMENDED :
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 day care RSV season , smoker
household preschool sib ( 3 ) chronic
lung disease .
2 . influenza immunization consider annually
fall preterm infant chronic lung disease
reach six month age . age family
care giver consider immunization
influenza protect infant .
FOLLOW - appointment :
1 . primary pediatrician , Dr. [ * * last Name ( STitle ) 19419 * * ] , [ * * 2156 - 9 - 6 * * ] .
2 . Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 51137 * * ] four week discharge
thyroid function test draw time include T4
thyroid bind globulin .
3 . pediatric ophthalmology eight month age .
discharge diagnosis :
1 . Prematurity 31 - 5/7 week gestation .
2 . Symmetric small gestational age .
3 . transitional respiratory distress .
4 . Thrombocytopenia .
5 . Anemia .
6 . Suspicion sepsis , rule .
7 . Polycythemia .
8 . Unconjugated hyperbilirubinemia .
9 . Hypothyroidism .
review : [ * * Doctor Last Name * * ] [ * * last Name ( NamePattern5 ) 36094 * * ] , M.D. [ * * MD Number(1 ) 36250 * * ]
dictate by:[**last Name ( NamePattern1 ) * * ]
medquist36
: [ * * 2156 - 9 - 2 * * ] 23:23
: [ * * 2156 - 9 - 3 * * ] 03:10
JOB # : [ * * Job number 51143 * * ]
|
[
"7742"
] |
Admission Date : [ * * 2108 - 4 - 4 * * ] Discharge Date : [ * * 2108 - 5 - 8 * * ]
Date Birth : [ * * 2036 - 9 - 21 * * ] sex : F
Service : SURGERY
allergy :
sulfa(sulfonamide Antibiotics ) / Heparin Agents
attending:[**first Name3 ( LF ) 32612 * * ]
Chief Complaint :
Painless jaundice .
Major Surgical Invasive Procedure :
[ * * 2108 - 4 - 4 * * ] :
-diagnostic laparoscopy .
-peritoneal washing cytology
-exploratory laparotomy .
-cholecystectomy .
-Harvest pedicle omental flap protection anastomosis .
-Pancreaticoduodenectomy standard gastrojejunostomy ,
antecolic .
- right hepatic artery reconstruction use right gonadal vein
interposition graft ( perform Dr. [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] ) .
history Present Illness :
71f present painless jaundice , dark urine , bloat ,
anorexia . first notice onset symptom [ * * Month ( ) * * ]
[ * * Month ( ) 1096 * * ] alert friend increase
jaundice , prompt medical evaluation . [ * * hospital3 3583 * * ] ,
lab follow : total bilirubin 28 , Alk phos 338 , ALT
128 prior arrival . undergo ultrasound ct
contrast find 2.4 x 1.8 cm mass cystic
structre head pancrea , distend thicken
gallbladder , intrahepatic ( 1.9 cm)and pancreatic duct ( 1.2 cm ) .
time consultation clinically well deny
nausea , vomiting , change bowel habit . undergo ERCP
reveal single irregular stricture malignant
appearance 2 cm long low third common
bile duct . severe post - obstructive dilation . limited
pancreatogram reveal stricture main duct head .
Cannulation biliary duct successful . contrast medium
inject result complete opacification .
sphincterotomy perform . 7 cm 10FR biliary stent
place . cytology sample obtain histology
return positive adenocarcinoma . patient offer
Whipple operation , following explain : 1 - 2 % risk
death , 30 - 40 % risk complication . OSH scan report ,
involvement mesenteric vessel evidence
metastatic disease , although periportal
lymphadenopathy . understand risk / benefit
surgery , decide proceed operation .
Past Medical history :
PMH : none
PSH : Tonsillectomy / adenoidectomy , tooth extract
Social History :
retire high school teacher , child , live female
HCP . [ * * Name ( NI ) 4084 * * ] [ * * name2 ( NI ) 1818 * * ] , drink [ * * 2 - 17 * * ] glass wine per night
symptom start [ * * Month ( ) * * ] /[**Month ( ) * * ] , drug use .
Family history :
Sister die leukemia age 65 , mother die cervical
cancer . history benign malignant pancreatic disease .
Physical Exam :
Physical Exam admission :
97.3 91 173/94 20 100%RA
Gen : alert oriented , pleasant
skin : pronounce scleral dermal jaundice
CV : RRR
Resp : clear auscultation
Abd : soft , non - tender , non - distended . negative [ * * Doctor Last Name 515 * * ] sign ,
palpable masse
Ext : 1 + edema , palp dp / PT pulse .
pertinent result :
[ * * 2108 - 4 - 12 * * ] 07:24AM blood vanco-31.4 *
[ * * 2108 - 5 - 8 * * ] 06:05am blood Vanco-12.4
[ * * 2108 - 4 - 4 * * ] 07:54PM blood albumin-2.1 * Calcium-8.9 Phos-5.7 * #
Mg-1.9
[ * * 2108 - 5 - 8 * * ] 01:56AM blood calcium-10.9 * phos-2.1 * mg-2.7 *
[ * * 2108 - 4 - 4 * * ] 07:54PM blood CK - MB-2 cTropnT-<0.01
[ * * 2108 - 4 - 15 * * ] 12:58PM blood CK - MB-2 cTropnT-0.03 *
[ * * 2108 - 4 - 5 * * ] 03:30am blood Lipase-13
[ * * 2108 - 5 - 7 * * ] 01:23AM blood Lipase-7
[ * * 2108 - 4 - 4 * * ] 07:54PM blood ALT-303 * ast-827 * ck(cpk)-57 alkphos-56
TotBili-5.7 *
[ * * 2108 - 4 - 18 * * ] 01:45am blood alt-38 AST-80 * alkphos-59 TotBili-32.4 *
DirBili-23.7 * indbili-8.7
[ * * 2108 - 5 - 2 * * ] 01:18AM blood ALT-49 * AST-82 * AlkPhos-65 TotBili-36.9 *
[ * * 2108 - 5 - 8 * * ] 01:56am blood ALT-59 * AST-94 * LD(LDH)-202 AlkPhos-77
TotBili-33.6 *
[ * * 2108 - 4 - 4 * * ] 07:54PM blood glucose-104 * UreaN-11 Creat-0.6 na-134
K-4.8 cl-100 HCO3 - 15 * angap-24 *
[ * * 2108 - 5 - 8 * * ] 01:56AM blood Glucose-143 * UreaN-4 * Creat-0.5 Na-142
K-4.7 Cl-101 HCO3 - 9 * angap-37 *
[ * * 2108 - 4 - 4 * * ] 08:12am blood Fibrino-515 *
[ * * 2108 - 4 - 5 * * ] 07:50PM blood fibrino-156 * #
[ * * 2108 - 4 - 4 * * ] 08:12am blood pt-12.3 PTT-27.8 INR(PT)-1.1
[ * * 2108 - 4 - 6 * * ] 03:48AM blood Plt Ct-139 *
[ * * 2108 - 4 - 7 * * ] 11:55PM blood Plt Smr - low Plt ct-62 *
[ * * 2108 - 4 - 12 * * ] 02:57AM blood Plt ct-56 * #
[ * * 2108 - 5 - 7 * * ] 08:15PM blood Plt ct-<5
[ * * 2108 - 5 - 8 * * ] 01:56am blood pt-49.9 * ptt-122.1 * INR(PT)-4.9 *
[ * * 2108 - 4 - 7 * * ] 11:55PM blood Neuts-86 * Bands-3 Lymphs-4 * Monos-3 Eos-2
baso-0 Atyps-0 Metas-1 * Myelos-1 * NRBC-1 *
[ * * 2108 - 5 - 6 * * ] 02:16am blood Neuts-90 * Bands-1 Lymphs-2 * Monos-4 Eos-1
baso-0 Atyps-0 Metas-1 * Myelos-0 Promyel-1 *
[ * * 2108 - 4 - 4 * * ] 07:54PM blood wbc-14.6 * # RBC-2.58 * Hgb-8.2 * Hct-24.1 *
MCV-93 # MCH-31.7 # mchc-34.0 RDW-16.5 * Plt Ct-88 *
[ * * 2108 - 4 - 5 * * ] 07:50PM blood WBC-26.4 * # rbc-3.07 * Hgb-9.7 * Hct-28.4 *
MCV-93 MCH-31.7 mchc-34.2 RDW-16.3 * Plt ct-102 *
[ * * 2108 - 4 - 7 * * ] 05:41am blood WBC-28.5 * RBC-3.23 * Hgb-9.7 * hct-29.7 *
MCV-92 MCH-30.0 MCHC-32.6 RDW-16.0 * Plt ct-93 *
[ * * 2108 - 4 - 9 * * ] 12:49PM blood WBC-16.4 * RBC-3.05 * Hgb-9.5 * Hct-28.8 *
MCV-95 MCH-31.3 mchc-33.0 RDW-18.0 * Plt ct-43 *
[ * * 2108 - 5 - 7 * * ] 08:15PM blood WBC-41.4 * RBC-2.19 * Hgb-7.5 * Hct-23.7 *
mcv-108 * MCH-34.3 * MCHC-31.7 RDW-22.5 * Plt ct-<5
[ * * 2108 - 5 - 7 * * ] 10:15pm blood WBC-48.1 * RBC-2.26 * Hgb-7.7 * Hct-24.9 *
mcv-110 * MCH-34.1 * mchc-31.0 RDW-22.8 * Plt Ct-88 *
[ * * 2108 - 5 - 8 * * ] 01:56am blood WBC-47.3 * RBC-2.21 * Hgb-7.7 * Hct-24.5 *
MCV-115 * MCH-34.7 * MCHC-30.2 * RDW-23.0 * Plt Ct-72 *
.
[ * * 2108 - 4 - 9 * * ] 11:46 SPUTUM source : Endotracheal .
GRAM STAIN ( Final [ * * 2108 - 4 - 9 * * ] ):
> 25 PMNs < 10 epithelial cells/100x field .
3 + ( 5 - 10 per 1000X field ): GRAM NEGATIVE ROD(S ) .
RESPIRATORY CULTURE ( final [ * * 2108 - 4 - 12 * * ] ):
Commensal Respiratory Flora Absent .
HAFNIA ALVEI . SPARSE growth .
Piperacillin / tazobactam sensitivity testing available
request .
sensitivity : MIC express
MCG / ML
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
HAFNIA ALVEI
|
AMPICILLIN------------ 16 R
AMPICILLIN / SULBACTAM-- = > 32 r
cefazolin------------- = > 64 R
cefepime-------------- < = 1
ceftazidime----------- < = 1
ceftriaxone----------- < = 1
CIPROFLOXACIN---------<=0.25
GENTAMICIN------------ < = 1
MEROPENEM-------------<=0.25
tobramycin------------ < = 1
TRIMETHOPRIM / SULFA---- < = 1
.
[ * * 2108 - 5 - 1 * * ] 5:55 PERITONEAL FLUID
DAS ACU VERIFIED [ * * first Name9 ( NamePattern2 ) 92514 * * ] [ * * Location ( un ) * * ] [ * * 5 - 1 * * ] @0950 .
GRAM STAIN ( Final [ * * 2108 - 5 - 1 * * ] ):
4 + ( > 10 per 1000X field ): POLYMORPHONUCLEAR
leukocyte .
MICROORGANISMS SEEN .
concentrated smear make cytospin method ,
please refer
hematology quantitative white blood cell count ..
FLUID CULTURE ( final [ * * 2108 - 5 - 5 * * ] ):
report read back [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] [ * * 2108 - 5 - 2 * * ] 2:45pm
4 - 3130 .
culture contain mixed bacterial type ( > =3 )
abbreviate
workup perform . growth P.aeruginosa , S.aureus
beta
hemolytic streptococci report . BACTERIA
report , present culture ..
work - organism(s ) list discontinue ( except
screen
organism ) due presence mixed bacterial flora
detect
incubation .
ENTEROCOCCUS SP .. RARE growth .
sensitivity : MIC express
MCG / ML
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ENTEROCOCCUS SP .
|
AMPICILLIN------------ = > 32 R
PENICILLIN G---------- = > 64 R
vancomycin------------ < = 0.5
ANAEROBIC CULTURE ( final [ * * 2108 - 5 - 5 * * ] ): ANAEROBES isolate .
FUNGAL CULTURE ( Preliminary ): FUNGUS ISOLATED .
ACID FAST SMEAR ( Final [ * * 2108 - 5 - 2 * * ] ):
ACID fast bacilli see DIRECT SMEAR .
ACID FAST CULTURE ( Preliminary ): MYCOBACTERIA isolate .
.
[ * * 2108 - 5 - 6 * * ] :
[ * * 2108 - 5 - 6 * * ] 10:54 URINE source : Catheter .
* * FINAL REPORT [ * * 2108 - 5 - 7 * * ] * *
URINE CULTURE ( final [ * * 2108 - 5 - 7 * * ] ):
YEAST . > 100,000 ORGANISMS / ML ..
.
[ * * 2108 - 4 - 12 * * ] : impression : non - occlusive deep vein thrombosis see
within one two leave brachial vein
.
[ * * 2108 - 4 - 16 * * ] : impression :
1 . status post Whipple serpiginous hypodensity see
leave lobe
consistent retraction injury . drainable collection .
2 . radiologically evident cause leukocytosis observe .
3 . extensive anasarca , likely secondary volume overload .
.
Final Pathology Report :
MACROSCOPIC
Specimen Type : Pancreaticoduodenectomy , partial pancreatectomy .
Tumor Site : pancreatic head , uncinate process .
Tumor Size : greatest dimension : 2.9 cm . additional dimension :
2.5 cm x 2.5 cm .
organ / Tissues receive : Gallbladder , Stomach .
MICROSCOPIC
Histologic Type : Ductal adenocarcinoma .
Histologic Grade : G2 : moderately differentiate .
extent INVASION
Primary Tumor : pt3 : tumor extend beyond pancrea
without involvement celiac axis superior
mesenteric artery .
Regional Lymph Nodes : pN1 : regional lymph node metastasis .
Lymph Nodes
number examine : 11 .
number involve : 1 .
distant metastasis : pmx : assess .
margin :
margin uninvolved invasive carcinoma :
distance close margin : 1 mm
peri - uncinate - process adipose tissue margin .
Venous / lymphatic vessel invasion : Absent .
Perineural invasion : Present .
additional Pathologic Findings : pancreatic intraepithelial
neoplasia -- high grade : PanIN : III ; chronic pancreatitis .
.
Brief Hospital course :
patient bring operating room [ * * 2108 - 4 - 4 * * ]
Whipple procedure , necessitate right hepatic artery
reconstruction gonadal vein vascular surgery
service consult intraoperatively . Reader refer
operative note full detail . receive 6 u prbc , 2 ffp ,
500 albumin , leave intubate
pressor , take surgical ICU post operatively .
course thereafter ICU complicated . brief :
require frequent blood transfusion prbcs , FFP , albumin ,
persistent pressor requirement ; develop acute renal
failure require CVVH , persistent elevation lft ,
persistent leukocytosis total cardiology , infectious
disease , renal , hepatology service consult .
significant event post - operative day include : POD2
renal service consult give persistent renal failure
postoperatively , begin CVVH . give - trending
platelet , HIT panel send return positive POD5 ,
patient begin bivalirudin drip per hematology
recommendation . POD6 TF initiate via NGT , foley
remove , sputum culture reveal GNR
begin vancomycin / ciprofloxacin / flagyl . antibiotic
thereafter tailor appropriately consultation
infectious disease service . POD8 left brachial vein clot
find non - invasive initiate
fondaparinux , subsequently discontinue . POD11 patient
note QTC prolongation , cardiology
service consult , recommendation follow
regard medication adjustment . [ * * 2108 - 4 - 17 * * ] patient
extubate , briefly pressor . find SBP ,
begin meropenem consultation hepatology
ID service . Lactulose initiate give poor mental status
( aox1 initially ) , seem initially improve .
POD20 patient fail speech swallow evaluation ,
continue tube feeding . pressor requirement remain
persistent , WBC continue trend upwards . [ * * 2108 - 5 - 4 * * ] ,
discussion patient 's HCP , make DNR / DNI .
evening [ * * 2108 - 5 - 7 * * ] note hypothermic 89 ,
DIC per labarotory value pass away [ * * 2108 - 5 - 8 * * ] ,
post - operative day 34 .
discharge disposition :
expire
discharge diagnosis :
-pancreatic cancer
-spontaneous bacterial peritonitis
-heparin Induced Thrombocytopenia
-Renal failure
discharge condition :
expire .
discharge instruction :
N / A.
Followup Instructions :
N / A.
complete by:[**2108 - 5 - 9 * * ]
|
[
"5845",
"5856",
"2762",
"2851",
"4019"
] |
Admission Date : [ * * 2118 - 5 - 7 * * ] Discharge Date : [ * * 2118 - 5 - 19 * * ]
Date Birth : [ * * 2047 - 9 - 30 * * ] sex :
Service : MEDICINE
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 2698 * * ]
Chief Complaint :
chest pain anemia
Major Surgical Invasive Procedure :
Colonoscopy Upper Endoscopy
history Present Illness :
70 year old man afib coumadin , insulin dependent DM ,
obseity , systolic diastolic heart failure LVEF 40 - 45 % , CAD
/ p CABG ' [ * * 93 * * ] , PTCA'[**15 * * ] , STEMI BMS SVG - OM graft
[ * * 2118 - 4 - 8 * * ] , present fatigue dyspnea exertion past
week . initially feel well discharge [ * * 3-/2117 * * ]
begin exercise lose weight . however , past week
dyspnea increase exertional capacity decrease . call
cardiologist think might overdiurese , therefore
lasix spironolactone reduce half prior dose .
Dyspnea worsen despite change . day
admission 2 bowel movement , second dark
black . bowel movement preceede crampy abdominal
pain . attempt walk bathroom kitchen
acutely dyspneic . sit develop chest
pain , take nitro relief . try walk
chest pain return , thus call EMS bring OSH .
chest pain relieve repeat nitroglycerin
eventually start nitroglycerin drip . Labs OSH
notable HCT 25 , INR 3.7 , K 7 . enroute [ * * Hospital1 18 * * ] ,
SBP drop increase nitro drip dose .
upon arrival [ * * Hospital1 18 * * ] , chest pain free VS 97.6
99/56 , 74 16 97 % 2l. ECG show new LBBB , trop negative .
Labs notable K 7.2 ( hemolyze ) thus receive
calcium , D50 / insulin , kayexalate . INR 4.9 . GI
call give HCT drop 31 25 make plan scope
morning . rectal exam notable brown stool guaiac
positive speck black stool . Nitroglycerin drip
stop pain control morphine PRN .
receive 1L NS . vital prior transfer 98.1 69 109/41 16 99 %
RA pain 0 .
arrival MICU , initially comfortable ,
develop chest pain prompt morphine 2 mg x3 without relief .
SL nitro give improvement pain . ECG show narrow
complex sinus rhythm ST depression , V4 - V6 . later
another episode pain relieve sl nitroglycerin .
Past Medical History :
CAD / p cabg [ * * 2093 * * ] , / p cath [ * * 2103 * * ] wiuth BMS Lcx , [ * * 2113 * * ]
reveal severe stenosis SVG OM / p BMS x 3 ,
[ * * 2115 * * ] [ * * Hospital1 112 * * ] ( patient say stent unknown location )
IDDM
morbid obesity
copd
sleep apnea BiPAP
CHF , diastolic , EF 71 % per OSH report
afib
HTN
CVA right sided numbness
history rheumatic fever
Social History :
live wife four child . work carpenter .
tob / ETOH / IVDA .
Family history :
adopt , unknown
Physical Exam :
admission exam :
vital : 98f 108/44 71 9 99 % RA
General : Alert , oriented , acute distress
HEENT : Sclera anicteric , MMM , oropharynx clear , EOMI , PERRL
Neck : supple , JVP elevate , LAD
CV : regular rate rhythm , normal S1 + S2 , murmur , rub ,
gallop
lung : clear auscultation bilaterally , wheeze , rale ,
ronchi
Abdomen : soft , obese , non - tender , non - distended , bowel sound
present , organomegaly
GU : foley
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
Neuro : CNII - XII intact , 5/5 strength upper / low extremity ,
grossly normal sensation
discharge exam :
VS - 98.0 , 98.6 , 96/49 ( 94 - 145/48 - 71 ) , 71 ( 52 - 81 ) , 20 , 100RA
GENERAL - Obese late - middle aged man NAD . orient x3 .
HEENT - NCAT . oropharynx clear
NECK - Supple , unable assess JVD due habitus
CARDIAC - RRR , normal S1 , S2 . / r / g. S3 S4 .
LUNGS - CTAB , crackle , wheeze rhonchus .
ABDOMEN - soft , obese NTND . HSM tenderness .
EXTREMITIES - WWP , LE edema , club
skin - multiple scar across low extremity vein
harvesting , chronic stasis change
pertinent result :
Admission Labs :
= = = = = = = = = = = = = = =
[ * * 2118 - 5 - 6 * * ] 11:55PM blood WBC-11.2 * RBC-2.82 * hgb-8.0 * Hct-24.7 *
MCV-87 MCH-28.3 mchc-32.3 RDW-19.2 * Plt ct-178
[ * * 2118 - 5 - 6 * * ] 11:55PM blood Neuts-85.1 * Lymphs-10.4 * Monos-3.0
eos-1.3 Baso-0.2
[ * * 2118 - 5 - 6 * * ] 11:55PM blood pt-49.3 * PTT-56.2 * INR(PT)-4.9 *
[ * * 2118 - 5 - 6 * * ] 11:55PM blood glucose-187 * UreaN-78 * Creat-1.9 * Na-131 *
K-7.2 * Cl-99 HCO3 - 22 AnGap-17
[ * * 2118 - 5 - 7 * * ] 03:20am blood calcium-9.6 Phos-4.1 mg-2.6
Pertinent Labs :
= = = = = = = = = = = = = = =
[ * * 2118 - 5 - 6 * * ] 11:55PM blood ctropnt-<0.01
[ * * 2118 - 5 - 7 * * ] 03:20AM blood CK - MB-4 cTropnT-0.02 *
[ * * 2118 - 5 - 7 * * ] 08:55am blood CK - MB-5 cTropnT-0.04 *
[ * * 2118 - 5 - 7 * * ] 10:58PM blood CK - MB-4 cTropnT-0.05 *
[ * * 2118 - 5 - 12 * * ] 10:50am blood hapto-164
[ * * 2118 - 5 - 12 * * ] 10:50am blood LD(LDH)-195 TotBili-2.0 * DirBili-0.5 *
indbili-1.5
helicobacter pylori antibody test : POSITIVE EIA .
Urine culture [ * * 5 - 9**]- growth
Discharge Labs :
= = = = = = = = = = = = = = =
[ * * 2118 - 5 - 19 * * ] 06:35AM blood hct-29.5 *
[ * * 2118 - 5 - 17 * * ] 11:00am blood pt-11.9 PTT-33.3 INR(PT)-1.1
[ * * 2118 - 5 - 18 * * ] 11:10am blood glucose-108 * UreaN-21 * Creat-1.1 na-136
K-4.6 cl-100 HCO3 - 28 angap-13
[ * * 2118 - 5 - 18 * * ] 11:10am blood calcium-8.0 * Phos-3.5 Mg-3.2 *
Micro / Path :
= = = = = = = = = = =
URINE CULTURE ( final [ * * 2118 - 5 - 10 * * ] ): growth .
helicobacter pylori ANTIBODY test ( final [ * * 2118 - 5 - 9 * * ] ): POSITIVE
EIA .
MRSA SCREEN ( final [ * * 2118 - 5 - 9 * * ] ): MRSA isolate .
Imaging / study :
= = = = = = = = = = = = = = = =
CXR [ * * 5 - 9**]- Status post sternotomy , mild prominence
cardiomediastinal silhouette . upper zone
- distribution without overt CHF . minimal atelectasis
basis . frank consolidation effusion .
EKG [ * * 5 - 9**]- LBBB - > sinus rhythm narrow complex , ST depression
V4 - V6 , avL
EGD [ * * 5 - 9**]- nodularity whole stomach compatible
nodular gastritis . normal EGD third part duodenum .
CT abd / pelvis [ * * 5 - 12**]-
1 . evidence retroperitoneal bleed acute
intra - abdominal process .
2 . Fatty infiltration liver .
3 . Cholelithiasis .
4 . right renal cyst .
Colonoscopy [ * * 2118 - 5 - 18 * * ] :
impression :
Grade 1 internal hemorrhoid
diverticulosis sigmoid colon
otherwise normal colonoscopy cecum
Brief Hospital Course :
70 year old man afib coumadin , insulin dependent DM ,
obseity , systolic diastolic heart failure LVEF 40 - 45 % , CAD
/ p CABG ' [ * * 93 * * ] , PTCA'[**15 * * ] , STEMI BMS SVG - OM graft
[ * * 2118 - 4 - 8 * * ] , present fatigue dyspnea exertion , find
hematocrit drop secondary GI bleed .
ACTIVE diagnosis :
= = = = = = = = = = = = = = = = =
# Chest pain : demand ischemia setting GI bleed .
know coronary vascular disease refractory angina
amenable intervention per cardiology team . evidence
consolidation ptx CXR suggest pulmonary cause . Patient
transfuse total 8 unit prbcs ; hematocrit initially
stabilize heparin gtt coumadin - start ,
hematocrit drop chest pain return without ekg
change . continue aspirin , plavix , ranolazine .
Imdur start low dose home dose give concern
hypotension setting bleeding , BP remain stable
imdur titrate home dose . return
chest pain , dynamic st change V3 - V5 / avl ,
consistent know non - intervenable area disease .
imdur increase 240 mg metoprolol increase
tartrate 150 mg po BID without episode chest pain .
# UGIB / H.Pylori + Nodular Gastritis : EGD , patient
evidence nodular gastritis superficial erosion .
H.pylori return positive patient begin triple therapy
amoxicillin ( candidate clarithromycin give interaction
ranolazine ) , metronidazole pantoprazole . Coumadin
hold INR reverse vitamin K. Patient ongoing
hematocrit drop without obvious bleeding heparin drip
restart , coumadin heparin stop . Patient
complete 2 week triple therapy , continue [ * * hospital1 * * ]
pantoprazole . require GI follow - test cure .
also undergo colonoscopy reveal additional
alternative source bleeding . continue bleed ,
next step would capsule endoscopy . [ * * hospital1 * * ]
check prior PCP appointment assess hematocrit .
# Acute blood loss anemia : source suspect gastritis
. Coumadin hold admission ICU reverse
vitamin k FFP . transfuse total 8 unit
admission ; initially 4 unit ICU
inappropriate response blood , floor
initiation coumadin bridge heparin drip , patient 's
hematocrit drift . Haptoglobin LDH normal ,
indirect bilirubin slightly elevate ( post
transfusion ) low suspicion hemolysis .
discontinuation heparin drip coumadin , hematocrit
stabilize patient require transfusion > 72 hour
prior discharge .
# constipation : significantly constipate admission .
require 2 day prep prior colonoscopy . Patient
discharge senna / colace / miralax prevent
constipation .
# Acute chronic systolic heart failure : admission ,
patient mild pulmonary edema secondary decrease lasix
spironolactone dose past week prior admission .
Patient diurese ICU , euvolemic transfer
floor . continue home lasix 40 mg daily ,
extra dose transfusion . episode
orthostatic hypotension prompt decrease lasix dose
20 mg PO daily . Patient euvolemic time discharge ,
weight stable 120 kg .
# hyperkalemia : 7.2 admission likely secondary ARF ,
spironolactone , lisinopril . ECG improve narrow complex
potassium normalize . potassium remain stable
remainder admission . Spironolactone restart ,
lisinopril restart low dose 5 mg po daily .
# lbbb : Suspect metabolic etiology give improve k
correction . Trop negative suggest acute coronary
syndrome . LBBB resolve correction K.
# Acute renal failure : likely secondary systolic CHF
poor forward flow second hit poor perfusion due acute
GIB . Patient 's creatinine trend 1.1 day
discharge .
# leukocytosis : unclear etiology , may due stress
GIB . evidence infectious colitis , UA without evidence
infection consolidation see CXR . White count
resolve remain normal remainder admission .
CHRONIC diagnosis :
= = = = = = = = = = = = = = = = = =
# HLD : continue atorvastatin
# Depression : continued venlafaxine
# DMII : blood sugar well control admission .
transitional issue :
# Spironolactone hold discharge give hyperkalemia 7.2
admission .
# Coumadin hold discharge - > anticipate hold
medication month gastritis heal
protection stroke aspirin 325 mg plavix 75 mg
interim .
# Lisinopril decrease 5 mg daily prevent hyperkalemia
increase pressure room uptitrate Imdur 240 mg po daily
metoprolol 150 mg tartrate [ * * hospital1 * * ]
# h.pylori triple therapy treatment continue [ * * 2118 - 5 - 23 * * ]
# Hematocrit electrolyte rechecke PCP
[ * * Name9 ( PRE ) 702 * * ] appointment , script .
# Insulin decrease 70/30 mix 80 unit daily give - house
hypoglycemia . suggest set [ * * last Name ( un ) * * ]
diabete management want discuss PCP
[ * * Name Initial ( PRE ) * * ] .
# weight discharge 120 kg , discharge furosemide 20 mg
daily .
medication admission :
1 . aspirin 325 mg DAILY
2 . nitroglycerin 0.4 mg q5min PRN
3 . furosemide 40 mg PO daily
4 . lisinopril 10 mg PO DAILY
5 . atorvastatin 80 mg PO DAILY
6 . insulin NPH & regular human 100 unit / ml ( 70 - 30 ) Suspension
Sig : one hundred ( 100 ) unit Subcutaneous twice day .
7 . metformin 500 mg PO daily
8 . venlafaxine 75 mg PO DAILY
9 . warfarin 5 mg po day .
10 . pantoprazole 40 mg PO day .
12 . ranolazine 1,000 mg po twice day .
13 . clopidogrel 75 mg PO daily
14 . isosorbide mononitrate 60 mg PO day .
15 . metoprolol succinate 200 mg po day .
16 . spironolactone 25 mg PO day .
Discharge medication :
1 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
2 . ranolazine 500 mg Tablet Extended Release 12 hr Sig : two ( 2 )
Tablet Extended Release 12 hr po BID ( 2 time day ) .
3 . atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
4 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q12H ( every 12 hour ) .
[ * * Name Initial ( PRE ) * * ] :* 60 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
5 . venlafaxine 75 mg Capsule , Ext Release 24 hr Sig : one ( 1 )
Capsule , Ext Release 24 hr po DAILY ( Daily ) .
6 . nitroglycerin 0.4 mg Tablet , Sublingual Sig : one ( 1 ) Tablet ,
Sublingual Sublingual PRN ( need ) need chest pain .
7 . metformin 500 mg Tablet Sig : one ( 1 ) Tablet po day .
8 . metronidazole 500 mg Tablet Sig : one ( 1 ) Tablet PO Q8H ( every
8 hour ) 4 day .
[ * * Name Initial ( PRE ) * * ] :* 12 Tablet(s ) * Refills:*0 *
9 . amoxicillin 500 mg Tablet Sig : two ( 2 ) Tablet PO twice day
4 day .
[ * * Name Initial ( PRE ) * * ] :* 16 Tablet(s ) * Refills:*0 *
10 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need Constipation .
[ * * Name Initial ( PRE ) * * ] :* 30 Tablet(s ) * Refills:*0 *
11 . docusate sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID
( 2 time day ) .
[ * * Name Initial ( PRE ) * * ] :* 30 capsule(s ) * Refills:*2 *
12 . aspirin 325 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) po day .
13 . metoprolol tartrate 50 mg Tablet Sig : three ( 3 ) Tablet PO
twice day .
[ * * Name Initial ( PRE ) * * ] :* 180 Tablet(s ) * Refills:*2 *
14 . insulin NPH & regular human 100 unit / ml ( 70 - 30 ) Suspension
Sig : eighty ( 80 ) unit Subcutaneous twice day .
15 . imdur 60 mg Tablet Extended Release 24 hr Sig : four ( 4 )
Tablet Extended Release 24 hr po day .
16 . Miralax 17 gram Powder Packet Sig : one ( 1 ) po
day .
[ * * Name Initial ( PRE ) * * ] :* 30 packet * Refills:*2 *
17 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet po day .
[ * * Name Initial ( PRE ) * * ] :* 30 Tablet(s ) * Refills:*0 *
18 . furosemide 20 mg Tablet Sig : one ( 1 ) Tablet po day .
[ * * Name Initial ( PRE ) * * ] :* 30 Tablet(s ) * Refills:*0 *
19 . Outpatient [ * * Name Initial ( PRE ) * * ] work
please obtain CBC , Chem 7 prior appointment .
result communicate PCP :
[ * * Name Initial ( NameIs ) 7274 * * ] : [ * * Name Initial ( NameIs ) * * ] , [ * * Name Initial ( NameIs ) * * ]
Address : [ * * hospital1 29147 * * ] , [ * * Location ( un ) * * ] , [ * * Numeric Identifier 29160 * * ]
phone : [ * * telephone / Fax ( 1 ) 29149 * * ]
fax : [ * * telephone / Fax ( 1 ) 29155 * * ]
discharge disposition :
Home Service
Facility :
[ * * Location ( un ) 86 * * ] VNA
Discharge Diagnosis :
primary diagnosis :
# unstable angina
# h. pylori + nodular gastritis erosion
# blood loss anemia
secondary diagnosis :
# Coronary artery disease
# Atrial Fibrillation
Discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : ambulatory - require assistance aid
( roll walker )
Discharge instruction :
dear Mr. [ * * know lastname * * ] ,
pleasure take care ! admit [ * * Hospital1 18 * * ]
evaluation treatment chest pain , shortness breath ,
GI bleeding . find low blood count likely
due slow bleed gi tract relate
blood thinner gastritis erosion h. pylori (
bacteria pre - dispose gastritis ulcer ) .
start medication protect gi tract , treatment
infection , give blood transfusion improve
blood count . undergo upper endoscopy show
inflammation stomach erosion colonoscopy
without source bleeding .
also elevation potassium level ,
spironolactone discontinue .
attempt - starting anticoagulation begin bleed
. result , coumadin hold resolution
gastritis . suggest wait month
resume coumadin would like - assure
recieve protection stroke afib
aspirin plavix .
follow change make medication regiman :
- START Metronidazole three time day Monday [ * * 2118 - 5 - 23 * * ] treat infection stomach
- START Amoxicillin twice day Monday [ * * 2118 - 5 - 23 * * ]
treat infection stomach
- INCREASE pantoprazole twice day protect stomach
lining
- INCREASE Imdur 240 mg mouth daily
- change Metoprolol Tartrate 150 mg mouth twice daily
- DECREASE Lisinopril 5 mg daily
- DECREASE Lasix 20 mg daily
- DECREASE Insulin 70/30 80 unit twice daily
- stop Spironolactone
- stop Coumadin - > discuss primary
care doctor restart medication month
gastritis heal
- START Senna Colace twice day need constipation
- START Miralax daily need constipation
please follow suggest .
Followup Instructions :
Name:[**Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , MD
Specialty : Primary Care
Address : [ * * hospital1 29147 * * ] , [ * * Location ( un ) * * ] , [ * * Numeric Identifier 29160 * * ]
phone : [ * * telephone / Fax ( 1 ) 29149 * * ]
: Tuesday , [ * * 5 - 24 * * ] 3:15pm
-please lab check prior appointment ,
discharge hematocrit 29.5
Department : CARDIAC SERVICES
: THURSDAY [ * * 2118 - 5 - 26 * * ] 9:40
: [ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , MD [ * * telephone / Fax ( 1 ) 62 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
complete by:[**2118 - 5 - 20 * * ]
|
[
"5849",
"4280",
"2851",
"2767",
"496",
"412",
"4019",
"311"
] |
Admission Date : [ * * 2146 - 5 - 11 * * ] Discharge Date : [ * * 2146 - 5 - 14 * * ]
Date Birth : [ * * 2068 - 2 - 6 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 458 * * ]
Chief Complaint :
Shortness breath
Major Surgical Invasive Procedure :
cardiac catheterization Drug elute stent right
coronary Artery
history Present Illness :
78 year - old male patient Dr. [ * * First Name ( STitle ) 28622 * * ] Attar Dr. [ * * first Name4 ( NamePattern1 ) * * ]
[ * * last Name ( NamePattern1 ) 11493 * * ] history include CAD , / p MI X 2 , / p CABG
[ * * 2139 * * ] , / p prior stent LAD / p prior PTCA
diagonal admit [ * * hospital6 17032 * * ]
[ * * 2146 - 5 - 7 * * ] shortness breath . diagnose acute
chronic CHF initial BNP 482 . diurese IV Lasix
rule mi negative cardiac enzyme .
nuclear
stress perform [ * * 5 - 9 * * ] show several area
questionable reversible inferolateral anteroapical ischemic
change ekg change chest pain . believe
heart rate response blunt [ * * 2 - 14 * * ] high dose BBlocker
deconditione . overall duration treadmill time
5 minute heart rate max 81 bpm . discharge
home return [ * * Location ( un ) * * ]
ED continue complaint shortness breath . Cardiac
enzyme negative transfer cardiac
cathterization evaluation symptom .
cath lab , pt unable lie flat secondary history
PTSD , claustrophia , anxiety therefore require
intubation . 90 % distal lesion , beyond PDA
stente [ * * Location ( un ) * * ] . end procedure , NGT
place dose plavix . Pt already start
integrelin heparin . subsequently , patient develop
significant nose bleed . Heparin integrelin hold , ENT
call , pressure hold patient give
intranasal afrin . right heart cath also notable elevated
RVEDP ( 16 mm Hg ) PCWP ( 28 mm Hg mean ) .
Past Medical History :
Coronary Artery Disease
/ p cabg [ * * 2139 * * ] ( LIMA->diag , SVG->OM1 , svg->lad )
/ p Myocardial Infarction X 2
/ p prior LAD stent PTCA diag
Chronic systolic heart failure [ * * 2 - 14 * * ] ischemic cardiomyopathy , last
know EF 20 %
Ischemic cardiomyopathy , / p ICD implantation [ * * 2141 - 7 - 14 * * ]
Type 2 diabetes Mellitus , insulin - dependent
Chronic Obstructive Pulmonary Disease , home O2 requirement
Hypertension
Hyperlipidemia
Diabetic Nephropathy / Chronic Renal Insufficiency
Diabetic Neuropathy
/ p right renal artery stent
Severe Peripheral Vascular Disease , / p leave fem-[**doctor last Name * * ] bypass
[ * * 2137 * * ]
GERD
Anxiety
Depression
Post Traumatic Stress Disorder
Paroxysmal Atrial Fibrillation
Nonsustained Ventricular Tachycardia
Social History :
married live wife . retire
Army . recently work cook [ * * Hospital * * ] [ * * hospital6 28623 * * ] . use drink alcohol heavily , none
40
year . 40 + pack year h / smoking , quit 40 year ago .
Family history :
Father die mi age 48 . Brother die
mi age 64 .
Physical Exam :
vital : 129/48 - 67 - 17 - 100 % room air
Neuro : Alert , orient person , place , time . hard
hearing .
Cardiac : regular rate rhythm . Normal S1,S2 .
murmur / rub / gallop .
Resp : lung fine crackle basis bilaterally .
breathing regular unlabored rest .
Periph vasc : bilateral femoral pulse palpable . bilateral
dp
PT pulse palpable . 1 + pedal edema bilaterally .
ECG : SR 73 PVC 's
pertinent result :
admission lab :
[ * * 2146 - 5 - 11 * * ] 09:52PM blood wbc-9.5 # RBC-4.34 * Hgb-13.3 * hct-39.0 *
mcv-90 mch-30.7 mchc-34.2 RDW-14.6 Plt Ct-280
[ * * 2146 - 5 - 11 * * ] 09:52PM blood neuts-76.0 * Lymphs-13.9 * Monos-6.5
eos-3.2 Baso-0.4
[ * * 2146 - 5 - 11 * * ] 09:52pm blood PT-13.7 * PTT-24.9 INR(PT)-1.2 *
[ * * 2146 - 5 - 11 * * ] 09:52PM blood glucose-264 * UreaN-29 * Creat-1.6 * na-134
K-4.6 Cl-99 HCO3 - 27 angap-13
[ * * 2146 - 5 - 11 * * ] 09:52PM blood calcium-9.0 phos-3.4 mg-2.4
.
Cardiac cath ( [ * * 5 - 13 * * ] ): 1 . coronary angiography right
dominant system reveal native three vessel coronary artery
disease . LMCA distal 50 % stenosis . LAD
occlude mid - vessel . major diagonal branch
ostial 60 % stenosis . LCx long 60 % lesion OM1 .
RCA 90 % stenosis beyond origin PDA .
2 . arterial conduit angiography demonstrate patent LIMA - D1
SVG - OM
graft . SVG - OM occlude proximally . 3 . resting
hemodynamic reveal elevate right leave sided fill
pressure ( RVEDP 16 mm hg , PCWP mean 28 mm Hg ) .
moderate severe pulmonary arterial hypertension ( PASP 61 mm
Hg ) . systemic arterial blood pressure normal ( SBP 122 mm
Hg ) . cardiac index normal 2.7 l / min / m2 . systemic
vascular resistance normal ( 911 dyne - sec / cm5 ) .
pulmonary vascular resistance normal ( PVR 135
dynes - sec / cm5 ) . 4 . Successful PTCA stente distal
RCA jail right pda Xience ( 3x18 mm ) drug eluting
stent postdilate 3.25 mm balloon . final angiography
demonstrate angiographically apparent dissection ,
residual stenosis TIMI III flow throughout vessel ( see
PTCA comment ) . 5 . successful closure right femoral
arteriotomy site Mynx closure device .
FINAL DIAGNOSIS :
1 . native three vessel coronary artery disease .
2 . patent LIMA - D1 SVG - LAD graft .
3 . occlude SVG - OM graft .
4 . moderate biventricular diastolic dysfunction .
5 . moderate pulmonary hypertension .
6 . Successful PTCA stente distal rca Xience
drug
elute stent .
7 . successful closure right femoral arteriotomy site
Mynx
closure device .
.
Discharge lab :
[ * * 2146 - 5 - 14 * * ] 07:41AM blood wbc-8.8 RBC-4.17 * Hgb-12.7 * hct-36.9 *
MCV-89 MCH-30.4 mchc-34.3 RDW-14.6 Plt Ct-275
[ * * 2146 - 5 - 14 * * ] 07:41am blood Glucose-206 * UreaN-31 * Creat-1.6 * na-137
K-4.1 Cl-99 HCO3 - 25 AnGap-17
[ * * 2146 - 5 - 14 * * ] 07:41am blood calcium-8.8 phos-2.8 Mg-2.4
Brief Hospital Course :
78 year - old man refer OSH cardiac
catheterization secondary persistent shortness breath .
# Coronary Artery Disease - Patient know hx CAD , prior
CABG , prior stent / PTCA refer cardiac ctah
persistent shortness breath . Patient tolerate lie
flat procedure due significant history claustrophobia ,
ptsd anxiety intubate procedure .
start heparin , integrillin plavix load pre - procedure
however develop severe epistaxis intubation
integrilin stop . Cardiac cath show distal 90 % rca
lesion [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] [ * * last Name ( Prefixes ) * * ] place . continue aspirin ,
plavix statin . cath , remain intubated airway
protection epistaxis nad admit CCU close
management . extubate hospital day # 2 without
complication .
.
# chronic systolic heart failure - Ischemic cardiomyopathy , EF
20 % . RHC notable elevated RVEDP ( 16 mm Hg ) PCWP ( 28 mm
hg mean ) . catheterization diurese bolus lasix
home dose lasix increase 100 mg [ * * hospital1 * * ] .
continue Inspra , Diovan Toprol . time discharge
exam notable low extremity edema , patient
evidence pulmonary edema oxygen requirement
instruct continue high dose lasix could
discuss lasix titration cardiologist outpatient .
.
# Epistaxis - develop cardiac catheterization ENT
consult . manage Afrin . estimate blood loss
200cc stabilize without tranfusion . resolve
within 24 hour recurrent event .
.
# hypertension : continue home [ * * hospital1 4319 * * ] Lasix , Diovan ,
Norvasc , Inspra Toprol good control
.
# hyperlipidemia : recent lipid panel .
admission tricor statin add regiman .
.
# Type II Diabetes , Insulin - Dependent : continue home
regimen basal - bolus insulin good control . change
amde insulin regimen admission .
.
# stage 3 chronic renal failure - Baseline Cr 1.8 , receive
pre - cath hydration mucomyst creatinine remain stable
contrast load procedure .
.
# depression : Mood stable admission . Patient
currently pharmacological treatment depression .
medication Admission :
flonase 50 mcg one spray nostril daily
Proventil inhaler two puff four time daily prn shortness
breath wheezing
Tricor 145 mg one tab daily
Lasix 80 mg twice day ( reduce time / c
NVMC prior dose 120 mg [ * * hospital1 * * ] )
Aspirin 325 mg one tab daily
Imdur 30 mg one tab daily
Insulin 70/30 60 unit subcutaneous injection breakfast
Insulin 50/50 60 unit subcutaneous injection dinnertime
Levemir 37 unit subcutaneous injection bedtime
Diovan 40 mg one tab daily ( recently add Dr. [ * * last Name ( STitle ) 11493 * * ]
Inspra 25 mg one tab daily
Norvasc 2.5 mg one tab daily
Toprol XL 200 mg one tab daily
( add NVMC )
Plavix 75 mg one tab daily
Discharge medication :
1 . aspirin 325 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
2 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
3 . fluticasone 50 mcg / Actuation Spray , Suspension Sig : one ( 1 )
Spray Nasal DAILY ( Daily ) .
4 . albuterol 90 mcg / Actuation Aerosol Sig : 1 - 2 puff Inhalation
every four ( 4 ) hour need shortness breath
wheezing .
5 . amlodipine 2.5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
6 . Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig : one ( 1 ) Tablet Sustained Release 24 hr po day .
7 . Insulin NPH & Regular Human 100 unit / ml ( 50 - 50 ) Suspension
Sig : Sixty ( 60 ) unit Subcutaneous twice day .
8 . Levemir 100 unit / mL Solution Sig : thirty Seven ( 37 ) unit
Subcutaneous bedtime .
9 . Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig : one ( 1 ) Tablet Sustained Release 24 hr po DAILY ( Daily ) .
10 . Diovan 40 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
11 . Tricor 145 mg Tablet Sig : one ( 1 ) Tablet po day .
12 . eplerenone 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
13 . furosemide 40 mg Tablet Sig : 2.5 tablets po BID ( 2 time
day ) .
Disp:*150 Tablet(s ) * Refills:*2 *
14 . Simvastatin 10 mg Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
discharge disposition :
home
discharge Diagnosis :
Coronary Artery Disease
Epistaxis
Post Traumatic Stress Syndrome
discharge condition :
stable .
Discharge instruction :
cardiac catheterization drug elute stent
place right coronary artery . need take
Plavix every day one year . miss [ * * First Name ( Titles ) 691 * * ] [ * * last Name ( Titles ) 4319 * * ] stop
take Plavix unless Dr. [ * * last Name ( STitle ) 11493 * * ] tell . lifting
10 pound 1 week . bath pool one week .
may shower take dressing groin .
procedure intubate breathing machine .
nose bleed cause blood thinner need
Afrin spray nose stop bleeding .
fever antibiotic short time . chest x - ray
show pneumonia antibiotic discontinue .
weigh every morning , [ * * Name8 ( MD ) 138 * * ] MD weight > 3 lbs 1 day
6 pound 3 day .
adhere 2 gm sodium diet
.
please call Dr. [ * * last Name ( STitle ) 11493 * * ] notice increase trouble
breathing , chest pain , nausea , light headedness , increase
bruise bleed groin region , increase cough ,
fever concern symptom .
Followup Instructions :
Primary Care :
ATTAR,[**Female First Name ( un ) * * ] phone : [ * * telephone / Fax ( 1 ) 24306 * * ] Date / time : please call
get home appt [ * * 1 - 14 * * ] week .
cardiology :
Provider : [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] phone:[**telephone / fax ( 1 ) 11767 * * ] Date / Time : Friday [ * * 6 - 10 * * ] 1:00pm
Provider : [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] phone:[**telephone / fax ( 1 ) 11767 * * ] Date / time:[**2146 - 8 - 5 * * ] 11:20
complete by:[**2146 - 5 - 16 * * ]
|
[
"4280",
"496",
"412",
"4168",
"2724"
] |
Admission Date : [ * * 2179 - 12 - 13 * * ] Discharge Date : [ * * 2179 - 12 - 23 * * ]
Date Birth : [ * * 2107 - 1 - 5 * * ] sex : F
Service : CARDIOTHORACIC SURGERY
CHIEF COMPLAINT : Shortness breath exertion .
history PRESENT ILLNESS : patient 72history
woman history hypertension , hyperlipidemia ,
congestive heart failure , rheumatic heart disease
paroxysmal atrial fibrillation , admit [ * * hospital6 1760 * * ] [ * * 2179 - 10 - 22 * * ] ,
cardioversion rapid atrial fibrillation .
admission , transesophageal echocardiogram
show ejection fraction 60 % 1 + aortic
insufficiency , 2 + mitral regurgitation , 2 + tricuspid
regurgitation , small pleural cardiac effusion .
echocardiogram unchanged previous echocardiogram
[ * * 2179 - 7 - 11 * * ] .
undergo cardiac catheterization [ * * 11 - 19 * * ]
anticipation future cardiac surgery . catheterization
show left main 30 % , leave anterior descend 70 % ,
circumflex 30 % , om1 70 % , right coronary artery 50 % . please
see catheterization report full detail .
admit [ * * 2179 - 12 - 13 * * ] , directly
operate Room coronary artery bypass grafting mitral
valve replacement postoperative admission .
PAST MEDICAL history : rheumatic heart disease , congestive
heart failure , hypertension , hypercholesterolemia , paroxysmal
atrial fibrillation .
PAST surgical history : right upper lobectomy nonsmall
cell cancer [ * * 2179 - 8 - 10 * * ] . bilateral cataract surgery .
social history : live alone . patient 30
pack - year tobacco history . quit 15 year ago . Alcohol
use occasional .
allergy : know drug allergy .
medication admission : Toprol XL 25 mg q.d . , amiodarone
200 mg b.i.d . , Aspirin 325 mg q.d . , Lipitor 200 mg q.d . ,
Levothyroxine 112 mcg q.d . , Coumadin 4 mg q.d . , Protonix 40
mg q.d . , Lisinopril 10 mg q.d .
PHYSICAL EXAMINATION : General : patient
frail - appear woman acute distress . skin : break
rash . HEENT : pupil equal , round reactive
light . extraocular movement intact . Oropharynx clear .
Upper denture intact . Neck : Supple . jugular venous
distention . bruit . lung : clear auscultation
bilaterally . well - heal lobectomy scar
right . heart : regular , rate rhythm . 2/6
systolic ejection murmur . Abdomen : Obese , soft , nontender ,
nondistende hepatosplenomegaly . extremity :
club , cyanosis , edema . patient bilateral
low extremity spider vein . Neurological : patient
alert oriented time three . pulse : grossly intact
pulse . Radial 2 + bilaterally , dorsalis pedis 2 +
bilaterally , posterior tibial 1 + bilaterally , femoral 2 +
bilaterally . Carotids identify .
HOSPITAL COURSE : state previously , patient
direct admission operating room .
[ * * 12 - 13 * * ] , undergo mitral valve replacement
coronary artery bypass grafting ; please see operative report
full detail .
summary , patient mitral valve replacement
# 25 mosaic coronary artery bypass grafting time two ,
LIMA left anterior descending , saphenous vein
graft obtuse marginal . tolerate operation
well . Cardiopulmonary bypass time 224 min ,
cross - clamp time 181 min . transfer
operate Room Cardiothoracic Intensive Care Unit .
time transfer , Milrinone 0.5 mcg / kg / min ,
Propofol 20 mcg / kg / min , Neo - Synephrine 3 mcg / kg / min .
additionally patient epinephrine Nitroglycerin
drip dose identify time .
patient well immediate postoperative period .
anesthesia reverse . allow awaken
initially resedate neurological check .
epinephrine drip wean shortly arrival
Cardiothoracic Intensive Care Unit .
cardioactive medication titrate tolerate
patient 's hemodynamic throughout night operative
date .
postoperative day # 1 , patient 's sedation
discontinue . wean ventilator
successfully extubate . Milrinone wean .
Neo - Synephrine wean 0.25 mcg / kg / min .
additionally , Nitroglycerin drip maintain 0.25
mcg / kg / min .
patient remain hemodynamically stable throughout
postoperative day # 1 2 . postoperative day # 3 ,
cardioactive intravenous medication wean
transition oral medication . patient 's chest tube
discharge , transfer
Cardiothoracic Intensive Care Unit Far two continued
postoperative care cardiac rehabilitation .
next several day , patient uneventful
hospital course exception intermittent atrial
fibrillation treat Amiodarone
beta - blockade . additionally patient restart
anticoagulation , receive preoperatively
atrial fibrillation .
assistance nursing staff Physical Therapy
staff , patient 's activity level increase .
postoperative day 8 , decide patient
stable would ready discharge home
follow day .
discharge PHYSICAL examination : vital sign : temperature
98.2 ? ? ? ? ? ? , heart rate 72 , sinus rhythm , blood pressure 108/64 ,
respiration 18 , oxygen saturation 98 % room air . Weight
preoperatively 58.5 kg , discharge 54.8 kg . General :
patient alert oriented time three . move
extremity . follow command . nonfocal exam . Chest :
Clear auscultation bilaterally . Sternum stable .
incision Steri - Strips , open air , clean dry .
heart : regular , rate rhythm . S1 S2 . Abdomen :
soft , nontender , nondistended . positive bowel sound .
extremity : warm well perfuse . patient 1 +
edema bilaterally . right saphenous vein graft site
Steri - Strips large echymotic area upper thigh .
discharge LABORATORY DATA : Sodium 138 , potassium 4.2 , BUN
21 , creatinine 1.0 ; PT 13 , INR 1.0 .
condition DISCHARGE : good .
discharge DIAGNOSIS :
1 . Coronary artery disease status post coronary artery
bypass grafting time two LIMA left anterior
descending , saphenous vein graft obtuse marginal .
2 . mitral regurgitation status post mitral valve replacement
# 25 mosaic valve .
3 . rheumatic heart disease .
4 . Congestive heart failure .
5 . Hypertension .
6 . Hypercholesterolemia .
7 . paroxysmal atrial fibrillation .
8 . gastroesophageal reflux disease .
9 . Status post right upper lobectomy .
10 . status post bilateral cardiac surgery .
discharge medication : amiodarone 200 mg q.d . , Lopressor 25
mg p.o . b.i.d . , Coumadin 4 mg q.d . , titrate goal INR
2.0 - 2.5 , Aspirin 81 mg q.d . , Lasix 20 mg q.d . x 10 day ,
Potassium Chloride 20 meq q.d . x 10 day , Levoxyl 112 mcg
q.d . , Lipitor 20 mg q.d . , Prilosec 40 mg q.d . , Imdur 30 mg
q.d . , Colace 100 mg b.i.d . , Percocet 5/325 [ * * 2 - 11 * * ] tab q.4 hour
p.r.n .
DISCHARGE STATUS : patient discharge home
VNA .
fo[**last Name ( STitle ) * * ] p : follow - Dr. [ * * last Name ( STitle ) * * ] [ * * 4 - 13 * * ]
week . follow - Dr. [ * * First Name ( STitle ) 2031 * * ] [ * * 4 - 13 * * ] week . follow -
Dr. [ * * last Name ( Prefixes ) * * ] four week . patient
PT / INR draw visit nurse Friday , [ * * 12 - 24 * * ] .
result call dr.[**name ( NI ) 48166 * * ] office ,
manage patient 's Coumadin dose point
forward .
[ * * Doctor Last Name 412 * * ] [ * * last Name ( Prefixes ) 413 * * ] , M.D. [ * * MD Number(1 ) 414 * * ]
Dictated By:[**Name8 ( MD ) 415 * * ]
medquist36
: [ * * 2179 - 12 - 22 * * ] 18:27
: [ * * 2179 - 12 - 22 * * ] 18:47
JOB # : [ * * Job number 48167 * * ]
|
[
"4019",
"2724"
] |
Admission Date : [ * * 2201 - 6 - 21 * * ] Discharge Date : [ * * 2201 - 7 - 3 * * ]
Date Birth : [ * * 2171 - 2 - 21 * * ] sex :
Service : SURGERY
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 4691 * * ]
Chief Complaint :
perforate diverticulitis
Major Surgical Invasive Procedure :
osh procedure :
[ * * 2201 - 6 - 20 * * ] : exploratory laparotomy , sigmoid colectomy
formation Hartmann 's pouch colostomy
[ * * Hospital1 18 * * ] operation :
[ * * 2201 - 6 - 26 * * ] : exploratory laparotomy revision sigmoid
colostomy
[ * * 2201 - 6 - 28 * * ] : abdominal washout , liver biopsy , abdominal closure
history Present Illness :
HPI : 30 yo male hx significant etoh abuse present
OSH perforate sigmoid colon , / p sigmoid colectomy ,
currently septic Neo . intubate evening prior
transfer .
pt initially present OSH one week abdominal
pain , nausea vomit associated diarrhea . CT scan
ED demonstrate free air . lab time pertinent
ARF Cr . 2.3 . Sodium 125 , bicarb 22 AG 19
T.bili 3.8 . Pt take ex - lap find
perforate viscous sigmoid area . fibrinous exudate
left side present c / w longstanding process .
Hartmann pouch LLQ colostomy perform . pt
start levaquin , flagyl zosyn .
postop pt persistent acidosis bicarb 15 ,
lactate 4.8 . start bicarb gtt . course
OSH stay pt 9 liter positive . remain
hypotensive neo . note pt drink half - - gallon
day whiskey . last drink 8 day ago .
Past Medical history :
Alcohol abuse
PSH : Hartmann 's procedure
Social History :
history alcohol abuse
life mother work [ * * hospital6 5016 * * ] ,
patient admit previosly
Family history :
Non - contributory
Physical Exam :
transfer [ * * Hospital1 18 * * ] :
100 115 102/55 26 93 % CMV 50 % 450/13 5
Neuro : awake responsive question / follow command
Card : tachycardic , / r / g / c
Pulm : intubate clear breath sound bilaterally
GI:+Bowel sound . midline incision c / / i. dusky sink appearing
colostomy . appropriately tender palpation
Ext : peripheral edema palpable dp , radial pulse
pertinent result :
[ * * 6 - 21 * * ] : OSH CT abd / pelvis CT ( OSH ) free air sigmoid
stranding / diverticulitis .
Labs admission :
[ * * 2201 - 6 - 21 * * ] 07:40PM wbc-7.4 RBC-2.62 * HGB-9.5 * HCT-29.2 * MCV-112 *
MCH-36.1 * MCHC-32.3 RDW-23.0 *
[ * * 2201 - 6 - 21 * * ] 07:40PM PLT count-171
[ * * 2201 - 6 - 21 * * ] 07:40PM pt-16.4 * PTT-31.7 INR(PT)-1.5 *
[ * * 2201 - 6 - 21 * * ] 07:40PM ALT(SGPT)-25 AST(SGOT)-58 * ALK phos-52 TOT
BILI-3.3 * DIR BILI-2.9 * INDIR BIL-0.4
[ * * 2201 - 6 - 21 * * ] 07:40PM glucose-141 * UREA N-45 * CREAT-1.8 * SODIUM-138
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2 - 20 * anion GAP-21 *
[ * * 2201 - 6 - 21 * * ] 07:40PM CALCIUM-6.5 * PHOSPHATE-4.7 * MAGNESIUM-2.2
[ * * 2201 - 6 - 21 * * ] 07:48PM freeca-0.90 *
[ * * 2201 - 6 - 21 * * ] 07:48PM GLUCOSE-127 * LACTATE-3.7 * K+-3.4
[ * * 2201 - 6 - 21 * * ] 07:48PM TYPE - ART PO2 - 70 * PCO2 - 37 PH-7.38 total CO2 - 23
BASE XS--
Brief Hospital course :
Mr. [ * * know lastname * * ] admit trauma ICU [ * * 2201 - 6 - 21 * * ]
management follow Hartmann 's procedure perforate
diverticulitis septic shock . remain pressor
wean slightly overnight . receive blood transfusion
hematocrit 24.1 increase 25.9 wean
pressor . copious secretion note ET tube .
intraoperative culture OSH obtain .
peritoneal culture polymicrobial . extubate
remain hemodynamically stable transfer floor
[ * * 2201 - 6 - 24 * * ] .
time transfer floor pt NPO IV
fluid NG tube suction . IV zosyn empiric
coverage also foley catheter place urine output
monitoring . [ * * 6 - 25 * * ] NG tube output remain low
remove along foley catheter make good
amount urine . however , appearance stoma continue
dusky necrotic WBC count increase 9.6
[ * * 6 - 24 * * ] 15.2 [ * * 6 - 26 * * ] . therefore , take back
ostomy revision [ * * 2201 - 6 - 26 * * ] .
intraoperatively , receive 3L crystalloid
hypotension . abdomen leave open due bowel edema
bring trauma ICU intubate sedate .
aggressively diurese overnight abdomen close
[ * * 2201 - 6 - 28 * * ] . also note , liver note quite yellowed
appearance suspicious acute fatty liver biopsy
send abdominal closure procedure ( please see
operative note detail ) . postoperatively , vent
wean continued diuresis . extubate [ * * 2201 - 6 - 29 * * ]
transfer back floor hemodynamically stable .
[ * * 6 - 30 * * ] note gas small amout stool
ostomy diet advanced tolerate . foley
catheter place upon return operating room
remove void without difficulty . vital
sign routinely monitor remain afebrile
hemodynamically . lung sound note crackle
chest x - ray appreare wet diurese lasix
need . white blood cell count begin trend downward
18 27 . hematocrit stabilize 27 .
encourage mobilize bed ambulate tolerate
throughout postoperative course remain SC
heparin DVT prophylaxis .
Ostomy nursing consult provide appropriate treatment
supply patient care colostomy .
HD # 13 , note mild erythema around low
aspect wound undergo removal staple
low aspect wound . remain inferior staple
remove POD # 5 wound lightly pack wet
dry dressing . patient instruct care
wound dressing change . partipate dress change
agree continue . vna service also provide
assistance .
vital sign stable afebrile .
prepare discharge home follow - acute care
clinic .
medication admission :
none
Discharge medication :
1 . ostomy supply
1 piece Coloplast
Sensura ( dist # [ * * Numeric Identifier 24338 * * ] [ * * Doctor First Name * * ] # [ * * Numeric Identifier 20839 * * ] )
# 3 box
Refills:6
2 . Ostomy Supplies
[ * * last Name ( un ) * * ] wafer Dist # [ * * Numeric Identifier 89560 * * ] , manf # [ * * Numeric Identifier 20840 * * ]
# 3 box
refill : 6
3 . hydromorphone 2 mg Tablet Sig : 1 - 2 tablet po Q4H ( every 4
hour ) need pain .
Disp:*40 Tablet(s ) * Refills:*0 *
4 . Colace 100 mg Capsule Sig : one ( 1 ) Capsule po twice day
need constipation .
5 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet PO twice day
need constipation .
discharge Disposition :
Home Service
Facility :
[ * * Hospital 16449 * * ] Homecare Hospice
discharge Diagnosis :
perforate diverticulitis
Sepsis
Acute Kidney Injury
Ischemic sigmoid colostomy
open abdoman secondary diverticulitis sepsis
Acute fatty liver
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
transfer [ * * hospital6 5016 * * ] undergo
emergent operation perforated diverticulitis . become
septic postoperatively transfer [ * * Hospital1 18 * * ]
management . manage ICU
condition improve transfer surgical
floor . take back operating
stoma necrotic stoma revise .
bowel swell abdoman leave open short period
time . two day later able close operating
room . also note liver appear abnormal
biopsy take last operation . result
biopsy still pende time .
infection improve colostomy
function well . resume regular diet
continue . discharge home
follow instruction :
please follow Acute Care Surgery Clinic
appointment schedule .
colostomy : receive teaching ostomy
nurse care stoma . empty pouch
become [ * * 2 - 10 * * ] full instruct .
ACTIVITY :
drive stop take pain medicine
feel could respond emergency .
may climb stair .
may go outside , avoid travel long distance
see [ * * Month / Day ( 4 ) 5059 * * ] next visit .
not lift [ * * 11 - 23 * * ] lbs 6 week . (
weight briefcase bag grocery . ) apply
lift child , may sit lap .
may start light exercise feel comfortable .
need stay bathtub swimming pool
time incision heal . ask doctor
resume tub bath swimming .
heavy exercise may start 6 week , use common
sense go slowly first .
[ * * Month ( ) * * ] FEEL :
may feel weak " wash " 6 week . might want
nap often . simple task may exhaust .
may sore throat tube
throat surgery .
might trouble concentrate difficulty sleep .
might feel somewhat depressed .
could poor appetite . food may seem
unappealing .
feeling reaction normal go
away short time . , tell [ * * Month ( ) 5059 * * ] .
incision :
incision may slightly red around staple .
normal . staple remove follow
appointment clinic .
may gently wash away dry material around incision .
normal feel firm ridge along incision .
go away .
avoid direct sun exposure incision area .
use ointment incision unless tell
otherwise .
may see small amount clear light red fluid stain
dress r clothe . staining severe , please call
[ * * Month ( ) 5059 * * ] .
may shower . note , ask doctor may
resume tub bath swimming .
Ove next 6 - 12 month , incision fade become
less prominent .
PAIN MANAGEMENT :
normal feel discomfort / pain follow abdominal
surgery . pain often describe " soreness " .
pain get well day day . find pain
get bad instead well , please contact [ * * name2 ( NI ) 5059 * * ] .
receive prescription [ * * name2 ( NI ) 5059 * * ] pain
medicine take mouth . important take medicine
directie . take frequently prescribe .
take medicine one time prescribe .
pain medicine work well take
pain get severe .
talk [ * * name2 ( NI ) 5059 * * ] long need take
prescription pain medicine . please not take pain
medicine , include non - prescription pain medicine , unless
[ * * name2 ( NI ) 5059 * * ] say okay .
experience pain , okay skip dose
pain medicine .
remember use " cough pillow " splint cough
deep breathing exercise .
experience folloiwng , please contact
[ * * name2 ( NI ) 5059 * * ] :
- sharp pain severe pain last several hour
- pain get bad time
- pain accompany fever 101
- drastic change nature quality pain
medication :
take medicine operation
, unless tell differently .
case prescription antibiotic
medication .
question medicine take
take , please call [ * * name2 ( NI ) 5059 * * ] .
DANGER sign :
please call [ * * name2 ( NI ) 5059 * * ] develop :
- worsen abdominal pain
- sharp severe pain last several hour
- temperature 101 degree high
- severe diarrhea
- vomiting
- redness around incision spread
- increase swelling around incision
- excessive bruising around incision
- cloudy fluid come wound
- bright red blood foul smell discharge come
wound
- increase drainage wound
Followup Instructions :
Department : GENERAL SURGERY/[**Hospital Unit Name 2193 * * ]
: Dr. [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ]
: TUESDAY [ * * 2201 - 7 - 14 * * ] 2:30 pm
: ACUTE care CLINIC [ * * telephone / Fax ( 1 ) 600 * * ]
building : LM [ * * Hospital Ward Name * * ] Bldg ( [ * * last Name ( NamePattern1 ) * * ] ) [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Hospital Ward Name * * ] Garage
complete by:[**2201 - 7 - 8 * * ]
|
[
"0389",
"5849"
] |
Admission Date : [ * * 2143 - 4 - 29 * * ] Discharge Date : [ * * 2143 - 5 - 12 * * ]
Date Birth : [ * * 2083 - 3 - 28 * * ] sex :
Service : MEDICINE
allergy :
codeine
attending:[**first Name3 ( LF ) 348 * * ]
Chief Complaint :
abd pain , nausea / vomiting
Major Surgical Invasive Procedure :
Intubation
Placement central venous catheter
CVVHD
Hemodialysis
history Present Illness :
60 / w / alcohol abuse , HTN , present [ * * hospital3 * * ]
Saturday [ * * 4 - 27 * * ] c / severe abd pain , n / v. start 2 day
prior setting binge drink whiskey . pain
epigastric radiate back . find lipase
> 3000 . admit medical service acute
pancreatitis . keep NPO give IVF . also give
Levaquin " lethargy " infiltrate CXR . next day ,
[ * * 4 - 28 * * ] , bilirubin increase ( 0.8 - 2.6 ) continue
severe abd pain , change levaquin primaxin ,
trnasferre ICU . put lasix [ * * hospital1 * * ]
due rale cardiomegaly , keep NS 100 cc / hr .
CT scan po IV contrast show acute
pancreatitis intrahepatic ductal dilatation ; multiple
hypodense irregular lesion right lobe liver ,
thicken GB wall pericholecystic fluid , 5x4 cm
hypodense collection RLQ adjacent psoas muscle .
.
[ * * 4 - 29 * * ] , suppose go MRCP claustrophobic
require ativan . , feel well require
ativan Radiology . [ * * Name8 ( MD ) * * ] RN note , heart rate
" sporadic " 40 160 . give ativan
hr drop 20 ( bp 145/63 time ) .
become diaphoretic , c / chest pain , MRCP
stop . transfer stretcher turn
[ * * Doctor Last Name 352 * * ] , " start seize " note pulseless . [ * * Name8 ( MD ) * * ] rn
note , asystolic per / c summary cardiology
consult note , VT / VF . receive " several " shock CPR
well one bolus dose amiodarone . intubate
code . regain pulse unknown amt time .
become hypotensive require dopamine . see Renal
due worsen renal failure ( creatinine 0.8 admission
3.5 / c ) feel likely pre - renal failure
volume depletion plus contrast CT . MRCP read
show small ascite , peripancreatic stranding , pericholecystic
fluid , large gallstone . cbd appear dilate
image quite limited ; obvious intrahepatic biliary
ductal dilatation pancreatic ductal dilatation . Complex T2
hyperintesnsity along right psoas muscle see CT measure
5.2 x3.7 cm , represent complex fluid collection .
transfer management .
Past Medical history :
Alcohol abuse ( reportedly binge drink regularly )
HTN
Hypothyroidism
? pancreatitis
Social History :
per OSH note , " binge drink time " recurrent
bout pancreatitis . smoke tobacco , amt document .
deny illicit drug use .
Family history :
unknown
Physical Exam :
admission :
: 99.4 bp : 87/49 p : 56
AC 500x14 fio2 0.7 PEEP 5 O2 sit 94 %
CVP 13
Gen : intubate , sedate , paralyze
HEENT : icteric , ETT / OGT place , pupil constrict
lung : CTA anteriorly , w / r / c
CV : RRR , / r / g
Abd : distend , hypoactive present bowel sound , tense
difficult assess peritoneal sign paralyze
Ext : edema , foot cold , 1 + dp bilaterally
pertinent result :
pre - admission lab note :
[ * * 4 - 29 * * ] 9 pm : Na 136 , K 6.0 , Cl 108 , Bicarb 18 , BUN 56 , Creat
3.7
Calcium 6.5 , bili 10.0 , AST 359 , ALT 168 , alk phos 161 , CK
282 , mb 6.2 , MBI 2.1 , Troponin 0.02
WBC 22 25 % band , Hct 42 , Plt 157 , INR 1.3
abg 2:30 pm 6.88/83/68
abg 6:30 pm 7.14/55/260
Urine cx < 1000 colony / ml
Hepatitis serology negative
Lipase [ * * 4 - 29 * * ] 1541
triglyceride 52
AFP 2.0
.
EKG : [ * * 2143 - 4 - 30 * * ]
Sinus rhythm . leave anterior fascicular block . non - specific ST -
wave
abnormality .
.
Labs :
[ * * 2143 - 4 - 30 * * ] 12:27AM blood WBC-16.1 * RBC-4.07 * Hgb-12.9 * Hct-38.7 *
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.6 Plt ct-153
[ * * 2143 - 4 - 30 * * ] 12:27AM blood Plt Smr - NORMAL Plt ct-153
[ * * 2143 - 4 - 30 * * ] 12:27AM blood Neuts-69 Bands-16 * Lymphs-6 * Monos-8
Eos-0 baso-0 Atyps-0 Metas-1 * Myelos-0
[ * * 2143 - 4 - 30 * * ] 12:27AM blood pt-13.8 * PTT-30.8 INR(PT)-1.2 *
[ * * 2143 - 4 - 30 * * ] 12:27AM blood Glucose-339 * UreaN-58 * Creat-4.4 * Na-139
K-5.8 * Cl-108 HCO3 - 21 * AnGap-16
[ * * 2143 - 4 - 30 * * ] 12:27AM blood ALT-134 * AST-313 * ld(ldh)-1755 *
CK(CPK)-559 * AlkPhos-142 * Amylase-[**2143 * * ] * TotBili-7.6 *
[ * * 2143 - 4 - 30 * * ] 12:27AM blood Lipase-1032 *
[ * * 2143 - 4 - 30 * * ] 12:27AM blood CK - MB-9 cTropnT-0.15 * , 0.14 , 0.13
.
Micro :
see OMR
.
Imaging :
[ * * 2143 - 4 - 30 * * ] : Abd u / -
1 . minimal ascite right upper right low quadrant .
2 . gallstone neck gallbladder edema
gallbladder wall . could reflect acute cholecystitis
also could manifestation change due patient 's
know acute pancreatitis .
3 . intrahepatic extrahepatic biliary dilatation .
4 . patent portal vein .
.
[ * * 2143 - 5 - 3 * * ] : Head CT -
Diffuse hypodensity loss [ * * Doctor Last Name 352**]-white differentiation
suggest global hypoxia infarction . however , similar
appearance could cause severe acute hepatic renal
failure .
Subacute leave parietal infarction without hemorrhage .
possible small right parietal subacute infarction .
Brief Hospital course :
brief , patient 60 year old man history
alcohol abuse , admit OSH severe acute
pancreatitis / pseudocyst , complicate cardiac arrest , ARDS
transfer management . patient treat
[ * * Hospital1 18 * * ] ICU approximately two week without recovery
neurologic function . time , treat ARDS ,
severe pancreatitis , acute renal failure ( CVVHD
HD ) , anemia , alter mental status . patient remain
unresponsive wean sedation , patient 's family
agree make comfort measure give
severely depressed mental status due anoxic brain
injury . conclusion establish aid
Neurology consultant . time , patient transfer
ICJ general medicine floor . pass away [ * * 5 - 12 * * ] , [ * * 2142 * * ] .
medication admission :
1 . amlodipine 10 mg daily
2 . Levothyroxine Sodium 100 mcg po DAILY
3 . lisinopril 40 mg daily
Discharge medication :
N /
discharge disposition :
expire
discharge diagnosis :
Anoxic brain injury secondary cardiac arrest
necrotize pancreatitis
Alcohol abuse
Renal failure
adult respiratory distress syndrome
discharge condition :
Deceased
Discharge instruction :
N /
Followup Instructions :
N /
complete by:[**2143 - 5 - 13 * * ]
|
[
"5845",
"5070",
"2768",
"2875",
"4275",
"4019",
"2449",
"3051",
"2859"
] |
Admission Date : [ * * 2166 - 4 - 9 * * ] Discharge Date : [ * * 2166 - 4 - 18 * * ]
Date Birth : [ * * 2108 - 8 - 25 * * ] sex :
Service : Fernard Intensive Care Unit
history PRESENT illness : Mr. [ * * know lastname 405 * * ] 57 - year - old
male present [ * * hospital 1474 * * ] Hospital [ * * 2166 - 4 - 8 * * ]
hematemesis . patient treat transfusion
octreotide . Esophagogastroduodenoscopy do
unsuccessful therapeutic treatment upper gastrointestinal
bleed .
patient transfer [ * * Hospital1 188 * * ] [ * * 2166 - 4 - 9 * * ] , [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] transjugular
intrahepatic portosystemic shunt procedure .
Indications include gastric variceal bleed
refractory endoscopic treatment . patient
electively intubate prior transfer .
[ * * 2166 - 4 - 10 * * ] , patient transjugular intrahepatic
portosystemic shunt procedure complicate innominate vein
perforation right internal mammary artery bleed
hemothorax . patient take operating room
sternotomy repair vascular lesion . patient
stabilize , chest tube place . patient require 12
unit pack red blood cell , 4 unit platelet ,
4 unit fresh frozen plasma .
initial period stability , patient become
increasingly hypotensive [ * * 2166 - 4 - 12 * * ] [ * * 2166 - 4 - 14 * * ]
require pressor support . Swan - Ganz catheter place
systemic vascular resistance decrease ,
cardiac output index increase . patient
transfer Fernard Intensive Care Unit
care give picture sepsis .
note , packed red blood cell requirement
3 unit per day three day stop bleed
clinically . nasogastric tube output .
patient still [ * * last Name ( un ) * * ] tube place . patient
paralyze due difficulty ventilation postoperatively .
operating room [ * * 4 - 10 * * ] , patient episode
hypotension one three minute .
PAST MEDICAL history :
1 . Cirrhosis .
2 . Status post esophageal variceal bleed .
3 . Status post transjugular intrahepatic portosystemic shunt
unsuccessful .
4 . Status post innominate vein right internal mammary
artery laceration resultant hemothorax .
5 . Status post sternotomy describe .
allergy : know drug allergy .
medication TRANSFER : medication transfer
Surgical Intensive Care Unit octreotide 50 mcg q.d . ,
insulin drip , Dilaudid drip , Ativan drip , oxacillin 2 g
q.6h . , levofloxacin 500 mg intravenously q.d . , Flagyl 500 mg
intravenously t.i.d . , Protonix 40 mg intravenously b.i.d . ,
Cisatracurium 80 mcg / kg per hour , Neo - Synephrine drip .
PHYSICAL EXAMINATION presentation : blood pressure
110/50 , pulse 80 , temperature 37 . patient
ventilatory support AC 550 x 12 FIO2
60 % , positive end - expiratory pressure 20 .
Swan - Ganz catheter reading follow : central venous
pressure 22 , pulmonary artery pressure 44/19 , cardiac output
7.8 , cardiac index 3.95 , systemic vascular resistance
522 . Ins - - out 2700 1800 ; 1300
urine . general , patient intubate sedate .
Pupils small reactive . Neck reveal leave internal
jugular place ; site look clean . oropharynx
clear . [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] place ; purulent green
discharge note . Chest reveal fair breath sound
bilaterally , positive rhonchi throughout . Cardiovascular
regular rate rhythm . murmur , rub gallop .
Abdomen soft , decrease bowel sound . extremity
warm fair pulse distally . skin rash . right
radial femoral line purulent discharge note
either line .
pertinent LABORATORY datum presentation : white blood cell
count 13.4 ( decrease 19.6 ) , hematocrit 33.4 ,
platelet 146 . PT 15.4 , PTT 42.2 , INR 1.7 .
chemistry-7 significant creatinine 1.5 ( increase
baseline 1 ) . Albumin 2.7 , phosphate 4.5 ,
magnesium 2.1 . ALT 19 , AST 32 , alkaline
phosphatase 108 , total bilirubin 13.1 ( increase
admission 6 ) . Urine sodium 19 [ * * 2166 - 4 - 11 * * ] .
arterial blood gas reveal 7.4 , PCO2 34 , PO2 135 ,
unknown FIO2 , lactate 3 . blood culture reveal
growth date far . Sputum positive
methicillin - sensitive Staphylococcus aureus .
RADIOLOGY / IMAGING : chest x - ray reveal bilateral
infiltrate suggestive congestive heart failure .
HOSPITAL COURSE : summary , 57 - year - old male
recent gastric variceal bleed , status post unsuccessful
transjugular intrahepatic portosystemic shunt complicated
hemothorax innominate vein injury require
thoracotomy , hypotensive pressor require increase
FIO2 positive end - expiratory pressure maintain
oxygenation .
Swan - Ganz catheter number physical complete
blood count increase white blood cell count left
shift suggestive sepsis . patient paralyze
due difficulty ventilation postoperatively .
patient seem long bleed varix .
1 . PULMONARY : give decrease blood pressure try
decrease positive end - expiratory pressure tolerate
try wean paralytic . patient also
give fluid maintain blood pressure . Diuresis
option give decrease blood pressure . Swan - Ganz
catheter place perioperatively subsequently
discontinue .
2 . CARDIOVASCULAR : patient require Neo - Synephrine
increase blood pressure . try wean
Neo - Synephrine add vasopressin ; however ,
unsuccessful .
3 . GASTROINTESTINAL : patient stable hematocrit
long transfusion requirement . patient
continue Protonix , [ * * last Name ( un ) * * ] tube continue
leave . patient hyperbilirubinemia ; likely
think secondary shocked liver give episode
hypotension .
4 . RENAL : Creatinine increase 1.5 continue
increase hospitalization . think
likely secondary hepatorenal syndrome . patient
continue maintain good urine output . [ * * 4 - 26 * * ] ,
patient start octreotide midodrine give
possibility hepatorenal syndrome ; however , creatinine
continue increase .
5 . ENDOCRINE : patient maintain insulin drip
later change subcutaneous .
6 . HEMATOLOGY : patient 's hematocrit remain stable .
coagulopathy likely secondary liver
disease .
7 . infectious DISEASE : Oxacillin change vancomycin
give patient continue febrile . also
think patient may sinusitis secondary
[ * * last Name ( un ) * * ] tube ; however , Gastroenterology feel
[ * * last Name ( un ) * * ] tube keep give recent episode
upper gastrointestinal bleed .
patient continue vancomycin , levofloxacin ,
Flagyl general sepsis cover sinusitis ,
mediastinitis , Staphylococcus aureus sputum .
8 . FLUIDS / ELECTROLYTES / NUTRITION : patient initiate
total parenteral nutrition .
patient significantly improve , give
worsen renal function , think patient 's
prognosis poor . family meeting , patient
make resuscitate .
[ * * 4 - 18 * * ] , give poor prognosis , family decide
make patient comfort measure . 11:58 ,
patient expire .
condition discharge : expire .
discharge diagnosis :
1 . Gastric variceal bleed secondary cirrhosis .
2 . Cirrhosis ; likely secondary ethanol use .
3 . Hemothorax secondary transjugular intrahepatic
portosystemic shunt procedure ; status post sternotomy
stabilization perforation .
4 . sepsis .
5 . Acute respiratory distress syndrome ( ARDS ) .
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , M.D. [ * * MD Number(1 ) 968 * * ]
dictate by:[**last Name ( NamePattern1 ) 218 * * ]
medquist36
: [ * * 2166 - 8 - 29 * * ] 11:36
: [ * * 2166 - 9 - 4 * * ] 16:33
JOB # : [ * * Job number 40542 * * ]
|
[
"5789",
"5849",
"5185"
] |
Admission Date : [ * * 2139 - 2 - 17 * * ] Discharge Date : [ * * 2139 - 2 - 24 * * ]
Date Birth : [ * * 2072 - 4 - 24 * * ] sex :
Service : CT Surgery
history PRESENT ILLNESS : patient 66 year old
male present exertional angina . patient note
two month exertional angina band - like chest pain
radiate left arm , relieve sublingual
nitroglycerin .
day admission , patient stress test
develop 1.[**street Address(2 ) 1755 * * ] elevation inferiorly [ * * Street Address(2 ) 2051 * * ]
depression V4 V6 . Imaging show severe reversible
perfusion defect inferior lateral wall .
Cardiac catheterization perform , demonstrate 60 %
70 % stenosis left anterior descend artery , 90 % leave
circumflex , 90 % right coronary artery left
ventricular ejection fraction approximately 50 % .
PAST MEDICAL history : 1 . Insulin dependent diabetes
mellitus . 2 . Hypertension . 3 . Hypercholesterolemia .
medication admission : Lisinopril 40 mg p.o.q.d . ,
lovastatin 20 mg p.o.q.d . , hydrochlorothiazide 25 mg
p.o.q.d . , amlodipine 10 mg p.o.q.d . , metformin 500 mg
p.o.q.d . , NPH insulin 36 unit q.a.m . 32 unit q.p.m . ,
terazosin 1 mg p.o.q.d . , zyrtec 10 mg p.o.q.d . , Ecotrin
p.o.q.d .
allergie : patient know drug allergy .
PHYSICAL EXAMINATION : physical examination , patient
heart rate 70 , blood pressure 134/71 oxygen
saturation 98 % two liter . General : Patient
acute distress . Neck : jugular venous distention .
Cardiovascular : regular rate rhythm , / VI systolic
murmur . lung : clear auscultation bilaterally . Abdomen :
soft , nontender , nondistended , positive bowel sound .
extremity : edema .
HOSPITAL COURSE : patient admit hospital
decide would take operating
Room [ * * 2139 - 2 - 19 * * ] . Coronary artery bypass grafting
perform left internal mammary artery left
anterior descend artery saphenous vein graft
obtuse marginal , posterior descend artery diagonal
three artery . pericardium leave open arterial
line place . two atrial wire place . two
mediastinal one leave pleural tube place .
Crossclamp time 61 minute .
postoperatively , patient transfer Intensive
Care Unit , rapidly extubate . postoperative
day number one , Neo - Synephrine drip appropriately
wean . patient - v pace . postoperative day
number one chest tube also remove .
postoperative day number two , patient transfer
floor . Foley catheter remove
postoperative day number two . atrially pace
entire day posterior day two . postoperative day number
three , wire cap patient heart rate
70 sinus rhythm .
wire remove postoperative day number five .
patient able ambulate level v , tolerate
oral diet , pain control oral medication .
condition DISCHARGE : Stable .
discharge medication :
Lasix 20 mg p.o.b.i.d . time seven day .
Potassium chloride 20 meq p.o.q.d . time seven day .
Lopressor 12.5 mg p.o.q.d .
Percocet one two tablet p.o.q.4 - 6h.p.r.n .
Lovastatin 20 mg p.o.q.d .
Amlodipine 10 mg p.o.q.d .
Glucophage 500 mg p.o.q.d .
NPH insulin 36 unit q.a.m . 32 unit q.p.m .
Terazosin 1 mg p.o.q.d .
Ecotrin 325 mg p.o.q.d .
Colace 100 mg p.o.b.i.d .
di[**last Name ( STitle ) 408**]e follow - : patient follow
primary care physician cardiologist three week
Dr. [ * * last Name ( Prefixes ) * * ] four week .
discharge diagnosis :
status post coronary artery bypass grafting time four .
[ * * Doctor Last Name 412 * * ] [ * * last Name ( Prefixes ) 413 * * ] , M.D. [ * * MD Number(1 ) 414 * * ]
Dictated By:[**Name8 ( MD ) 1308 * * ]
medquist36
: [ * * 2139 - 2 - 24 * * ] 11:28
: [ * * 2139 - 2 - 24 * * ] 11:33
JOB # : [ * * Job number 29720 * * ]
|
[
"4111",
"4019",
"2720"
] |
Admission Date : [ * * 2153 - 1 - 5 * * ] Discharge Date : [ * * 2153 - 1 - 11 * * ]
Date Birth : [ * * 2067 - 1 - 25 * * ] sex :
Service : MEDICINE
allergy :
Codeine / Iodine
attending:[**first Name3 ( LF ) 2782 * * ]
Chief Complaint :
malaise
Major Surgical Invasive Procedure :
Percutaneous Chol .
history Present Illness :
85 yo male w/ h / afib , systolic CHF , recent cholecystitis
treat medically p / w fatigue , poor po intake , malaise . upon
questioning admit mild ruq pain chill fever .
lose ten lbs last week due poor po intake . son
bring [ * * Name ( NI ) * * ] evaluation appointment
cardiologist 's office .
.
hospitalize [ * * 2152 - 12 - 10 * * ] OSH rx
cholecytitis afterwhich develop low extremity edema
dyspnea exertion . start lasix one week ago
improve since . say get extremely short
breath 20 step . chest pain .
.
several mechanical fall lately reason ,
anticoagulate .
ED , initial VS : 97.8 48 95/76 18 90 % . give
1.5l ivf . treat azithromycin 500 mg iv ,
ceftriaxone 1 g iv , unasyn 3 g iv . Lactate decrease
4.6 2.2 fluid . Troponin stable .03 . surgical
consultation recommend percutaneous cholecystostomy tube . CT
head
.
upon transfer micu , 98.0 , pulse : 94 , RR : 16 , BP : 129/72 ,
O2Sat : 97 % , O2 . arrival MICU , acute
complaint .
.
Review system :
( + ) per hpi
( - ) Denie night sweat , recent wt gain . Denies headache , sinus
tenderness , rhinorrhea congestion . denie wheezing . denie
chest pain , chest pressure , palpitation , weakness . denie
nausea , vomiting , diarrhea , constipation , abdominal pain ,
change bowel habit . Denies dysuria , frequency , urgency .
Denies arthralgia myalgia . Denies rash skin change .
Past Medical history :
/ P BILATERAL TKR
* / P ILIAL FRACTURE
ATRIAL FIBRILLATION
AWB donation- DEFFERRAL
B12 DEFICIENCY ANEMIA
BLADDER CANCER
CERVICAL SPONDYLOSIS
CHRONIC RENAL FAILURE
gastroesophageal REFLUX
HERNIATED DISC
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM
MGUS
MITRAL VALVE PROLAPSE
PROCTITIS
PROSTATE CANCER
r SHOULDER DJD
TRANSIENT ISCHEMIC ATTACK
[ * * 2141 * * ] LVEF 25 %
Social History :
live alone daily help ; smoking etoh
family history :
Mother die alzheimers dementia
Father die prostate cancer
Physical Exam :
general : Alert , oriented , acute distress
HEENT : Sclera anicteric , MMM , oropharynx clear , EOMI , PERRL
Neck : supple , JVP elevate , LAD
CV : regular rate rhythm , normal S1 + S2 , murmur , rub ,
gallop
lung : clear auscultation bilaterally , wheeze , rale ,
ronchi
Abdomen : soft , non - tender , non - distended , bowel sound present ,
organomegaly
GU : foley
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
Neuro : CNII - XII intact , 5/5 strength upper / low extremity ,
grossly normal sensation , 2 + reflexe bilaterally , gait
defer , finger - - nose intact
pertinent result :
Admission Labs
[ * * 2153 - 1 - 5 * * ] 09:45pm glucose-136 * UREA N-41 * CREAT-1.8 * SODIUM-141
POTASSIUM-3.9 CHLORIDE-109 * TOTAL CO2 - 21 * anion GAP-15
[ * * 2153 - 1 - 5 * * ] 09:45PM CALCIUM-8.1 * PHOSPHATE-4.3 MAGNESIUM-2.0
[ * * 2153 - 1 - 5 * * ] 12:03pm URINE HOURS - RANDOM UREA N-932 CREAT-99
sodium-50 potassium-68 chloride-41
[ * * 2153 - 1 - 5 * * ] 12:03pm URINE OSMOLAL-595
[ * * 2153 - 1 - 5 * * ] 12:03pm URINE COLOR - Yellow APPEAR - Clear SP [ * * last Name ( un ) 155**]-1.018
[ * * 2153 - 1 - 5 * * ] 04:49am glucose-136 * UREA N-45 * creat-2.1 * SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2 - 21 * anion GAP-17
[ * * 2153 - 1 - 5 * * ] 04:49am ALT(SGPT)-55 * AST(SGOT)-55 * LD(LDH)-255 * ALK
phos-128 TOT bili-0.6
[ * * 2153 - 1 - 5 * * ] 04:49am CALCIUM-8.2 * PHOSPHATE-4.2 MAGNESIUM-2.0
iron-38 *
[ * * 2153 - 1 - 5 * * ] 04:49am calTIBC-179 * VIT B12 - 740 FOLATE - greater TH
FERRITIN-246 TRF-138 *
[ * * 2153 - 1 - 5 * * ] 04:49am WBC-8.6 rbc-3.08 * hgb-9.9 * HCT-30.7 * MCV-100 *
MCH-32.2 * MCHC-32.4 RDW-17.9 *
[ * * 2153 - 1 - 5 * * ] 04:49am PLT COUNT-239
[ * * 2153 - 1 - 5 * * ] 04:49am pt-13.4 * PTT-20.7 * INR(PT)-1.2 *
[ * * 2153 - 1 - 5 * * ] 01:04AM LACTATE-2.2 *
[ * * 2153 - 1 - 5 * * ] 12:55am cTropnT-0.03 *
[ * * 2153 - 1 - 4 * * ] 08:25PM urine COLOR - Yellow APPEAR - Clear SP [ * * last Name ( un ) 155**]-1.013
[ * * 2153 - 1 - 4 * * ] 08:25PM URINE RBC-1 WBC-10 * BACTERIA - MANY yeast - NONE
EPI-0
[ * * 2153 - 1 - 4 * * ] 08:25PM urine MUCOUS - RARE
[ * * 2153 - 1 - 4 * * ] 06:25PM lactate-4.6 * k+-4.8
[ * * 2153 - 1 - 4 * * ] 06:25PM HGB-11.3 * calcHCT-34
[ * * 2153 - 1 - 4 * * ] 06:12pm PT-14.7 * PTT-24.4 * INR(PT)-1.4 *
[ * * 2153 - 1 - 4 * * ] 06:12PM PLT COUNT-267 #
[ * * 2153 - 1 - 4 * * ] 06:12pm ctropnt-0.03 *
[ * * 2153 - 1 - 4 * * ] 06:12PM lipase-33
Brief Hospital course :
BRIEF HOSPITAL COURSE : 85 year old gentleman
history atrial fibrillation , systolic heart failure
recent medically treat cholecystitis present
recurrent cholecystitis treat percutaneous
drainage antibiotic . hospital course complicate
delirium mild pulmonary edema .
.
ACTIVE ISSUES :
ACUTE cholecystiti : Mr. [ * * know lastname 79 * * ] present right upper
quadrant pain nausea fatigue . lab significant
normal lft . RUQ ultrasound demonstrate dacute cholecystitis .
Suurgery consult recommend percutaneous drainage
gallbladder carry IR . Initial pus
drain gallbladder transione bilious
drainage Day # 2 admission . cover Vancomycin
Zosyn initially . culture datum biliary drain grow
ecoli sensitive ciprofloxacin . antibiotic therapy change
ciprofloxacin metronidazole include anaerobic coverage
total 14 day . biliary drain keep place
plan discontinuation general surgery [ * * 5 - 25 * * ] week .
afebrile duration hospital course .
.
CONGESTIVE HEART FAILURE : admission note dyspneic .
initial chest xray concern right low lobe
pneumonia could rule setting
pulmonary edema . initially vancomycin zosyn
admission intensive care unit . diuresis
initially hold secondary concern acute kidney injury
pulmonary edema accumulate initial hospital
day . give IV lasix 20 mg twice restart
home dose lasix 20 mg daily . dose uptitrated 40 mg
daily appear well control volume status
improve breathing . echo demonstrate symmetric left
ventricular hypertrophy cavity dilation global systolic
dysfunction suggestive non - ischemic pattern EF 25 % .
low dose ace - inhibitor ( lisinopril 5 mg ) start
continue aspirin beta blocker . report cough
afebrile duration hospitalization . repeat
chest xray diuresis reveal evidence pneumonia .
nighttime oxygen saturation note stably low
90 .
.
URINARY tract infection : urine sample admission
concern infection culture grow ecoli sensitive
ciprofloxacin . repeat UA prior discharge clear
infection .
.
ATRIAL FIBRILLATION : Mr. [ * * know lastname 79 * * ] rate control metoprolol
anticoagulate aspirin give fall risk . note
heart rate 110 frequent episode non
sustained ventricular tachycardia , therfore metoprolol
incrase 50 mg three time day improvement
frequency NSVT heart rate 60 - 70 day .
Cardiology consult agree management change .
question whether domperidone
past . take medication list .
.
DELIRIUM : Mr. [ * * know lastname 79 * * ] note progressive delirium
throughout hospitalization improve prior
discharge . pharmacologic agent require management .
attentive family bedside time .
repeat infectious work - include UA , chest xray cdiff
toxin negative infection . electrolyte stable .
etiology attribute age , dementia hospitalization
include ICU stay .
.
speech swallow : delirius , Mr. [ * * know lastname 79 * * ] note
small aspiration event eating drinking . speech
swallow evaluation recommend nectar thicken liquid
suggest - evaluation delirium clear .
.
INACTIVE ISSUES
CHRONIC KIDNEY DISEASE : renal function range 1.8
2.0 throughout hospitalization
baseline .
.
HYPERTENSION : well controlled . furosemide increase 40 mg po .
Amlodipine discontine favor lisinopril 5 mg .
Hydralazine hold discharge give normotensive .
discuss restart medication primary care
physician discharge .
.
HYPOTHYROID : continue levothyroxine .
.
VITAMIN : continue vitamin D.
.
dyslipidemia : continue crestor 20 mg daily .
.
DEPRESSION : continue wellbutrin 300 mg daily .
.
BENIGN PROSTATIC hypertrophy : continue flomax .
.
PAIN : secondary frequent fall . continue tylenol
gabapentin .
.
INSOMNIA : Lunesta hold admission
reconsider discharge .
.
GERD : continue ranitidine nexium .
.
TRANSITIONAL ISSUES :
- continue ciprofloxacin metronidazole 8 additional day
- primary care follow - , electrolyte check within
1 week start lasix lisinopril .
- Full Code
medication admission :
tylenol # 3 daily prn
furosemide 20 mg daily
amlodipine 5 mg daily
bupropion 300 mg daily
calcitriol .25mcg
domperidone 5 mg daily
gabapentin 900 mg daily
esmeprasole 40 mg daily
eszopiclone ( lunesta ) 2 mg hs
gabapentin 800 mg daily
hydralazine 25 mg [ * * hospital1 * * ]
levothyroxine 112 mcg daily
metoprolol succinate 50 mg [ * * hospital1 * * ]
ranitidine 150 mg daily
rosuvastatin 20 mg daily
tamsulosin .4 mg daily
asa 325
vitamin
b12 1000mcg daily
Discharge medication :
1 . acetaminophen 325 mg Tablet Sig : 1 - 2 tablet po Q6H ( every 6
hour ) need pain .
2 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
3 . calcitriol 0.25 mcg Capsule Sig : one ( 1 ) Capsule po
day .
4 . esomeprazole magnesium 40 mg Capsule , Delayed Release(E.C. )
Sig : one ( 1 ) Capsule , Delayed Release(E.C. ) po day .
5 . eszopiclone 2 mg Tablet Sig : one ( 1 ) Tablet po bedtime
need insomnia .
6 . levothyroxine 112 mcg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
7 . rosuvastatin 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
8 . tamsulosin 0.4 mg Capsule , Ext Release 24 hr Sig : one ( 1 )
Capsule , Ext Release 24 hr po HS ( bedtime ) .
9 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
10 . vitamin 2,000 unit Capsule Sig : one ( 1 ) Capsule po
day .
11 . cyanocobalamin ( vitamin B-12 ) 1,000 mcg Tablet Sig : one ( 1 )
Tablet PO day .
12 . ciprofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet po Q12H
( every 12 hour ) 8 day : day 1 = [ * * 1 - 5 * * ] ( total course 14
day ) .
13 . metronidazole 500 mg Tablet Sig : one ( 1 ) Tablet PO Q8H
( every 8 hour ) 8 day : day 1 = [ * * 1 - 5 * * ] ( total 14 day ) .
14 . bupropion HCl 300 mg Tablet Extended Release 24 hr Sig : one
( 1 ) Tablet Extended Release 24 hr po day .
15 . gabapentin 800 mg Tablet Sig : one ( 1 ) Tablet po day .
16 . metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig : three ( 3 ) Tablet Extended Release 24 hr po day .
17 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet po day .
discharge Disposition :
Extended Care
Facility :
[ * * first Name8 ( NamePattern2 ) 1495 * * ] [ * * Hospital 122 * * ] Rehabilitation Center
discharge Diagnosis :
Acute cholecystitis
Urinary tract infection
atrial fibrillation
decompensate systolic heart failure
Hypertension
Chronic kidney disease
Discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Bed assistance chair
wheelchair .
Discharge instruction :
pleasure take care . come feeling
fatigue fever . reason inflammation
galbladder urinary tact infection . tube
place gallblader bile drain . give
antibiotic recover .
.
tube stay gallbladder . Wou see
surgeon [ * * 1 - 26 * * ] give
instruction .
.
do follow change medication :
CONTINUE ciprofloxacin 500 mg tbl . twice day 8 day
CONTINUE metronidazole 500 mg tbl . three time day 8
day
CHANGE furosemide 20 mg po daily furosemide 40 mg daily
DISCONTINUE dronedorol
DISCONTINUE amlodipine 5 mg daily
START lisinopril 5 mg daily
DISCONTINUE hydralazine 25 mg twice day
DISCONTINUE ranitidine 150 mg daily
Followup Instructions :
Department : GENERAL SURGERY/[**Hospital Unit Name 2193 * * ]
: FRIDAY [ * * 2153 - 1 - 26 * * ] 10:15
: ACUTE care CLINIC [ * * telephone / Fax ( 1 ) 600 * * ]
building : LM [ * * Hospital Ward Name * * ] Bldg ( [ * * last Name ( NamePattern1 ) * * ] ) [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Hospital Ward Name * * ] Garage
.
Department : WEST [ * * Hospital 2002 * * ] CLINIC
: WEDNESDAY [ * * 2153 - 2 - 7 * * ] 11:30
: [ * * First Name11 ( Name Pattern1 ) 177 * * ] [ * * last Name ( namepattern4 ) 720 * * ] , M.D. [ * * telephone / Fax ( 1 ) 721 * * ]
building : De [ * * hospital1 * * ] building ( [ * * Hospital Ward Name 121 * * ] Complex ) [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Street address(1 ) 592 * * ] Garage
.
Department : WEST [ * * Hospital 2002 * * ] CLINIC
: WEDNESDAY [ * * 2153 - 3 - 28 * * ] 11:30
: [ * * First Name11 ( Name Pattern1 ) 177 * * ] [ * * last Name ( namepattern4 ) 720 * * ] , M.D. [ * * telephone / Fax ( 1 ) 721 * * ]
building : De [ * * hospital1 * * ] building ( [ * * Hospital Ward Name 121 * * ] Complex ) [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Street address(1 ) 592 * * ] garage
|
[
"5990",
"5849",
"2930",
"4280",
"2449",
"4589",
"4240",
"2724",
"2720"
] |
Admission Date : [ * * 2166 - 4 - 30 * * ] Discharge Date : [ * * 2166 - 5 - 9 * * ]
Date Birth : [ * * 2100 - 7 - 6 * * ] sex : F
Service : MEDICINE
allergy :
Amoxicillin / Bactrim / Sulfa ( Sulfonamides ) / penicillin
attending:[**first Name3 ( LF ) 613 * * ]
Chief Complaint :
/ p fall
Major Surgical Invasive Procedure :
none
history Present Illness :
65 y.o . female PMHx COPD , esophageal stricture / p
dilatation [ * * Month ( ) 404 * * ] present chief complaint
fall . Patient report long history fall , 1 fall
day past 3 consecutive day . report dizziness
occasionally prior fall , otherwise deny prodrome
chest pain , SOB , palpitation . report hit head
fall , deny LOC . also recently fall
right chest subsequent pain . attribute
fall decrease vision ( history cataract / p two
surgery right , many year ago ) also suppose
ambulate walker , not always comply . also
wear 2 liter oxygen baseline note
occasionally trip oyxgen tubing try
ambulate . thus primarily come complaint fall ,
note cough productive yellow / brown sputum past
2 month subjective fever ( sweats )
evaluate . report grandchild well
gentleman building potential sick contact ,
otherwise deny recent travel exposure . report
get flu shot last year receive pneumovax 2
year ago .
.
ED , patient note tachycardic 120s
hypoxic 89 % RA . improve 96 % NRB fail
attempt nasal cannula . Patient also note
lactate 3.3 leukocytosis 22.8 bandemia 9 % .
CXR show right middle low lobe infiltrate , concern
PNA give hypoxia , lactic acidosi leukocytosis ,
patient start Levofloxacin Ceftriaxone . otherwise ,
patient note acute renal failure 0.6 1.3
give 1 L NS . additionally , potassium 2.4
replete . ekg perform unremarkable , troponin
x 1 elevate 0.05 setting ARF ASA
give . Patient asymptomatic otherwise . lastly , give history
recent fall , CT neck head perform without
evidence fracture bleed . Patient subsequently admit
ICU management probable pneumonia
significant hypoxia bandemia .
.
upon arrival ICU , patient NRB , speak full
sentence , acute distress . complain right side
chest pain due fall also endorse dysuria
hematuria . otherwise , complaint .
Past Medical History :
# esophageal stricture / p dilatation [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ]
# peptic ulcer disease / p subtotal gastrectomy repair
hiatal hernia fundoplication [ * * 2163 - 8 - 19 * * ] Dr.
[ * * last Name ( STitle ) * * ]
nonhealing ulcer
# copd ( pft OMR )
# gerd
# depression
# ptsd
# anemia
# hyperlipidemia
# c - section x 2 ( ' [ * * 27 * * ] , ' [ * * 28 * * ] )
Social History :
live alone [ * * hospital3 * * ] [ * * Hospital1 3494 * * ] SSI
disability . still continue smoke unquantified amount .
deny alcohol illicit drug . 3 child ,
estranged . victim domestic dispute
ex - husband , currently live alone feel safe .
Family history :
Asthma ( child ) , brother depression PTSD
Physical Exam :
vital : : 99.0 , BP : 141/87 , p : 110 r : 24 O2 : 94 % 4L NC .
General : awake , alert , NAD , speak full sentence ,
accessory muscle use .
HEENT : NC / ; pale conjunctiva , PERRLA , EOMI ; op clear ,
nonerythematous
neck : Supple , JVD
Lungs : decrease BS bilaterally , wheeze , ronchi , crackle
CV : RR , normal S1 + S2 , [ * * 1 - 24 * * ] sm 2rics radiate ,
murmur , rub , gallop
Abdomen : soft , tender palpation RLQ , rebound guarding ,
+ BS , old midline surgical incision
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
.
Neuro : Alert , orient x 2 , attention impaired . Pt . unable
cooperate full neurlogical exam . proprioception appear
impair LLE , upgoing toe b / l. dtr 3 + patella b / l.
Impaired FTN [ * * Doctor First Name * * ] .
pertinent result :
Labs admission discharge :
.
[ * * 2166 - 4 - 30 * * ] 05:10PM blood WBC-23.8 * # RBC-3.35 * Hgb-7.9 * Hct-25.8 *
MCV-77 * # mch-23.5 * # mchc-30.5 * RDW-16.9 * Plt ct-548 *
[ * * 2166 - 4 - 30 * * ] 07:35pm blood Neuts-72 * Bands-19 * Lymphs-4 * Monos-5
Eos-0 baso-0 Atyps-0 Metas-0 Myelos-0
[ * * 2166 - 5 - 7 * * ] 07:05am blood WBC-11.6 * RBC-3.00 * Hgb-7.7 * Hct-23.3 *
MCV-78 * mch-25.6 * mchc-32.9 rdw-18.3 * Plt ct-431
.
[ * * 2166 - 4 - 30 * * ] 05:10PM blood PT-15.8 * PTT-33.1 INR(PT)-1.4 *
.
[ * * 2166 - 5 - 5 * * ] 07:50AM blood Ret Aut-0.3 *
.
[ * * 2166 - 4 - 30 * * ] 05:10PM blood Glucose-181 * UreaN-31 * Creat-1.3 * Na-136
K-2.4 * Cl-95 * HCO3 - 24 AnGap-19
[ * * 2166 - 5 - 7 * * ] 07:05AM blood Glucose-122 * UreaN-3 * creat-0.5 na-141
K-3.1 * cl-100 HCO3 - 33 * AnGap-11
.
[ * * 2166 - 4 - 30 * * ] 05:10PM blood ALT-11 AST-25 CK(CPK)-794 * AlkPhos-122 *
TotBili-0.5
.
[ * * 2166 - 4 - 30 * * ] 05:10PM blood cTropnT-0.05 *
[ * * 2166 - 5 - 1 * * ] 12:00am blood CK - MB-5 cTropnT-0.05 *
[ * * 2166 - 5 - 1 * * ] 06:15AM blood CK - MB-6 ctropnt-0.03 *
.
[ * * 2166 - 4 - 30 * * ] 05:10PM BLOOD Calcium-8.7 Phos-2.3 * # mg-2.1 iron-7 *
[ * * 2166 - 4 - 30 * * ] 05:10PM blood calTIBC-256 * Ferritn-160 * TRF-197 *
[ * * 2166 - 5 - 1 * * ] 06:15AM blood albumin-2.4 * Calcium-7.4 * Phos-2.6 *
Mg-2.7 *
.
[ * * 2166 - 4 - 30 * * ] 05:27pm blood lactate-3.3 *
[ * * 2166 - 5 - 1 * * ] 01:12AM blood lactate-1.0
[ * * 2166 - 5 - 3 * * ] 04:48am blood tsh-0.33
.
[ * * 2166 - 4 - 30 * * ] 05:55PM urine Color - Yellow Appear - Clear Sp [ * * last Name ( un ) * * ] -1.017
[ * * 2166 - 4 - 30 * * ] 05:55PM urine blood - SM Nitrite - NEG Protein-30
Glucose - NEG Ketone - TR Bilirub - NEG Urobiln - NEG ph-5.0 Leuks - NEG
[ * * 2166 - 4 - 30 * * ] 05:55PM URINE RBC-0 - 2 WBC-2 Bacteri - yeast - NONE
Epi-1
[ * * 2166 - 4 - 30 * * ] 10:49pm URINE Eos - NEGATIVE
[ * * 2166 - 4 - 30 * * ] 10:49pm URINE Hours - RANDOM Na - LESS
.
[ * * 2166 - 5 - 6 * * ] 04:01AM URINE Color - Yellow Appear - Clear Sp [ * * last Name ( un ) * * ] -1.009
[ * * 2166 - 5 - 6 * * ] 04:01AM URINE blood - MOD Nitrite - NEG Protein-30
Glucose - NEG Ketone - NEG Bilirub - NEG Urobiln - NEG pH-7.0 Leuks - NEG
[ * * 2166 - 5 - 6 * * ] 04:01AM urine RBC-45 * WBC-2 Bacteri - none yeast - none
Epi-0
.
Microbiology :
.
[ * * 2166 - 5 - 7 * * ] SEROLOGY / blood RAPID PLASMA REAGIN test - PENDING
INPATIENT
[ * * 2166 - 5 - 7 * * ] STOOL CLOSTRIDIUM DIFFICILE toxin & B test - pende
INPATIENT
[ * * 2166 - 5 - 6 * * ] STOOL CLOSTRIDIUM DIFFICILE toxin & B TEST - FINAL
INPATIENT
[ * * 2166 - 5 - 6 * * ] blood CULTURE Blood Culture , Routine - PENDING
INPATIENT
[ * * 2166 - 5 - 6 * * ] URINE URINE CULTURE - FINAL INPATIENT
[ * * 2166 - 5 - 6 * * ] blood CULTURE Blood Culture , Routine - PENDING
INPATIENT
[ * * 2166 - 5 - 5 * * ] blood CULTURE Blood Culture , Routine - PENDING
INPATIENT
[ * * 2166 - 5 - 5 * * ] blood CULTURE Blood Culture , Routine - PENDING
INPATIENT
[ * * 2166 - 5 - 4 * * ] blood CULTURE Blood Culture , Routine - PENDING
INPATIENT
.
[ * * 2166 - 5 - 2 * * ] URINE Legionella Urinary Antigen - negative
.
[ * * 2166 - 5 - 1 * * ] blood CULTURE Blood Culture , Routine - growth
[ * * 2166 - 5 - 1 * * ] SPUTUM GRAM STAIN - FINAL ; RESPIRATORY CULTURE - mix
flora
.
[ * * 2166 - 4 - 30 * * ] URINE URINE culture - mix flora
[ * * 2166 - 4 - 30 * * ] MRSA SCREEN MRSA SCREEN - FINAL INPATIENT
[ * * 2166 - 4 - 30 * * ] blood CULTURE Blood Culture , Routine - FINAL
{ STREPTOCOCCUS PNEUMONIAE } ; Anaerobic Bottle Gram Stain - FINAL
EMERGENCY [ * * hospital1 * * ]
[ * * 2166 - 4 - 30 * * ] blood CULTURE Blood Culture , Routine - FINAL
{ STREPTOCOCCUS PNEUMONIAE } ; aerobic Bottle Gram Stain - FINAL ;
Anaerobic Bottle Gram Stain - FINAL EMERGENCY [ * * hospital1 * * ]
.
Blood Culture , Routine ( Final [ * * 2166 - 5 - 6 * * ] ):
STREPTOCOCCUS PNEUMONIAE .
MEROPENEM = 0.016 MCG / ML = SENSITIVE E - TEST .
Penicillin SENSITIVE 0.032 MCG / ML Sensitivity
testing
perform Etest .
CEFTRIAXONE SENSITIVE 0.023 MCG / ML Sensitivity
testing
perform Etest .
note : treatment meningitis , penicillin G MIC
breakpoint
< = 0.06 ug / ml ( ) > = 0.12 ug / ml ( r ) .
note : treatment meningitis , ceftriaxone MIC
breakpoint
< = 0.5 ug / ml ( ) , 1.0 ug / ml ( ) , > = 2.0 ug / ml ( r ) .
treatment oral penicillin , MIC break
point
< = 0.06 ug / ml ( ) , 0.12 - 1.0 ( ) > = 2 ug / ml ( r ) .
sensitivity testing perform [ * * First Name8 ( NamePattern2 ) 3077 * * ] [ * * last Name ( NamePattern1 ) 3060 * * ] .
sensitivity : MIC express
MCG / ML
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
STREPTOCOCCUS PNEUMONIAE
|
erythromycin----------
PENICILLIN G----------
TETRACYCLINE----------
TRIMETHOPRIM / SULFA----
vancomycin------------
.
Imaging / study :
.
CXR admission :
.
finding : portable upright AP chest radiograph obtain .
patchy consolidation right mid low lung ,
concern right middle low lobe pneumonia . left
lung appear essentially clear .
cardiomediastinal silhouette appear grossly unremarkable .
pneumothorax . bony structure appear intact .
.
IMPRESSION : finding concern right middle low lobe
pneumonia .
.
ECG admission : sinus tachycardia , rate 118 . low voltage
standard lead . leave atrial abnormality . compare
previous tracing [ * * 2165 - 8 - 28 * * ] sinus tachycardia new
borderline first degree - v block .
.
CT head admission :
.
NON - contrast head ct : hemorrhage , edema , mass
effect , acute
large vascular territory infarction . extensive
periventricular white
matter hypodensity , consistent sequelae small vessel
ischemic disease .
mild prominence sulci ventricle , likely
secondary global
parenchymal atrophy . shift normally midline
structure .
basilar cistern preserve . osseous structure
surround soft
tissue , include globe orbit , unremarkable .
left len
appear prosthetic . visualized paranasal sinus mastoid
air cell
normally pneumatized clear .
IMPRESSION :
1 . global parenchymal atrophy sequelae small vessel
ischemic disease .
2 . hemorrhage , edema , mass effect , acute large vascular
territory
infarction .
.
CT neck admission :
.
IMPRESSION :
1 . fracture malalignment .
2 . mild multifocal cervical spondylosis evidence
canal stenosis .
3 . biapical pleural scarring .
.
CT chest [ * * 5 - 1 * * ] :
.
IMPRESSION :
1 . finding consistent multifocal pneumonia without
evidence
cavitation . partial right middle leave low lobe atelectasis
small
bilateral pleural effusion .
2 . boarderline enlarge mediastinal lymph node , likely reactive
nature .
3 . 2.6 - cm benign - appear leave adrenal lesion .
.
CXR [ * * 5 - 2 * * ] -
.
since yesterday , right mid low lung opacity increase .
leave upper
mid lung opacity also increase , worrisome rapidly
progress
multifocal pneumonia , could Legionella . small leave pleural
effusion also
increase . tiny right pleural effusion unchanged .
cardiomediastinal
silhouette hilar contour otherwise normal
.
ECHO [ * * 2166 - 5 - 5 * * ] :
.
left atrium right atrium normal cavity size .
estimate right atrial pressure 0 - 5 mmHg . leave ventricular
wall thickness , cavity size regional / global systolic
function normal ( LVEF > 55 % ) . estimate cardiac index
normal ( > = 2.5l / min / m2 ) . right ventricular chamber size free
wall motion normal . diameter aorta sinus
arch level normal . aortic valve leaflet ( ? # ) appear
structurally normal good leaflet excursion . masse
vegetation see aortic valve , fully
exclude due suboptimal image quality . mitral valve
appear structurally normal trivial mitral regurgitation .
mitral valve prolapse . pulmonary artery systolic
pressure could determine . pericardial
effusion .
IMPRESSION : suboptimal image quality . valvular pathology
pathologic flow identify .
.
CXR [ * * 5 - 5 * * ] : impression : right upper right middle lobe
pneumonia , significantly
change . small right pleural effusion .
.
CT chest [ * * 2166 - 5 - 6 * * ]
.
IMPRESSION :
1 . consolidation left lung almost completely
resolve .
2 . consolidation right middle lobe right upper lobe
new
area cavitation present .
3 . unchanged leave adrenal lesion .
4 . persistent slight decrease small effusion , great
right side .
Brief Hospital Course :
65 y.o . female PMHx significant COPD esophageal
stricture , / p dilatation [ * * Month ( ) 404 * * ] present
multifocal Streptococcal PNA , sepsis .
.
brief ICU course :
.
diagnose w/ PNA via CT w/ S. pneumococcal
bacteremia ( [ * * 2 - 19 * * ] BCx [ * * 4 - 30 * * ] ) . start IV CFTX
Levaquine . BCx negative since start CFTx
Levofloxacin , persistent WBC count low grade
fever . treat w/ ABx , last fever
note [ * * 5 - 1 * * ] 101F prior transfer floor ,
low grade 100 fever since admission . oxygen
requirement improve 4L NC RR decrease 18 - 22 .
Pt . also note microcytic anemia unclear
etiology , nadir HCT 18 , transfuse 2 u prbc
since hd stable w/ HCT mid 20 . finally , patient
tachycardic 100s - 110s , sinus rhythm . feel
due sepsis . transfer medical floor
management .
.
course complicate worsen WBC fever
medical floor rml consolidation develop cavitation ,
multiple loose stool . please see detailed
discussion problem .
.
# PNA s.pneumo Sepsis . infiltrate feel due
CAP resultant bacteremia ( strep pneumo ) . Pt . persistent
leukocytosis . aspiration note video
swallow , however note penetration thin
liquid . continue CFTX floor . however ,
[ * * 5 - 6 * * ] , develop Fever , increase O2 requirement .
panculture CT repeat show improve L
consolidation , slight improvement right new air
loculation . due concern empyema ( staph strep ) ,
ABx regiman broaden Vancomycin Zosyn treatment
HAP Aspiration PNA . Patient remain HD stable . due
wheezing exam , start stand ipratropium
albuterol nebulizer . treatment , WBC continue
improve , O2 requirement resolve . episode
fever [ * * 5 - 6 * * ] 101.3F. CT chest obtain show
improve infiltrate l r , newe air loculation .
broaden Vanco / Zosyn one day defervesce prior
ABx administer . Pulmonary team consult
regardge bronchoscopy , decide face
clinical improvement likelyhood cavitation [ * * 1 - 20 * * ]
Strep Pneumo and/or anaerobe ( short course Staph
develop cavitation < 24hrs VAP ) .
switch Cefpodoxime PO Flagyl po 2 week ( day 1 =
[ * * 5 - 8 * * ] , pt already receive 7 day either CFTX / Levofloxacin
Vanc / Zosyn ) total course 3 week . require
follow CXR end 2 week ( last day [ * * 2166 - 5 - 22 * * ] ) . PCP
follow arrange [ * * 5 - 19 * * ] . please fax summary
rehab course note pcp office prior discharge .
require weaning nebulizer restart home advair
start tiotropium COPD .
.
# leukocytosis : likely reactive pulmonary infection vs.
C.diff . patient loose stool ABx > 5d prior
onset diarrhea . give high grade bacteremia new
murmur , TTE obtain show vegetation .
first C.Diff negative tx empiricaly PO
Vanco give persistently loose stool Age > 65 . UA / ucx
negative . C.Diff retunre negative x3 PO vanco
discontinue [ * * 5 - 8 * * ] 2 day tx . start Flagyl
. remain afebrile since [ * * 5 - 5 * * ] WBC 11
day discharge . persistent [ * * last Name ( un ) 940 * * ] stool , low
frequency , 5 - > 3 / day .
.
# Anemia , microcytic . Hct baseline , 29 - 30 . currently HCT
23 - 25 , admission / p 2U PRBCs . Pt . hx iron
deficiency anemia , confirm lab [ * * 2162 * * ] . previously
iron stop unclear reason . colonoscopy
system , patient history UGI bleed , last egd
unremarkable . Guaiac negative ED . sign
hemolysis . Anemia feel multifactorial ( ACD , Fe
defficiency ) . per discussio w/ PCP , [ * * last Name ( namepattern4 ) * * ] . [ * * Doctor First Name 111639 * * ] ,
report colonoscopy reveal 12 cm
colitis , show acute chronic inflammation , ?
chronic ischemia . HCT upon discharge 25 stable .
require repeat outpatient colonoscopy endoscopy .
.
# Elevated Troponin : setting renal failure normal
ekg asymptomatic . troponin trend ,
CK elevation . likely due demand . sign HF , EF > 60 % ,
wma . continue ASA 81 mg .
.
# PTST / Depression : Contact[**Name ( NI ) * * ] patient 's outpatient provider
confirm diagnosis ptsd Depression . Patient
actively obtain treatment op prior admission .
two episode emotional lability cry spell .
attention impair ( feel due delerium setting
infection ) . Patient probably underlie dementia ( global
parenchymal atrophy periventricular white matter disease
CT head ) , however could evaluate setting
delirium . continue Celexa , Quetiapine
Duloxetine home dose . ativan temporarily hold due
delerium restart 2 mg [ * * hospital1 * * ] . home dose 2 mg
[ * * hospital1 * * ] 4 mg qhs , restart prn pt remain
stable .
.
# / P fall : appear multifactorial - decrease vision ,
non - compliance walker , complicate oxygen tubing
tripping likely acutely worsen setting impending
infection prior admission . CT head c - spine without
bleeding fracture . per PT require acute level
rehabilitation .
.
# poor nutritional status . Pt . deny poor po intake ,
Albumin 2.4 . note poor po intake nursing staff
CCU . hx esophageal stricture . start Ensure
supplementation TID .
.
# Code : full ( confirm patient )
.
# communication : Patient currently odd child
would prefer communication do SW - [ * * First Name8 ( NamePattern2 ) 51796 * * ]
[ * * last Name ( NamePattern1 ) 111640 * * ] [ * * Street Address(2 ) 111641 * * ] [ * * location 17065 * * ] . counseling
SW report history domestic violence
past . currently feel safe . allow staff
speak son . finally , Pt report
process evict , state want
family know . say case manager Elder Services
help deal eviction problem , consent sw
call ( Anjale [ * * first Name9 ( NamePattern2 ) 111642 * * ] [ * * hospital1 8 * * ] [ * * Hospital1 3494 * * ] elder Services
[ * * telephone / Fax ( 1 ) 16681 * * ] ) .
medication admission :
1 . combivent
2 . citalopram 40 mg PO QD
3 . advair 250 - 50 mcg [ * * hospital1 * * ]
4 . lorazepam 2 mg PO QID 4 mg qhs
5 . pantoprazole 40 mg PO BID
6 . Quetiapine 300 mg po QHS 200 mg QPM .
7 . duloxetine 30 mg po QHS
8 . Albuterol PRN
9 . Mesalamine ( OMR , patient can not recall still take )
10 . ondansetron 4 mg PO Q8 PRN
11 . aspirin 325 mg
Discharge medication :
1 . citalopram 20 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ) .
2 . Fluticasone - Salmeterol 250 - 50 mcg / Dose Disk Device Sig :
one ( 1 ) puff Inhalation [ * * hospital1 * * ] ( 2 time day ) .
3 . Quetiapine 300 mg Tablet Sustained Release 24 hr Sig : one ( 1 )
Tablet Sustained Release 24 hr po HS ( bedtime ) .
4 . Quetiapine 100 mg Tablet Sig : one ( 1 ) Tablet PO QPM need
insomnia .
5 . duloxetine 30 mg Capsule , Delayed Release(E.C. ) Sig : one ( 1 )
Capsule , Delayed Release(E.C. ) PO HS ( bedtime ) .
6 . Albuterol Sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) Inhalation Q6H ( every 6 hour )
need SOB / wheezing .
7 . ferrous Sulfate 325 mg ( 65 mg Iron ) Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) .
8 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) po twice day .
9 . lorazepam 1 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
10 . Ativan 2 mg Tablet Sig : 1 - 2 tablet po bedtime need
insomnia , anxiety : hold sedation .
11 . aspirin 81 mg Tablet , Chewable Sig : one ( 1 ) Tablet , Chewable
po DAILY ( Daily ) .
12 . oxycodone 5 mg Tablet Sig : one ( 1 ) Tablet po Q4H ( every 4
hour ) need Pain .
13 . Heparin ( Porcine ) 5,000 unit / mL Solution Sig : one ( 1 )
Injection TID ( 3 time day ) .
14 . Cefpodoxime 100 mg Tablet Sig : two ( 2 ) Tablet po Q12H ( every
12 hour ) 2 week .
15 . metronidazole 500 mg Tablet Sig : one ( 1 ) Tablet PO Q8H
( every 8 hour ) 2 week .
16 . Acetaminophen 500 mg Tablet Sig : 1.5 tablet po Q6H ( every 6
hour ) need pain .
17 . Tiotropium Bromide 18 mcg Capsule , w / Inhalation Device Sig :
one ( 1 ) Cap Inhalation DAILY ( Daily ) .
18 . outpatient Lab Work
CBC , Chem 10 within 1 week discharge hospital
19 . Imaging
Patient require CXR completion ABx result
fax PCP 's office confirm resolution PNA .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital 2251 * * ] Nursing Rehab
discharge diagnosis :
primary : streptococcal sepsis , multifocal community acquire
pneumonia
secondary : COPD , PUD , esophageal stricture , Anemia , PTSD
Discharge condition :
stable
Discharge instruction :
admit [ * * Hospital1 18 * * ] severe pneumonia bacterial
blood . treat intravenous
antibiotic . treatment breathing improve .
transition mouth antibiotic .
course complicate worsen anemia ( low blood cell
count ) require blood transfusion . transfusion ,
blood level remain stable . require
outpatient colonoscopy endoscopy .
several change make medication , please refer
list take medication prescribe .
outpatient colonoscopy evaluate
anemia . PCP gi doctor arrange .
please call doctor return near emergency room
: recurrent nausea / vomiting , dehydration , blood
vomit , chest pain , bloody stool , shortness breath , chest
pain , abdominal pain ,
fainting , fever , chill , cough , concern
symptom .
Followup Instructions :
Provider : [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 1982 * * ] , MD phone:[**telephone / fax ( 1 ) 463 * * ]
Date / time:[**2166 - 9 - 22 * * ] 12:30
Provider : [ * * Name10 ( NameIs ) * * ] [ * * apartment address(1 ) * * ] ( ST-3 ) GI ROOMS Date / time:[**2166 - 9 - 22 * * ] 12:30
please follow psychiatrist , Dr. [ * * First Name ( STitle ) * * ] [ * * first Name9 ( NamePattern2 ) 111643 * * ]
[ * * 2168 - 5 - 27**].30 , please call confirm appointment ,
[ * * telephone / Fax ( 1 ) 111644 * * ] .
please follow primary care doctor , [ * * first name5 ( NamePattern1 ) * * ]
[ * * last Name ( NamePattern1 ) * * ] -[**doctor First Name * * ] , [ * * 2166 - 5 - 19 * * ] 11.30 . please call
[ * * telephone / Fax ( 1 ) 14315 * * ] confirm appointment .
rehabilitation time pcp appointment , please change
acommodate discharge rehabilitation .
[ * * first name5 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] MD [ * * MD Number(2 ) 617 * * ]
complete by:[**2166 - 5 - 9 * * ]
|
[
"5849",
"496",
"2859"
] |
Admission Date : [ * * 2198 - 9 - 7 * * ] Discharge Date : [ * * 2198 - 9 - 11 * * ]
Date Birth : [ * * 2117 - 12 - 20 * * ] sex : F
Service : MEDICINE
allergy :
Codeine / Penicillins / Erythromycin Base / Morphine
attending:[**first Name3 ( LF ) 800 * * ]
Chief Complaint :
hypotension / p syncope
Major Surgical Invasive Procedure :
none
history Present Illness :
80 year old woman history COPD , HTN , CRI present
syncope hypotension . report recent past
5 day whitish phlegm turn green 1 day prior
admission . deny fever , chill night sweat . accord
patient awake morning sound someone
knock door phone ringing . go get
slide bed floor . deny hit head
lose consciousness . state leg give .
report leg give 2 time past .
deny dizziness , lightheadedness , palpitation . accord
daughter find concierge home
floor vomit urine fall witness .
deny lose urine recall vomit . EMS
call . initial vital EMS BP 120/70 O2 sat 95 %
NRB .
.
ED , initial vs : T97.4 HR77 bp71/31 RR20 o2sat 93
4L NC . Patient give 4L NS resuscitation . fast scan
do show 3.8 cm AAA . give aaa hypotension ,
vascular surgery consult call . undergo non - contrast
CT torso show LLL infiltrate . vascular surgery
concerned AAA . give 1gm CTX , 750 mg
Levofloxacin 500 mg Flagyl . blood pressure improve
mid-90 start trend . r femoral CVL
place start Levophed . Lactate 2.2 .
find acute renal failure creatinine 2.6 .
Potassium 5.6 . WBC 19.1 13 % band . INR
note 4.3 . blood culture obtain .
.
arrival ICU complain cough without significant
shortness breath . otherwise comfortable without pain .
deny nausea , headache , chest pain , dysuria . pressor
wean , patient transfer floor
afebrile .
.
Review sytem :
( + ) diarrhea past week . report diarrhea
lifetime .
( - ) Denies fever , chill , night sweat , recent weight loss
gain . Denies headache , sinus tenderness , rhinorrhea
congestion . deny chest pain tightness , palpitation . deny
nausea , vomiting , diarrhea , constipation abdominal pain .
recent change bowel bladder habit . dysuria . deny
arthralgia myalgia .
Past Medical History :
- Pulmonary Embolism [ * * 2 - 25 * * ] coumadin
- Hypertension
- Hypercholesterolemia
- monoclonal gammopathy
- COPD
- Arthritis
- gastrointestinal ulcer
- gastric esophageal reflux disease
- Kidney stone 55 year ago setting pregnancy
- Elevated PTH
- chronic renal insufficiency baseline 1.1 1.5
- abdominal aortic aneurysm measure 4.2 cm
- possible pon lacune infart note [ * * 1 - 24 * * ] MR [ * * Name13 ( STitle ) 2853 * * ]
- Peripheral Neuropathy unclear etiology
Social History :
patient live alone . divorced former husband
deceased . five child . previously work
laboratory technician [ * * Location ( un ) 86 * * ] State Hospital office
manager . 50 pack year smoking history quit great
25 year ago . drink [ * * 2 - 17 * * ] glass wine per day .
deny use illicit drug .
Family history :
patient 's mother die myocardial infarction age
60 . mother hyperthyroidism . patient 's father
myocardial infarction age [ * * age 90 * * ] benign brain tumor .
sister breast cancer . daughter juvenile
rheumatoid arthritis . family history gastric
disorder kidney stone .
Physical Exam :
vital : : 98.4 bp : 118/80 p : 81 r : 18 O2 : 93 % RA
General : Alert , oriented , elderly female , acute distress
HEENT : Sclera anicteric , MMM , oropharynx clear
Neck : supple , JVP flat , LAD
lung : decrease breath sound left side , otherwise clear
CV : regular rate rhythm , normal S1 + S2 , 2/6 systolic
ejection murmur LUSB
Abdomen : soft , non - tender , non - distended , bowel sound present ,
rebound tenderness guarding , organomegaly
GU : foley
Ext : warm , well perfuse , 2 + pulse , club , cyanosis , 1 +
peripheral edema bilaterally , former site femoral catheter
( withdraw ) right C / /
Neuro : A&O x 3 , CNII - XII grossly intact .
pertinent result :
Labs
admission :
[ * * 2198 - 9 - 7 * * ] 07:31PM URINE COLOR - Yellow APPEAR - Clear SP [ * * last Name ( un ) 155**]-1.015
[ * * 2198 - 9 - 7 * * ] 07:31PM URINE blood - NEG NITRITE - NEG protein - NEG
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-5.0
LEUK - SM
[ * * 2198 - 9 - 7 * * ] 07:31PM URINE RBC-0 - 2 WBC-[**7 - 26 * * ] * BACTERIA - MOD
yeast - none EPI-0 - 2
[ * * 2198 - 9 - 7 * * ] 06:30PM URINE hours - RANDOM creat-96 sodium-27
potassium-98 CHLORIDE-62
[ * * 2198 - 9 - 7 * * ] 06:30PM URINE OSMOLAL-440
[ * * 2198 - 9 - 7 * * ] 03:51PM K+-5.6 *
[ * * 2198 - 9 - 7 * * ] 12:42pm lactate-2.2 *
[ * * 2198 - 9 - 7 * * ] 12:20pm glucose-144 * UREA N-49 * CREAT-2.6 * #
sodium-137 POTASSIUM-7.0 * chloride-105 TOTAL CO2 - 25 anion gap-14
[ * * 2198 - 9 - 7 * * ] 12:20pm estGFR - use
[ * * 2198 - 9 - 7 * * ] 12:20pm ALT(SGPT)-47 * AST(SGOT)-69 * ALK PHOS-65 TOT
BILI-0.3
[ * * 2198 - 9 - 7 * * ] 12:20pm lipase-18
[ * * 2198 - 9 - 7 * * ] 12:20pm cTropnT-<0.01
[ * * 2198 - 9 - 7 * * ] 12:20pm ALBUMIN-3.4 *
[ * * 2198 - 9 - 7 * * ] 12:20pm WBC-19.1 * # RBC-3.84 * HGB-10.9 * HCT-33.2 *
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7
[ * * 2198 - 9 - 7 * * ] 12:20pm NEUTS-81 * BANDS-13 * LYMPHS-1 * MONOS-4 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[ * * 2198 - 9 - 7 * * ] 12:20pm HYPOCHROM - NORMAL ANISOCYT - NORMAL
POIKILOCY - NORMAL MACROCYT - NORMAL MICROCYT - NORMAL
POLYCHROM - NORMAL
[ * * 2198 - 9 - 7 * * ] 12:20pm PLT SMR - NORMAL PLT COUNT-248
[ * * 2198 - 9 - 7 * * ] 12:20pm PT-40.5 * PTT-41.4 * INR(PT)-4.3 *
Discharge :
[ * * 2198 - 9 - 11 * * ] 05:15am blood WBC-9.2 RBC-3.56 * Hgb-10.0 * Hct-29.9 *
MCV-84 MCH-28.1 mchc-33.5 RDW-14.3 Plt ct-260
[ * * 2198 - 9 - 11 * * ] 05:15am blood Glucose-103 * UreaN-18 Creat-1.0 Na-138
K-4.0 Cl-103 HCO3 - 29 angap-10
[ * * 2198 - 9 - 11 * * ] 05:15am blood ALT-31 AST-17
[ * * 2198 - 9 - 11 * * ] 05:15am blood Calcium-9.4 Phos-3.2 Mg-1.4 *
radiology :
CHEST ( portable AP ) Study Date [ * * 2198 - 9 - 7 * * ] 12:18 pm
impression : mild central vascular congestion without overt
failure .
Bibasilar atelectasis . increase opacity retrocardiac
leave low lobe may reflect underlie pneumonia aspiration .
correlate clinically .
CT CHEST W / CONTRAST Study Date [ * * 2198 - 9 - 7 * * ] 12:34 pm
lung basis : consolidation ground - glass
opacification
superior segment left low lobe , well portion
posterior basal segment right low lobe .
CT HEAD W / CONTRAST Study Date [ * * 2198 - 9 - 7 * * ] 12:33 pm
impression : acute intracranial process .
CT ABDOMEN W / CONTRAST Study Date [ * * 2198 - 9 - 7 * * ] 12:34 pm
impression :
1 . evidence rupture patient 's 3.8 - cm abdominal
aortic aneurysm . stability size maintain .
2 . area density within left breast lucent center ,
may
represent intramammary lymph node , fat necrosis , oil cyst .
recommend
correlation mammogram .
3 . stable appearance adrenal nodule 5 year , describe
.
4 . status post cholecystectomy , stable expect
dilatation
common bile duct .
5 . diverticulosis evidence diverticulitis .
US ABD LIMIT , single organ PORT Study Date [ * * 2198 - 9 - 8 * * ] 1:54 pm
impression : stable common bile duct approximately 9 mm .
liver
echotexture normal underlying suggestion
cirrhosis
parenchymal disease . mass lesion identify .
intrahepatic biliary dilatation . interval
development
small right pleural effusion . know abdominal aortic aneurysm
stable
size since yesterday .
BILAT EXT VEINS US Study Date [ * * 2198 - 9 - 8 * * ] 1:54 pm
impression : dvt either upper extremity .
Brief Hospital Course :
80 year old woman hx PE coumadin , HTN present
syncope , hypotension likely PNA concern sepsis .
.
1 . hypotension : likely sepsis give chest CT finding
PNA , elevate WBC cough . fever . receive
4L NS ed continue appear clinically dry . volume
resuscitation continue MICU along levophe
wean 24 hour . PNA treatment begin
ceftriaxone levofloxacin , later switch
cefpodoxime levofloaxin , total 8 day course .
Patient 's blood pressure floor normotensive , although
continue hold home medication HCTZ , Amlodipine ,
Benzepril , discharge instruction follow -
PCP resume medication .
.
2 . Acute Renal Failure : prior kidney function 1.2 . patient make
good urine throughout hospitalization . creatinine peak
2.6 trend nadir 1 upon discharge
volume resuscitation hold nephrotoxic med .
3 . UTI : [ * * 2198 - 9 - 7 * * ] , patient note UTI urine
culture E. Coli , sensitive ceftriaxone .
patient treat PNA ceftriaxone
levofloxacin , change antibiotic regimen ,
appropriately cover uncomplicated UTI .
.
3 . hyperkalemia : feel secondary acute renal failure
setting take potassium triamterene benazepril .
ECG without peaked wave . offend med hold
hospitalization , hold patient follow -
primary care physician . [ * * Name10 ( NameIs ) * * ] patient 's hyperkalemia improve
aggressive IV fluid resusitation , discharge K
4.0 .
.
4 . syncope : likely hypotension , hypovolemia .
concern patient lose urine sign
seizure activity stay MICU floor .
patient monitor tele without event . EEG
do .
.
5 . elevate INR : likely due infection coumadin use .
sign active bleeding . would expect INR rise recent
antibiotic . Coumadin initially hold restart
prior discharge , INR discharge 2.7 .
.
Code : full ( discuss patient )
medication admission :
hydrochlorothiazide 25 mg Tab PO daily
Bisoprolol Fumarate 2.5 mg Tab PO daily
Omeprazole 40 mg Cap , Delayed Release 1 tab PO Daily
Klor - Con 8 meq Tab 1 tab po BID
Amlodipine 5 mg Tab 1 tab po daily
Benazepril 40 mg Tab PO daily
Multivitamin Tab 1 tab po daily
Triamterene 50 mg PO daily
Simvastatin 80 mg PO daily
Trazadone 100 - 150 mg po qhs PRN - take past
day perhaps monday , tuesday wednesday
Coumadin alternate 1.5 mg 2 mg week
Gabapentin 100 mg PO TID
discharge disposition :
home
discharge Diagnosis :
Primary Diagnosis :
sepsis secondary Community Acquired Pneumonia
Urinary Tract infection
.
secondary diagnosis :
Hx Pulmonary Embolism
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
admit ICU low blood pressure
setting pneumonia . treat IV fluid
antibiotic symptom improve . complete
total 8 day antibiotic , follow - PCP .
.
make follow change home medication :
-start cefpodoxime - continue 6 day end [ * * 2198 - 9 - 16 * * ]
-start Levofloxacin - continue 6 day end [ * * 2198 - 9 - 16 * * ]
( every - - day medication ) .
-STOP hydrochlorothiazide , Amlodipine , Benazepril , Triamterene
Klor - Con see PCP [ * * Name9 ( PRE ) 2974 * * ] . decide
resume medication .
-CHANGE Coumadin 1.5 Mg daily week - please
INR draw tomorrow , Wednesday 28th PCP 's
office .
Followup Instructions :
please INR draw tomorrow PCP 's office .
appointment see PCP [ * * Name9 ( PRE ) 2974 * * ] :
name : [ * * last Name ( LF ) 7726**],[**first name3 ( LF ) 177 * * ] a.
: FRIDAY , [ * * 2198 - 9 - 14**]:30
Address : [ * * Street Address(2 ) 7727**],2nd fl , [ * * Location ( un ) * * ] , [ * * Numeric Identifier 809 * * ]
phone : [ * * telephone / Fax ( 1 ) 7728 * * ]
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern4 ) 810 * * ] MD , [ * * MD Number(3 ) 811 * * ]
|
[
"0389",
"5849",
"486",
"5990",
"5859",
"2767",
"496",
"2720"
] |
Admission Date : [ * * 2117 - 7 - 22 * * ] Discharge Date : [ * * 2117 - 7 - 31 * * ]
Date Birth : [ * * 2036 - 6 - 4 * * ] sex : F
Service : MEDICINE
allergy :
Sulfa ( Sulfonamides )
attending:[**first Name3 ( LF ) 943 * * ]
Chief Complaint :
nausea , vomiting , abdominal pain
Major Surgical Invasive Procedure :
EGD
central venous line access
history Present Illness :
81 year old female present outside
hospital 3 week prior admission nausea , vomiting ,
diarrhea , abdominal pain . diagnose cirrhosis
unknown etiology ; negative hepatitis ,
hemachromatosis , history alcoholism . symptom
improve discharge . present [ * * Hospital1 18 * * ]
similar symptom . CT scan abdoman demonstrate complete
thrombosis SMV partial thrombosis main pv
intrahepatic left right portal vein multiple abnormal
loop small bowel pelvis wall thickening .
Patient start heparin drip . Foley & NGT place .
receive vancomycin & Zosyn ED , switch
Cipro Flagyl admission ICU .
Past Medical history :
hypertension
cirrhosis
osteoarthritis
dyslipidemia
h / ureteral stone
seborrheic keratosis
thrombocytopenia
appendectomy
herpe zoster
GERD
osteopenia
depression
hip replacement
cellulitis
Social History :
deny EtOH , tobacco , illicit drug use . deny
herbal - - counter medication .
Family history :
aunt ovarian ca
daughter breast ca 50
family history liver disease
Physical Exam :
per Dr. [ * * last Name ( STitle ) * * ] initial presentation :
98.1 65 145/61 20 98 % 4L
gen : minimally response
cv rrr
pulm : CTAB
abd : soft , nondistended , mildley tender right
rectal : heme pos
pertinent result :
admission lab :
137 105 15
------------- < 117
3.7 21 0.7
Ca : 9.4 Mg : 1.7 p : 2.6
ALT : 25 AP : 271 Tbili : 2.0 Alb : 3.2
AST : 32 LDH : Dbili : TProt :
[ * * Doctor First Name * * ] : 52 lip : 54
.
12.9
9.9 > ----- < 165
41
N:85.3 Band:0 L:9.7 M:3.7 e:0.9 Bas:0.4
.
trend discharge lab :
[ * * 2117 - 7 - 31 * * ] 06:45AM blood wbc-5.7 RBC-3.16 * Hgb-10.1 * Hct-30.7 *
MCV-97 MCH-32.0 mchc-32.9 RDW-16.2 * Plt Ct - PND
[ * * 2117 - 7 - 26 * * ] 05:06AM blood pt-19.5 * PTT-67.8 * INR(PT)-1.9 *
[ * * 2117 - 7 - 27 * * ] 06:00AM blood pt-21.1 * ptt-62.3 * INR(PT)-2.0 *
[ * * 2117 - 7 - 28 * * ] 05:21am blood PT-21.5 * PTT-93.3 * INR(PT)-2.1 *
[ * * 2117 - 7 - 29 * * ] 05:03AM blood pt-20.7 * PTT-33.5 INR(PT)-2.0 *
[ * * 2117 - 7 - 30 * * ] 06:15AM blood pt-20.6 * PTT-33.0 INR(PT)-2.0 *
[ * * 2117 - 7 - 31 * * ] 06:45am blood Glucose-90 UreaN-13 creat-0.8 na-134
K-3.4 Cl-98 HCO3 - 33 * AnGap-6 *
[ * * 2117 - 7 - 22 * * ] 06:05am blood alt-25 AST-32 AlkPhos-271 * Amylase-52
TotBili-2.0 *
[ * * 2117 - 7 - 23 * * ] 02:15am blood ALT-17 AST-26 LD(LDH)-231 AlkPhos-193 *
Amylase-36 totbili-0.8
[ * * 2117 - 7 - 24 * * ] 01:57AM blood ALT-17 AST-21 LD(LDH)-202 alkphos-171 *
Amylase-28 TotBili-0.6
[ * * 2117 - 7 - 25 * * ] 05:30AM blood ALT-15 AST-21 LD(LDH)-191 AlkPhos-164 *
Amylase-27 TotBili-0.7
[ * * 2117 - 7 - 26 * * ] 05:06AM blood ALT-15 AST-25 AlkPhos-159 * Amylase-46
totbili-0.8
[ * * 2117 - 7 - 27 * * ] 06:00AM blood alt-13 AST-26 LD(LDH)-213 AlkPhos-151 *
Amylase-45 TotBili-0.8
[ * * 2117 - 7 - 28 * * ] 05:21am blood ALT-16 AST-31 AlkPhos-156 * TotBili-1.0
[ * * 2117 - 7 - 29 * * ] 05:03AM blood ALT-15 AST-34 alkphos-179 * totbili-0.8
[ * * 2117 - 7 - 27 * * ] 06:00AM blood albumin-2.1 * Calcium-7.9 * phos-2.8 mg-2.1
[ * * 2117 - 7 - 24 * * ] 06:21am blood lactate-1.4
.
CT Abd / Pelvis ( [ * * 2117 - 7 - 22 * * ] )
IMPRESSION :
1 . complete thrombosis superior mesenteric vein
partial thrombosis main portal vein intrahepatic left
right portal vein .
2 . multiple abnormal loop small bowel within pelvis
wall thickening . likely represent venous congestion
thrombosis mesenteric vein . enterocolitis
( inflammatory / infectious ) secondary thrombosis
mesenteric vein also possibility . mesenteric artery
patent ; however , mesenteric ischemia venous congestion
exclude .
3 . Shrunken , nodular liver , esophageal varix ascite ,
compatible cirrhosis .
.
CT Abd / Pelvis ( [ * * 2117 - 7 - 27 * * ] )
IMPRESSION :
1 . stable thrombosis portal vasculature include partial
thrombosis main portal vein , complete thrombosis
leave portal vein , partial thrombosis right portal vein ,
complete thrombosis superior mesenteric vein .
2 . improve multiple small bowel loop decrease wall
thickening dilatation .
3 . stable cirrhotic liver .
4 . markedly increase ascite .
.
EGD :
impression : Grade 1 varix low third esophagus
Portal Hypertensive Gastropathy - ooze blood cause
melena .
otherwise normal egd second part duodenum
recommendation : require :
1 ) Protonix- 40 mg [ * * hospital1 * * ]
2 ) Carafate - 1gram qid
.
Micro :
c diff neg
stool cx neg
blood cx ngtd
Brief Hospital Course :
81yo woman cirrhosis SMV thrombosis . hospital
course problem :
.
# complete smv partial portal vein thrombosis .
SMV portal vein thrombose demonstrate CT [ * * 7 - 22 * * ]
repeat [ * * 7 - 27 * * ] show little change . Hepatobiliary
Surgery consult urgently ed management SMV
thrombosis ischemic bowel . serial abdominal exam
benign . Lactate peak 1.5 [ * * 7 - 22 * * ] . episode
melena [ * * 7 - 17 * * ] , remain otherwise asymptomatic .
ICU close monitoring transfer floor
[ * * 7 - 25 * * ] . NGT remove Coumadin start . [ * * 7 - 26 * * ] ,
diet advanced transfer Hepatology
management newly diagnose cirrhosis . continue
heparin coumadin INR 2.0 two consecutive day .
receive coumadin follow : 1 mg , 1 mg , 1 mg , 2 mg , 2 mg , 2 mg
discharge 2 mg daily . HCT remain stable .
followup Dr. [ * * last Name ( STitle ) * * ] liver clinic . [ * * last Name ( STitle ) 18303 * * ] INR [ * * 2 - 20 * * ] .
.
# GI Bleeding
Patient guaiac positive stool undergo egd
assess varix show active bleeding
portal gastropathy think explain patient 's
melena . Melena may also come venous congestion
small bowel result SMV thrombosis . Repeat CT scan
show resolve venous congestion . HCT drop 5.5 point
41 34.5 HD0 HD1 30 HD4 , remain
stable , without melena . Ms. [ * * know lastname 73649 * * ]
spot red blood pad toilet paper think
cause persistant guaiac positive stool . Exam confirm
presence hemorrhoid also raise possibility
vaginal bleeding , investigate outpatient .
Colonoscopy defer give likely friable colon set
thrombosis . BRBPR , recommend check hematocrit
[ * * know lastname * * ] > 28 . less 28 , discuss patient 's PCP
stop coumadin need eval . term possible
vaginal bleeding , recommend outpt gynecology appt .
continue nadolol PPI sucralfate .
.
# Cirrhosis / Edema / abdominal pain
Etiology cirrhosis remain uncertain . Report
investigation OSH rule common viral autoimmune
etiology , genetic cause would unlikely present
81year age . nash remain possibility ,
investigate outpatient hepatology follow
arrange Ms. [ * * know lastname 73649 * * ] .
experience significant fluid retention ascite
low extremity edema , weight increase approximately 4kgs .
Lasix Aldactone , low extremity edema improve
significantly ascite persistant .
Ascites cause intermittent band like upper abdominal pain
mostly control oxycodone occassionally
require 0.5 mg dilaudid IV . time discharge , pain
control oral medication alone .
.
# HTN : regulate nadolol , spirono , lasix .
continue HCTZ
.
# Depression : sertraline
.
# activity : see PT . able ambulate assist .
.
# Code : full
.
# Contact : daughter [ * * Name ( NI ) * * ] : [ * * telephone / Fax ( 1 ) 100371 * * ]
medication Admission :
lorazepam , Darvocet , Fosamax , HCTZ , MVI , Propoxyphene ,
ranitidine , sertraline , Zocor
Discharge medication :
1 . spironolactone 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
2 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
3 . Nadolol 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q12H ( every 12 hour ) .
Disp:*60 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
5 . sertraline 50 mg Tablet Sig : 0.5 Tablet PO DAILY ( Daily ) .
6 . Sucralfate 1 g Tablet Sig : one ( 1 ) Tablet PO QID ( 4 time
day ) .
disp:*120 Tablet(s ) * Refills:*2 *
7 . propoxyphene 65 mg Capsule Sig : one ( 1 ) Capsule po every six
( 6 ) hour need pain .
8 . oxycodone 5 mg Tablet Sig : 1 - 2 tablet po Q4H ( every 4 hour )
need Pain 1 week .
Disp:*20 Tablet(s ) * Refills:*0 *
9 . warfarin 1 mg Tablet Sig : two ( 2 ) Tablet PO HS ( bedtime ):
please adjust per recommendation PCP . [ * * Name10 ( NameIs ) 18303 * * ] INR [ * * 2 - 20 * * ] .
Disp:*60 Tablet(s ) * Refills:*2 *
discharge Disposition :
Extended Care
Facility :
[ * * hospital3 9475 * * ] Care Center - [ * * Location ( un ) 3146 * * ]
discharge diagnosis :
Primary :
- SMV thrombosis
- Cirrhosis
- portal gastropathy
secondary :
- GERD
- arthritis
- HTN
- Hyperchol
- thrombocytopenia
Discharge condition :
well . able ambulate assist
Discharge instruction :
admit abdominal pain note SMV
thrombosis . clot vein near liver .
also cirrhosis fluid overload . treat
ICU stabilize . continue heparin start
coumadin keep blood thin . also perform egd
look bleeding stomach . remain stable .
.
please take medication instruct . please keep
followup appt . important
coumadin level check Monday follow closely
PCP .
.
please contact PCP [ * * Name ( NI ) * * ] experience worsen
shortness breath , chest pain , abdominal pain , fever ,
blood loss .
.
describe possible vaginal bleeding .
discuss PCP possibly see gynecologist .
Followup Instructions :
please followup Dr. [ * * last Name ( STitle ) * * ] Thursday [ * * 8 - 5 * * ]
11:30am . office [ * * telephone / Fax ( 1 ) * * ]
.
please followup Dr. [ * * last Name ( STitle ) * * ] [ * * 8 - 24 * * ] @ 12:15pm .
may reach ( [ * * telephone / Fax ( 1 ) 1582 * * ] .
|
[
"5715",
"4019",
"311"
] |
Admission Date : [ * * 2165 - 8 - 2 * * ] Discharge Date : [ * * 2165 - 8 - 5 * * ]
Date Birth : [ * * 2098 - 2 - 18 * * ] sex :
Service : MED
allergy :
Patient record known allergy drug
Attending:[**Last Name ( NamePattern4 ) 290 * * ]
Chief Complaint :
Dark blood g - tube
Major Surgical Invasive Procedure :
egd - ulcer distal esophagus active bleeding . / p
clipping vessel good homostasis .
history Present Illness :
67 yo h / cad , recently admit [ * * 6 - 21 * * ] [ * * 7 - 25 * * ]
present severe headache , CT notable large
intracranial bleed . find vertebrobasilar aneurysm , / p
coiling stenting , ventriculostomy . course complicate L
side PE treat heparin . Hospital course also
complicate CHF , failure wean vent , / p trach , PEG
placment . Patient eventually wean vent end
hospitalization . discharge , patient able open eye
stimulation , spontaneous movment r side . Patient
discharge [ * * Month / Day ( 4 ) * * ] , plavix , heparin gtt . Pt . send
[ * * hospital3 * * ] . come ED [ * * 7 - 26 * * ] hypotension , sbp
80 , respond IV bolus , clear N-[**Doctor First Name * * ] ( change ) .
[ * * 8 - 1 * * ] , patient note 50 cc dark blood g - tube
rehab . ED , patient afebrile , hr-82 , bp-121/64 . Dark
blood fail clear lavage . GI subsequently
consult . ED , hct-30 , inr-2.9 . Got vit K 5 mg sq , IV
protonix , 4 unit FFP , 2 large [ * * last Name ( un ) * * ] iv place . CXR show CHF
opacity effusion . ekg show NSR 90 bpm , nl axis ,
IVCD L bundle pattern , 1-[**street Address(2 ) 1766 * * ] depr V3 - 6 ( old ) TWI
V3 - 6 , l ( old ) .
Past Medical history :
-CAD , / p MI , CABG x 2 ' [ * * 50 * * ] ' [ * * 62 * * ] , multiple stent
-htn
-s / p MV annuloplasty ' [ * * 62 * * ]
-s / p AICD
-s / p intracranial bleed [ * * 5 - 28 * * ] , per hpi
-mult L side pes ( [ * * 6 - 28 * * ] )
-h / hyponatremia
-VRE pos
-CHF - [ * * 6 - 28 * * ] echo EF 30 % , moderate regional LV systolic
dysfunction near AK inferior inferolateral wall ,
sever HK anterolat . wall .
Physical Exam :
97.6 BP 121/64 P82 RR30 100 % 4lnc
Gen : minimally resonsive , unable follow command
HEENT : NC / , PERRL 2 mm bilaterally
lung : + upper airway sound , crackle , wheezing , good air
movement
CV : RRR , nl S1 , S2 , murmurs
Abd : soft , NTND , withdraw deep palpation . + g - tube
Ext : edema , club , cyanosis
Neuro : respond minimally verbal stimulus , withdraw pain .
pertinent result :
[ * * 2165 - 8 - 5 * * ] 04:49am blood WBC-9.2 RBC-3.52 * Hgb-10.6 * hct-32.2 *
MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6 * Plt ct-400
[ * * 2165 - 8 - 4 * * ] 04:34PM blood Hct-34.2 *
[ * * 2165 - 8 - 3 * * ] 11:41pm blood hct-32.5 *
[ * * 2165 - 8 - 3 * * ] 04:00am blood wbc-10.0 rbc-3.51 * Hgb-10.6 * hct-31.5 *
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6 * Plt ct-379
[ * * 2165 - 8 - 2 * * ] 10:42pm blood hct-28.3 *
[ * * 2165 - 8 - 2 * * ] 08:13PM blood hct-29.2 *
[ * * 2165 - 8 - 2 * * ] 10:03am blood Hct-23.7 * #
[ * * 2165 - 8 - 5 * * ] 04:49am blood PT-14.7 * PTT-56.5 * INR(PT)-1.4
[ * * 2165 - 8 - 4 * * ] 08:16pm blood PTT-39.1 *
[ * * 2165 - 8 - 4 * * ] 04:32AM blood PT-14.7 * PTT-24.2 INR(PT)-1.4
[ * * 2165 - 8 - 3 * * ] 04:00am blood PT-15.2 * PTT-26.1 INR(PT)-1.5
[ * * 2165 - 8 - 2 * * ] 10:40AM blood PT-16.7 * PTT-30.1 INR(PT)-1.8
[ * * 2165 - 8 - 2 * * ] 04:15am blood pt-20.8 * PTT-37.0 * INR(PT)-2.9
[ * * 2165 - 8 - 5 * * ] 04:49am blood glucose-117 * UreaN-22 * Creat-0.4 * Na-143
k-3.9 Cl-108 HCO3 - 27 AnGap-12
[ * * 2165 - 8 - 2 * * ] 04:15am blood Glucose-113 * UreaN-26 * Creat-0.6 Na-133
K-5.3 * Cl-96 HCO3 - 29 angap-13
[ * * 2165 - 8 - 4 * * ] 04:32AM blood ALT-28 AST-30 AlkPhos-124 *
[ * * 2165 - 8 - 3 * * ] 06:45PM blood CK - mb-3 cTropnT-0.07 *
[ * * 2165 - 8 - 2 * * ] 10:43pm blood CK - MB-4 cTropnT-0.05 *
[ * * 2165 - 8 - 2 * * ] 04:00PM blood CK - MB-3 cTropnT-<0.01
Brief Hospital Course :
1)upper gi bleed : Patient coumadin recent hx PE
receive 4 unit FFP vit K EW correct
INR . Coumadin hold intinitally possible active bleed .
GI consult EGD do [ * * 2165 - 8 - 2 * * ] show
ulcer distal esophagus active bleeding
site . successful clipping vessel achieve use
Resolution Endoclip device inject epinephrine
hemostasis . Patient receive total 3 unit PRBC .
Patient continue PPI prophylaxis serial
hematocrit do remain stable ( Hct>30 ) .
2)Neuro : Patient hx intracranial bleed / p basilar
stent . Patient Plavix [ * * Date Range * * ] post - stent prophylaxis .
Patient remain lethargic baseline . able
follow simple command time , move hand foot
occasionally give verbal response . per family member ,
patient appear alert . Neurosurgery
follow patient strongly urge hold Coumadin
risk - bleeding intracranially . discussion
Dr. [ * * last Name ( STitle ) 1132 * * ] neurosurgery , decide discharge patient
Lovenox .
3)a - fib : EGD proceduse , clip bleed vessel
do epinephrine inject site . right
epinephrine inject , go rapid afib 150 's
ST depression . give total 10 mg lopressor
decrease hr 120's-130 's . 10 mg
IV diltiazem , hr come 90's-100 's bp
drop 80 's briefly . mi rule serial
cardiac enzyme give 25 mg lopressor . Patient
remain sinus tachycardia , lopressor titrate
50 mg tid . Patient show good response IV diltiazem 10
mg .
4)pe prophylaxis : patient initially Coumadin 12.5 mg qd
Dalteparin 7500 unit [ * * hospital1 * * ] , hold due GI bleed
INR 2.9 PTT 37 . Neurosurgery see patient strongly
discourage discontinue Coumadin due recent history
intracranial bleed . however , patient PE risk
another thrombotic event . discussion
neurosrugery attend Dr. [ * * last Name ( STitle ) 1132 * * ] , decide discharge
patient Lovenox .
5)id : [ * * 8 - 4 * * ] sputum gram stain show gram positive cooci
rhonchi exam . CXR intially appear LLL opacity
Vancomycin 1 g q12 start . however review
film team [ * * 2165 - 8 - 5 * * ] , CXR consistent
fluid overload effusion consolidation . since patient
afebrile normal WBC show symptom
pneumonia , Vancomycin discontinue .
medication admission :
protonix 40 qd , senna 2 [ * * hospital1 * * ] , epo [ * * 2161 * * ] unit q Tu / Sat , amantidine
100 [ * * hospital1 * * ] , coumadin 12.5 [ * * last Name ( LF ) * * ] , [ * * first Name3 ( LF ) * * ] 325 qd , lopresor 25 [ * * hospital1 * * ] ,
dalteparin 7500 unit [ * * hospital1 * * ]
Discharge medication :
1 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO QD ( day ) .
2 . Clopidogrel Bisulfate 75 mg Tablet Sig : one ( 1 ) Tablet PO QD
( day ) .
3 . Metoprolol Tartrate 50 mg Tablet Sig : one ( 1 ) Tablet PO TID
( 3 time day ) .
4 . Enoxaparin Sodium 80 mg/0.8 ml Syringe Sig : eighty ( 80 ) mg
Subcutaneous Q12H ( every 12 hour ) .
5 . Protonix 40 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) po twice day .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 85 * * ] - [ * * Location ( un ) 86 * * ]
discharge diagnosis :
Esophageal bleed
Atrial fib
Intracranial bleed / p stent vertebrobasilar aneurysm
Hx pulmonary embolism
CAD
CHF
discharge condition :
hemodynamically stable , active bleeding .
Discharge instruction :
Patient need seek medical attention ( ED , PCP ) ,
bloody vomit , bloody stool , blood g - tube , dyspnea , chest
pain , new neurological deficit , fever / chill .
Followup Instructions :
Patient need see PCP soon possible
appointment neurosurgery follow date .
Provider : [ * * Name10 ( NameIs ) * * ] [ * * last Name ( namepattern4 ) * * ] , MD : LM [ * * Hospital Unit Name 12006 * * ] phone:[**telephone / fax ( 1 ) 3666 * * ] Date / time:[**2165 - 8 - 9 * * ] 2:30
[ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(1 ) 292 * * ]
complete by:[**2165 - 8 - 5 * * ]
|
[
"4280",
"2851",
"4019",
"412"
] |
Admission Date : [ * * 2127 - 5 - 30 * * ] Discharge Date : [ * * 2127 - 6 - 11 * * ]
Date Birth : [ * * 2127 - 5 - 30 * * ] sex :
Service : NB
discharge diagnosis :
1 . prematurity 34 week gestation .
2 . feed immaturity , resolve .
history PRESENT ILLNESS : [ * * known firstname 37958 * * ] [ * * Name ( NI ) * * ] [ * * know lastname * * ] 3125 gram
product 33 [ * * 5 - 3 * * ] week gestation ( EDC [ * * 2127 - 7 - 10 * * ] ) [ * * Month / Day / Year * * ]
33 year - old , Gravida , Para 0 , mom , prenatal
screen 0 positive , antibody negative , RPR nonreactive .
Rubella immune . Hepatitis B surface antigen negative . GBS
negative . Pregnancy complicate hypertension .
[ * * know firstname * * ] [ * * name2 ( NI ) * * ] emergent cesarean section non
reassuring fetal heart rate trace trial
induction labor secondary hypertension . apgar
score 4 1 minute 8 5 minute . Mom
give general anesthesia . require positive pressure
ventilation delivery room first minute
half life . bring Neonatal Intensive Care
Unit evaluation .
PHYSICAL EXAMINATION : infant large gestational
age ; weight 2125 gram , great 90th percentile . Head
circumference 32.75 cm , 90th percentile . Length 48 cm ,
90th percentile . temperature 98 . Heart rate 160 .
respiratory rate 44 . saturate 98 % room air . blood
pressure 86/37 , mean 53 . HEENT : Normocephalic , atraumatic .
anterior fontanel open flat . red reflex present
bilaterally . Neck supple . lung clear bilaterally . CV :
regular rate rhythm , murmur . Femoral pulse 2 +
bilaterally . Abdomen soft , active bowel sound ,
masse distention . extremity : warm well perfuse .
foot smooth . Consistent premature infant . anus
normally place , patent . Spine midline . hip stable .
clavicle intact . Neurologic : good tone , move
extremitie equally .
HOSPITAL COURSE : Respiratory : remain stable room
air throughout hospitalization . episode apnea
desaturation .
Cardiovascular : remain hemodynamically stable
hospitalization .
Fluids , electrolyte nutrition : start total
fluid volume 80 cc per kg per day advanced
total fluid volume 150 cc per kg per day day life
five . start enteral feed day life two
able take p.o . feed day life six .
currently breast milk premature Enfamil 24 calorie per
ounce take 140 150 cc per kg per day volume
feed . G - stick stable . electrolyte day
life four sodium 144 ; potassium 4.7 ; chloride
107 bicarbonate 21 .
Gastrointestinal : Peak bilirubin day life 3 10.5
direct component .3 . require
phototherapy .
infectious disease : receive Ampicillin Gentamycin
48 hour . discontinue culture remain
negative 48 hour .
routine health care management : Hepatitis B vaccine
give . hearing screen pass . initial car seat test
fail time dictation repeat
discharge .
discharge medication : Fer - in-[**Male First Name ( un ) * * ] .
WEIGHT TIME discharge : 3.070 kg .
discharge date : discharge day life 12 , correct
35 3/7 week .
[ * * First Name11 ( Name Pattern1 ) 449 * * ] [ * * last Name ( NamePattern1 ) * * ] , [ * * MD Number(1 ) 54604 * * ]
dictate by:[**last Name ( NamePattern1 ) * * ]
medquist36
: [ * * 2127 - 6 - 10 * * ] 16:41:37
: [ * * 2127 - 6 - 10 * * ] 17:03:11
Job # : [ * * Job number 94151 * * ]
|
[
"V053"
] |
Admission Date : [ * * 2103 - 7 - 24 * * ] Discharge Date : [ * * 2103 - 7 - 26 * * ]
Service :
CHIEF COMPLAINT : patient 78 year old female
past medical history significant obstructive sleep apnea ,
pulmonary hypertension , chronic hypercapnic hypoxemic
respiratory failure , present worsen shortness
breath decrease oxygen saturation .
history PRESENT ILLNESS : patient 78 year old
woman history long - stand obstructive sleep apnea
subsequent pulmonary hypertension . two day prior
admission , patient report experience gradual
worsen shortness breath . morning admission ,
patient 's daughter find patient severely short
breath , cyanotic call EMS . EMS arrive ,
patient note room air oxygen saturation
60 % range note tachypneic
respiratory rate 40 .
upon arrival [ * * Hospital1 69 * * ]
Emergency Department , patient note cyanotic
vital sign show heart rate 85 , blood pressure
175/77 , respiratory rate 32 , saturate 97 %
100 % nonrebreather face mask . deny chest pain
time Emergency Department presentation . deny
[ * * last Name ( LF ) * * ] , [ * * first Name3 ( LF ) 691 * * ] fever chill . deny nausea
vomit . abdominal pain . deny
urinary symptom , deny symptom paroxysmal
nocturnal dyspnea .
patient place full face mask BIPAP
admit Medical Intensive Care Unit monitoring
respiratory status .
PAST MEDICAL history :
1 . obstructive sleep apnea . diagnose least five
year prior time admission sleep study
perform [ * * 2098 - 2 - 17 * * ] , show 43 hypopnea oxygen
saturation 70 . datum record provide
patient 's primary pulmonologist , Dr. [ * * last Name ( STitle ) 10132 * * ] , [ * * hospital3 * * ] Medical Center . home , patient wear cpap
four six hour every night receive oxygen via
nasal cannula rate 2 2.5 liter per minute
day .
2 . chronic hypercapnic hypoxemic respiratory failure .
patient room air oximetry study perform [ * * 2102 - 7 - 21 * * ] , outpatient hospital show
spend approximately 63 % time oxygen saturation
90 , 24 % time oxygen saturation 80
5 % time oxygen saturation 70 .
3 . restrictive lung disease .
4 . Pulmonary hypertension .
5 . Hypertension .
6 . Coronary artery disease , status post coronary artery
catheterization [ * * 2097 - 10 - 18 * * ] , show clean coronary
artery .
7 . Status post inferior myocardial infarction approximately
fifteen year ago .
8 . inguinal hernia .
9 . Chronic anemia think due Vitamin B12
deficiency .
medication admission :
1 . Lasix 40 mg q.d .
2 . Atenolol 25 mg day .
3 . Nitroglycerin patch 0.4 mg transdermal patch apply
day .
4 . Carvedilol 3.125 mg day .
5 . allopurinol .
allergy : report allergy Penicillin
Streptomycin .
FAMILY history : assess .
SOCIAL history : patient russian speak woman
come United States [ * * Country 532 * * ] eight year ago .
live alone [ * * Location ( un ) 86 * * ] area two daughter
live nearby . history tobacco use
history exposure asbestos know industrial agent .
PHYSICAL EXAMINATION : examine patient ,
vital sign reveal heart rate 48 , blood pressure
89/48 , respiratory rate 26 , oxygen saturation 92 % BIPAP
face mask pressure support 15 , PEEP 5 fio2
40 % . note awake , alert able respond
question help translation . skin
examination notable pallor cyanosis .
examination jugular venous distention reveal jugular
venous pulse 9.0 centimeter . chest examination
show diffusely decrease breath sound , decrease
left side right side , however ,
wheeze crackle note . cardiac examination
reveal bradycardic heart rate regular rhythm
harsh IV / VI systolic murmur hear across
precordium , occasional S3 rub . abdominal
examination reveal normoactive bowel sound , obese soft
abdoman , nontender . costovertebral
angle tenderness . examination extremity show
dorsalis pedis pulse 1 + bilaterally . extremity
warm . 1 + bilateral low extremity edema .
also note bilateral calf tenderness .
LABORATORY DATA : admission , sodium 142 , initial potassium
7.0 hemolyzed speciman repeat potassium
4.9 , chloride 96 , bicarbonate 37 , blood urea nitrogen 23 ,
creatinine 0.8 , glucose 151 . complete blood count
reveal white blood cell count 6.9 , hematocrit 37.5 ,
platelet count 357,000 . white blood cell count
differential include 72 % poly , 20 lymphocyte 7
monocyte . coagulation panel show prothrombin time
13.0 , partial thromboplastin time 29.1 INR 1.2 .
Initial CK level 65 .
Electrocardiogram show normal sinus rhythm rate 78
beat per minute right axis deviation right
bundle branch block unchanged previous
electrocardiogram provide outside hospital .
chest x - ray show opacification right mediastinal
border prominent pulmonary vasculature focal
consolidation .
HOSPITAL COURSE : Emergency Department , initial
arterial blood gas perform patient 100 %
nonrebreather face mask . blood gas reveal ph 7.19 ,
pco2 122 , pO2 150 . patient place
face mask 50 % FIO2 , repeat blood gas show ph
7.13 , pco2 137 , pO2 132 . patient give
single dose Levofloxacin Emergency Department
treat community acquire pneumonia . also give
intravenous Solu - Medrol treat underlying
bronchospastic component contribute pulmonary
decompensation . give 1 mg Morphine Sulfate
also Nitroglycerin paste Emergency Department .
time Emergency Department presentation ,
patient report DNR / DNI code status . therefore ,
intubation attempt patient . instead , full
face mask preferred method oxygen delivery
admit Medical Intensive Care Unit
monitoring oxygenation ventilatory status .
evening admission , ultrasound study low
extremity perform reveal evidence deep
vein thrombosis . patient also diurese Lasix ,
receive total 100 mg intravenous Lasix
Emergency Department additional 40 mg Lasix
admission Intensive Care Unit . produce net
diuresis negative two liter evening admission .
antibiotic hold time patient
afebrile elevated white blood cell count
low clinical suspicion pneumonia .
steroid also hold .
overnight , patient 's oxygenation ventilatory status
improve somewhat base repeat arterial blood gas
analysis . place nasal CPAP overnight .
subsequently rule myocardial infarction via cardiac
enzyme .
[ * * 2103 - 7 - 25 * * ] , hospital day two , echocardiogram obtain
order assess possible role diastolic congestive
heart failure contribute pulmonary edema
patient 's shortness breath . follow echocardiogram
perform bedside , patient experience
desaturation oxygen saturation note 30
40 % range . patient note profoundly cyanotic
also begin report leave side chest pain .
electrocardiogram obtain show change
suggestive acute ischemia . stat portable chest x - ray also
show acute change prior chest x - ray .
time desaturation event , patient
nasal CPAP ultimately place full face
mask BIPAP , patient 's oxygen saturation return
80 % range . echocardiogram ultimately show ejection
fraction great 55 % , mild symmetric leave ventricular
hypertrophy . left atrium right atrium
note dilate . overall decrease right
heart function severe pulmonary artery systolic
hypertension .
although previously obtain low extremity ultrasound
reveal deep vein thrombosis , continue entertain
diagnosis pulmonary embolism . time
Emergency Department presentation , patient
unable lie flat without become profoundly short
breath . therefore , unable send patient
CT angiogram study prove presence pulmonary
embolism . however , desaturation event ,
decision make empirically anticoagulate patient
Heparin . Levofloxacin also restart treat
presumptive pneumonia .
day initial blood culture take Emergency
Department return positive gram positive cocci pair
cluster one two bottle patient
begin Vancomycin .
patient subsequently remain stable respiratory
standpoint note intermittent bradycardia
heart rate 30 40 transient
associate hypotension . Atropine place
patient 's bedside .
morning [ * * 2103 - 7 - 26 * * ] , patient restart
Solu - Medrol treat possible underlying component
bronchospastic disease decision make obtain
bedside abdominal ultrasound evaluate question
pleural effusion right lung base see serial chest
x - ray . however , ultrasound could obtain ,
patient experience another desaturation event early
afternoon [ * * 2103 - 7 - 26 * * ] . accompany
bradycardia eventually cardiopulmonary arrest
patient ultimately succumb declare deceased
afternoon [ * * 2103 - 7 - 26 * * ] .
dr.[**last Name ( STitle ) * * ] , [ * * first Name3 ( LF ) * * ] R. 12 - 207
dictate by:[**doctor last Name 35468 * * ]
medquist36
: [ * * 2103 - 7 - 27 * * ] 14:50
: [ * * 2103 - 7 - 30 * * ] 17:13
JOB # : [ * * Job number 35469 * * ]
|
[
"486",
"496",
"4168",
"0389",
"4280"
] |
Admission Date : [ * * 2196 - 6 - 10 * * ] Discharge Date : [ * * 2196 - 6 - 14 * * ]
Date Birth : [ * * 2145 - 1 - 10 * * ] sex :
Service : SURGERY
allergy :
penicillin
attending:[**first Name3 ( LF ) 3223 * * ]
Chief Complaint :
/ p Motor vehicle crash
Major Surgical Invasive Procedure :
none
history Present Illness :
51 restrained driver / p - bone motor vehicle crash + LOC .
take area hospital find mulitple
injury transport [ * * Hospital1 18 * * ] care .
Past Medical History :
HTN , kidney stone , GERD
Family history :
Noncontributory
Physical Exam :
upon exam :
Gen : WD / WN , comfortable , NAD .
HEENT : NCAT
Neck : cervical collar .
lung : CTA bilaterally .
Cardiac : RRR . S1 / S2 .
Abd : Soft , NT , BS+
Extrem : warm well - perfuse .
Neuro :
mental status : awake alert , cooperative exam , normal
affect .
orientation : orient person , place , date .
language : speech fluent good comprehension repetition .
name intact . dysarthria paraphasic error .
Cranial Nerves :
: test
II : pupil equally round reactive light , 3.5 2
mm bilaterally . visual field full confrontation .
III , IV , VI : extraocular movement intact bilaterally without
nystagmus .
V , VII : facial strength sensation intact symmetric .
VIII : hear intact voice .
IX , X : palatal elevation symmetrical .
[ * * Doctor First Name 81 * * ] : trapezius normal bilaterally .
XII : tongue midline without fasciculation .
motor : normal bulk tone bilaterally . abnormal movement ,
tremor . strength full power [ * * 5 - 10 * * ] throughout . pronator drift
sensation : intact light touch throughout .
reflex : b Br Pa Ac
right 2 2 2 2 2
leave 2 2 2 2 2
toe downgoe bilaterally
coordination : normal rapid alternate movement
pertinent result :
[ * * 2196 - 6 - 10 * * ] 11:38PM glucose-158 * UREA N-14 CREAT-0.8 sodium-141
POTASSIUM-3.3 chloride-104 total CO2 - 24 anion GAP-16
[ * * 2196 - 6 - 10 * * ] 11:38PM WBC-17.6 * rbc-4.61 HGB-14.1 HCT-40.0 MCV-87
MCH-30.6 MCHC-35.2 * RDW-14.4
[ * * 2196 - 6 - 10 * * ] 11:38PM PLT count-302
[ * * 2196 - 6 - 10 * * ] 11:38PM pt-13.1 PTT-21.5 * INR(PT)-1.1
[ * * 2196 - 6 - 10 * * ] 08:54PM ASA - NEG ETHANOL - NEG ACETMNPHN - NEG
bnzodzpn - NEG barbitrt - NEG tricyclic - NEG
[ * * 2196 - 6 - 10 * * ] 08:54PM WBC-23.7 * RBC-5.03 HGB-15.2 HCT-44.6 MCV-89
MCH-30.1 mchc-34.0 RDW-14.0
CT Head [ * * 2196 - 6 - 10 * * ]
IMPRESSION :
1 . longitudinal leave temporal bone skull base fracture appear
spare carotid canal . fracture traverse
middle ear ossicular disruption exclude .
2 . small leave posterior frontal subarachnoid hemorrhage .
3 . Asymmetric leave occipital hypoattenuation suggest
acute infarct exclude . recommend MRI / MRA versus CTA
evaluation
CT C - spine [ * * 2196 - 6 - 10 * * ]
IMPRESSION : non - displace fracture right intra - articular
portion C7 , describe . fracture listhesis .
CT Chest / Abdomen / Pelvis [ * * 2196 - 6 - 10 * * ]
IMPRESSION :
1 . moderately large mesenteric hematoma may represent
significant vascular injury small bowel .
2 . leave inferior pole renal infarct . left renal artery
appear
intact , dissection exclude CTA recommend
evaluation .
3 . nondisplace right first rib fracture .
4 . bilateral transverse process fracture L3 left
transverse process fracture L4 .
5 . bibasilar consolidation lingular consolidation likely
represent
atelectasis , however component aspiration exclude .
5 . right adrenal nodule , small characterize .
CTA Head / Neck [ * * 2196 - 6 - 11 * * ]
IMPRESSION :
1 . leave parietal subarachnoid hemorrhage less apparent .
new
hemorrhage .
2 . normal CT angiography neck .
3 . normal CT angiography head .
4 . fracture right C7 visualize extend
transverse foraman ,
vertebral artery enter foraman
transversarium
level interrupt c6 level . right first rib fracture
identify .
CT right arm [ * * 2196 - 6 - 11 * * ]
finding : distal humerus normal appearance .
evidence
acute fracture .
Brief Hospital course :
admit Trauma service . neurosurgery
Orthopedic spine consult injury . left
parietal subarachnoid hemorrhage manage non operatively ;
serial head CT scan perform remain stable .
follow Dr. [ * * First Name ( STitle ) * * ] 4 week repeat head imaging .
note skull base fracture left
temporal bone ; dedicate CT temporal bone do
require outpatient follow ENT audiogram .
spine injury also manage non operatively hard
cervical collar wear time lumbar corset
wear bed . follow 2 week Dr.
[ * * last Name ( STitle ) 363 * * ] , Orthopedic Spine surgery .
orthopedic consult concern possible right
humerus fracture give patient increase complaint
right arm pain movement upon palpation . CT arm
perform fracture identify . feel
pain experience likely relate
cervical spine fracture dermatome path follow
along arm . start Neurontin , Ultram prn
Percocet pain report helpful .
evaluate physical therapy discharge home
hospital day 5 specific instruction follow .
medication admission :
hctz , nexium , simvastatin
Discharge medication :
1 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) need constipation .
2 . milk Magnesia 800 mg/5 ml Suspension Sig : thirty ( 30 ) ML
PO Q6H ( every 6 hour ) need constipation .
3 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : one ( 1 ) Tablet
po Q4H ( every 4 hour ) need pain .
Disp:*60 Tablet(s ) * Refills:*0 *
4 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q6H ( every
6 hour ) need pain : exceed 2,000 mg day .
5 . gabapentin 300 mg Capsule Sig : one ( 1 ) Capsule PO TID ( 3
time day ) .
Disp:*90 Capsule(s ) * Refills:*2 *
6 . tramadol 50 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need pain .
Disp:*90 Tablet(s ) * Refills:*1 *
discharge Disposition :
home
discharge Diagnosis :
/ p Motor vehicle crash
small subarachnoid hemorrhage
Basilar skull fracture
leave temporal bone fracture
C7 facet fracture
Bilateral tranverse process fracture L3 & leave L4
mesenteric hemotoma
Neuropathic pain
discharge condition :
hemodynamically stable , tolerate regular diet , pain
adequately control .
Discharge instruction :
must continue wear cervical collar time
next 10 week .
need wear corsett brace bed
lumbar fracture .
wear sling comfort left arm .
return emergency room develop fever , chill ,
headache , weakness / numbness extremity ,
shortness breath , chest pain , nausea , vomiting , diarrhea ,
loss bowel bladder function and/or symptom
concern .
Followup Instructions :
follow next week [ * * Hospital * * ] clinic , need audiogram
appointment well . call [ * * telephone / Fax ( 1 ) 41 * * ] appointment .
follow 2 week Dr. [ * * last Name ( STitle ) 363 * * ] , Orthopedics Spine Surgery
spine fracture . call [ * * telephone / Fax ( 1 ) 3573 * * ] appointment .
follow 4 week Dr. [ * * First Name ( STitle ) * * ] , neurosurgery
subarachnoid hemorrhage . call [ * * telephone / Fax ( 1 ) 1669 * * ] appointment .
inform office need repeat head CT scan
appointment .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 520 * * ] MD , [ * * MD Number(3 ) 3226 * * ]
complete by:[**2196 - 6 - 22 * * ]
|
[
"4019",
"2768",
"2724"
] |
Admission Date : [ * * 2109 - 7 - 21 * * ] Discharge Date : [ * * 2109 - 8 - 13 * * ]
Date Birth : [ * * 2053 - 6 - 5 * * ] sex : F
Service : [ * * Doctor Last Name 1181 * * ] MEDICINE
history PRESENT ILLNESS : 56 - year - old white
female history right frontal craniotomy [ * * 2109 - 7 - 1 * * ] , dysembryoplastic angioneural epithelial lesion
feature oligodendroglioma start
Dilantin postoperatively seizure prophylaxis
subsequently develop eye discharge see
optometrist treat sulfate ophthalmic drop .
patient develop oral sore rash chest
night admission rapidly spread face ,
trunk , upper extremity within last 24 hour .
patient unable eat secondary mouth pain .
fever , weakness , diarrhea . genital
morning [ * * 7 - 20 * * ] .
PAST MEDICAL history : 1 . Hypercholesterolemia . 2 . Benign
right frontal cystic tumor status post right frontal
craniotomy [ * * 2109 - 7 - 1 * * ] .
allergy : know drug allergy .
medication : Lipitor , Tylenol Codeine , Dilantin ,
previously Decadron q.i.d . taper one week
discontinue week ago .
SOCIAL history : patient live husband ,
daughter , son . [ * * Name ( NI ) * * ] smoking ethanol use history .
PHYSICAL EXAMINATION : vital sign : - max 104.3 ? ? ? ? ? ? , currently
100.8 ? ? ? ? ? ? , heart rate 107 - 110 , blood pressure 110/27 ,
respiration 15 - 20 , oxygen saturation 98 % room air .
General : patient alert , ill - appear woman
postsurgical occiput . Head neck : inject conjunctivae ,
greenish ocular discharge , ulcerative oral lesion .
Cardiovascular : regular rhythm . rapid rate . murmur .
Pulmonary : clear auscultation bilaterally . Abdomen :
normoactive bowel sound . soft , nontender , nondistended .
extremity : edema . skin : Diffuse erythema pustule
face . patulous pustule chest , back ,
proximal upper extremity . GU : genital lesion .
LABORATORY DATA : Hematocrit 34.1 , WBC 10.3 , platelet count
291,000 , differential 87 neutrophil , 0 band ; sodium 133 ,
potassium 3.8 , chloride 93 , CO2 21 , BUN 17 , creatinine 0.9 ,
glucose 121 ; ALT 39 , AST 42 , LDH 434 , amylase 63 , albumin
3.4 , total bilirubin 0.3 ; urinalysis positive ketone ,
negative nitrite ; urine culture pende ; blood culture
time two pende ; conjunctival culture pende .
HOSPITAL COURSE : give patient 's severe exfoliative skin
involvement rapid progression extensive involvement
body , admit Medical Intensive Care
Unit close monitoring . start prophylactic
Oxacillin cover skin flora , Dermatology consult
along Neurology Ophthalmology ophthalmic
involvement .
patient 's course Intensive Care Unit
uneventful , discharge floor
close monitoring include q.1 hour Pred Forte
application eye close consultation
Ophthalmology . regard skin lesion ,
continue exfoliate next couple day ,
skin care include frequent Vaseline hydrated petroleum
application decrease insensible loss . patient 's
intake output closely monitor replace
appropriately ; however , intensive nursing care
requirement make difficult patient receive
adequate floor , therefore , transfer
Medical Intensive Care Unit frequent ophthalmic
application skin care .
MICU , patient continue meticulous
skin care eye care . skin lesion continue
desquamate exfoliate natural
progression disease . begin involvement
genital area continued desquamation
exfoliative lesion . course Intensive Care Unit
within next 8 - 10 day slow gradual improvement
dermatologic ophthalmologic standpoint .
cardiovascular standpoint , sinus
tachycardia feel secondary
[ * * Doctor Last Name * * ] -[**Location ( un ) * * ] syndrome lead dehydration
insensible fluid loss .
Intensive Care Unit , also find
mildly hypoxic likely secondary atelectasis
patient 's immobility . low extremity
doppler also do , deep venous thrombose
find .
Infectious Disease standpoint , patient
start intravenous Oxacillin empirically . blood culture
5th growth time two ; however , one bottle
PICC line grow gram - positive cocci [ * * 7 - 27 * * ] .
start course Vancomycin . subsequently
organism find cns Corynebacterium ,
Vancomycin discontinue prior transfer floor
[ * * 8 - 5 * * ] .
patient 's course floor uncomplicated
continue improvement .
dermatology : patient , indicate , improve
dramatically presentation time discharge .
exfoliative lesion heal course
admission . skin care requirement decrease Petroleum
jelly twice day time discharge . able
take oral foot without problem .
ophthalmology : patient 's eye care requirement improve
markedly . able open eye use vision
without significant problem time discharge .
Pred Forte discontinue day discharge ,
follow - Ophthalmology couple day
discharge .
Fluid , electrolyte , nutrition : admission patient
begin TPN nutritional support . patient
improve medical perspective , TPN wean ,
time discharge , patient take adequate
p.o . supplementation Boost .
infectious Disease : time admission ,
start empiric antibiotic place contact
precaution secondary extensive skin lesion ; however ,
patient improve throughout course
admission , contact precaution discontinue ,
patient discharge home service .
Cardiology / Pulmonology : patient tachycardiac
throughout admission attribute fluid
loss secondary [ * * Doctor Last Name * * ] -[**Location ( un ) * * ] syndrome ; however , give
patient 's immobility throughout course
admission , CT angiogram perform evaluate
possible pulmonary embolism , none find .
Neurology : patient history cystic tumor status
post resection [ * * Month ( ) 205 * * ] year start
prophylactic Dilantin lead presume [ * * Doctor Last Name * * ] -[**Location ( un ) * * ]
syndrome . time admission , patient 's
Dilantin discontinue , anticonvulsant
start , give patient 's risk seizure several week
surgery unlikely . decision make
support neurosurgeon , Dr. [ * * last Name ( STitle ) * * ] [ * * last Name ( NamePattern4 ) 1338 * * ] .
five day discharge , patient syncopal
event bathroom shower help
nursing aide . likely etiology orthostatic
hypotension fluid loss ; however , give
patient 's neurologic history , Neurology consult
evaluate possible seizure . Neurology 's recommendation
obtain repeat CT scan unchanged
previous show right frontal lobe extra - axial hypodensity
stable . also recommend repeat MR imaging
unremarkable except stable extra - axial
lesion note CT scan . Neurology therefore agree
primary team syncopal event likely secondary
vasovagal reaction . follow - MR scan would
recommend gadolinium evaluate presence
residual tumor . do outpatient Dr.
[ * * last Name ( STitle ) 1338 * * ] .
rehabilitation : patient throughout admission work
physical therapy people continue improve
regard range motion strength upper
low extremity , time discharge ,
ambulate throughout [ * * Doctor Last Name * * ] around hospital
without problem . therefore discharge home without
need Physical Therapy Services .
time discharge , patient markedly improve
initial presentation discharge home
nursing assistance .
DISCHARGE STATUS : markedly improve .
discharge DIAGNOSIS :
1 . [ * * Doctor Last Name * * ] -[**Location ( un ) * * ] syndrome secondary Dilantin .
2 . Status post craniotomy [ * * 2109 - 7 - 1 * * ] , cystic
cranial lesion , likely dysembryoplastic angioneural
epithelial lesion feature consistent
oligodendroglioma .
discharge medication : Polysporin ophthalmology O.U. q.i.d . ,
hydrate Petroleum need , Lipitor 10 mg p.o . q.d . ,
Nystatin , Boost t.i.d .
FOLLOW - : 1 . Ophthalmology [ * * 2109 - 8 - 20 * * ] , 12:45
p.m. 2 . primary care physician two week . 3 .
Dermatology need .
DISCHARGE note : please note patient ALLERGIC
DILANTIN TEGRETOL give [ * * Doctor Last Name * * ] -[**Location ( un ) * * ] SECONDARY
DILANTIN . patient recommend wear alert
bracelet indicate reaction .
[ * * Name6 ( MD ) 2415 * * ] [ * * last Name ( NamePattern4 ) 3474 * * ] , M.D. [ * * MD Number(1 ) 3475 * * ]
dictate by:[**last Name ( NamePattern4 ) 40425 * * ]
medquist36
: [ * * 2109 - 9 - 3 * * ] 12:59
: [ * * 2109 - 9 - 3 * * ] 12:58
JOB # : [ * * Job number 99931 * * ]
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , M.D.(cclist )
|
[
"2765",
"311",
"2720"
] |
Admission Date : [ * * 2144 - 3 - 7 * * ] Discharge Date : [ * * 2144 - 3 - 16 * * ]
service : MEDICINE
allergy :
codeine
attending:[**first Name3 ( LF ) 2145 * * ]
Chief Complaint :
transfer OSH [ * * State 108 * * ] r hip fx .
Major Surgical Invasive Procedure :
r hip orif
history Present Illness :
HPI : [ * * age 90 * * ] F hx dementia , CAD , CHF EF 40 % , chronic afib , live
24 hour caretaker . bring OSH neck pain
inability hold head well confusion , find
transverse C2 den fracture , immobilize
[ * * Location ( un ) 5622 * * ] collar . Pt fall 3 week prior admission ,
home aide state injury fall .
note CHF exacerbation -- > resolve diuresis
reportedly stable [ * * 3 - 20 * * ] liter NC ( use O2 home ) .
- house OSH , fall unfortunately suffer right
intertrochanteric fracture . Pt family [ * * Hospital1 1559 * * ]
pt med flight [ * * State 108 * * ] [ * * Hospital1 18 * * ] . family connection [ * * first Name4 ( NamePattern1 ) * * ]
[ * * last Name ( NamePattern1 ) * * ] .
reportedly , C2 fracture stable surgeon
want immobilize hip could address .
.
Pt cardiology consult [ * * State 108 * * ] , chf
exacerbation BNP 15,000 . Toprol XL increase
37.5 50 mg po qd plan increase 100 mg po
QD . start digoixin . lasix increase .
.
note , transfer paperwork note pt see PCP
[ * * Name9 ( PRE ) 108 * * ] exertional CP SOB relieve NTG [ * * Month ( ) 1096 * * ]
[ * * 2143 * * ] . time Imdur increase 30 60 mg po
qd .
.
hospitalization increasingly agitate
start Risperdal , recently / c'd
become increasingly confused .
.
Labs OSH :
[ * * 3 - 6 * * ] : INR 1.1 , Na 146 , K 3.8 , Cl 106 , HCO3 33 , BUN 29 , Cr 1.0 ,
can 8.7
Dig 1.0 , [ * * 3 - 2 * * ] Blood Cx : NGTD
.
study :
[ * * 3 - 2 * * ] EKG : afib 98bpm RAD , LVH , QTc 526 , bad baseline
[ * * 3 - 4 * * ] CT Head mod - severe atrophy , bleed
[ * * 3 - 5 * * ] r hip / pelvis , comminute fx r hip
[ * * 3 - 5 * * ] CT cervical spine : transverse fx base dens .
displacement . transverse lucency spinous process
C3 ( chronic ) Transverse lucency spinous process C3
( chronic ) .
[ * * 3 - 3 * * ] CXR : Mild CHF , patchy infiltrate base right lung , small
bilateral pleural effusion .
.
Past Medical history :
PMH :
CHF EF 40 % , [ * * 2 - 20 * * ] echo : inf hypokinesis
CAD , hx MI , / p pci LAD , LCx RCA stent [ * * 2136 * * ]
[ * * hospital1 * * ]
afib
hypercholesterolemia
COPD
HTN
severe ( [ * * 2 - 20 * * ] echo 59 mmHg peak gradient , valve area 0.6 cmsq )
mod - severe MR
mild MS [ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) * * ]
Dementia ( Mild Alzheimer 's vs vascular ) per transfer paperwork ,
however pt 's family state hospitalization pt
live independently live help .
Hiatal hernia / p repair
hx GIB AVM associate elevated INR [ * * 4 - 18 * * ]
/ p ccy
/ p TAH
macular degeneration
kyphoscoliosis
DJD / OA
Social History :
Social Hx : widow , 4 child . live independently
24 hour aide . EtOH tob .
transfer physician : [ * * last Name ( namepattern4 ) * * ] . [ * * first Name4 ( NamePattern1 ) 24606 * * ] [ * * last Name ( NamePattern1 ) 79 * * ] cell [ * * telephone / Fax ( 1 ) 65356 * * ] (
- call weekend ) [ * * Hospital 32303 * * ] Medical Center [ * * Hospital 65357 * * ] ,
[ * * State 108 * * ] [ * * telephone / Fax ( 1 ) 65358 * * ] . [ * * Name ( NI ) * * ] son : [ * * Name ( NI ) * * ] [ * * Name ( NI ) 122 * * ]
[ * * telephone / Fax ( 1 ) 65359 * * ] HCP , live [ * * Name ( NI ) 108 * * ] come
[ * * 3 - 7 * * ] . Pts daughter ( [ * * Name ( NI ) 19948 * * ] [ * * last Name ( NamePattern1 ) * * ] ) live [ * * Name ( NI ) 1559 * * ]
phone number [ * * telephone / Fax ( 1 ) 65360 * * ] .
.
[ * * Hospital1 1559 * * ] pcp : [ * * last Name ( namepattern4 ) * * ] . [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 1683 * * ] ( [ * * hospital1 * * ] )
[ * * Hospital1 1559 * * ] cardiologist : Dr. [ * * last Name ( STitle ) 65361 * * ] ( [ * * hospital1 * * ] )
Physical Exam :
pe : vs : 98.6 hr 64 r 20 BP 88/54 95%2L
Gen : NAD , lay bed Aspen collar
HEENT : slight droop L eyelid , PERRL , MMM , / p clear
Neck : Aspen collar
chest : crackle basis , clear apex
CV : [ * * last Name ( un ) 3526 * * ] [ * * last Name ( un ) 3526 * * ] rate rhythm , 3/6 SEM RUSB rad carotid ,
3/6 systolic murmur apex
Abd : soft , NT , ND + BS
Ext : pain palpation r hip , lim ROM . edema , 2 + dp pulse
bilaterally
Neuro : alert , orient person , move 4 .
Brief Hospital course :
[ * * age 90 * * ] yo F h / dementia , CAD , diastolic CHF ( EF 55 % ) , severe
, chronic afib , transfer OSH r hip fracture
possible C2 fracture operative management hip .
stable floor initial arrival . give chf
, high risk surgical candidate , family
decide go ahead operation . postoperatively
MICU briefly hypotension extubate without
difficulty , wean pressor rehydration
transfer back floor . perioperatively , develop
UTI lij clot , treat . postoperatively ,
also develop delirium , less verbal
previously . fail speech swallow evaluation ,
medical team optomistic would improve .
meantime , multiple attempt NGT placement unsuccessful .
floor , [ * * 3 - 14**]-30 , patient show sign
inability clear secretion . [ * * 3 - 15 * * ] , episode
hypoxia . CXR time reveal fluid overload ,
seem improve lasix . overnight night , 1/2 blood
culture bottle positive S.aureus Vancomycin
start . [ * * 3 - 16 * * ] , continue poorly ,
hypoxic . CXR time reveal dry lung , likely
aspiriation PNA LUL . despite aggressive suctioning
broaden antibiotic coverage , Mrs. [ * * know lastname 65362 * * ] continue
deteriorate ultimately die approx 4:25 pm [ * * 3 - 16 * * ] .
.
# COde - DNR / DNI verify son HCP .
.
# communication : son [ * * Name ( NI ) * * ] [ * * Name ( NI ) 122 * * ] [ * * telephone / Fax ( 1 ) 65359 * * ] ( HCP ; daughter
( [ * * Name ( NI ) 19948 * * ] [ * * Name ( NI ) * * ] [ * * telephone / Fax ( 1 ) 65360 * * ] ) . [ * * Hospital1 1559 * * ] pcp : [ * * last Name ( namepattern4 ) * * ] . [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 1683 * * ]
( [ * * hospital1 * * ] ) ; [ * * Hospital1 1559 * * ] cardiologist : Dr. [ * * last Name ( STitle ) 65361 * * ] ( [ * * hospital1 * * ] ) .
previously [ * * Hospital 32303 * * ] Medical Center [ * * last Name ( LF ) 65357 * * ] , [ * * first Name3 ( LF ) 108 * * ]
[ * * telephone / Fax ( 1 ) 65358 * * ] .
.
medication admission :
med transfer :
lipitor 40 mg po qd
Digoxin 0.125 mg qD
Lasix 80 mg IV BID
Atrovent neb QID
Imdur 30 mg PO qd
Levalbuterol neb QID
Losartan 12.5 mg PO BID
Toprol XL 50 mg PO qd
coumadin 2 mg po alternate 3 mg po qd ( hold )
Tylenol prn
discharge Disposition :
expire
discharge diagnosis :
Hip fracture / p ORIF
LIJ clot
UTI
Aspiration PNA
perioperative delirium
Discharge condition :
death
discharge instruction :
none .
Followup Instructions :
none .
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 2158 * * ]
|
[
"5990",
"5070",
"4241",
"496",
"2851",
"2930",
"4019",
"2720"
] |
Admission Date : [ * * 2179 - 3 - 5 * * ] Discharge Date : [ * * 2179 - 3 - 24 * * ]
Date Birth : [ * * 2105 - 3 - 13 * * ] sex : F
Service : MEDICINE
allergy :
benzodiazepine
attending:[**first Name3 ( LF ) 3984 * * ]
Chief Complaint :
shortness breath , red hand foot
Major Surgical Invasive Procedure :
endotracheal intubation , mechanical ventilation , right IJ
central line place , tracheostomy tube place
history Present Illness :
Ms. [ * * know lastname 94714 * * ] 73yo woman h / ALS present 3
week redness hand foot well recent
difficulty breathing . patient complain dyspnea
husband note tachypnea respiratory distress
per husband go doctor today , note
" breathe well " send er
hypoxic 80 , respond well O2 NC .
find abg 7.19/126/525/51 start
Bipap . tolerate non - invasive mask ventilation
despite sedateion ( verse 2 mg , fentanyl 100 mg ) .
experience reduction blood pressure 66/30 ,
subsequently intubated .
per husband , patient al three year .
perform adls trouble speech well
keep mouth close baseline .
respiratory complaint . previously lose 40 pound
last year give Gtube since gain back
14 pound . [ * * Name ( NI ) 1094 * * ] husband state prior last 3 week
USOH , deny new symptom include
cough , sputum , sick contact . entirely npo
year . CXR ER show acute CP process
UA negative sign infection .
per pt 's husband never sort
conversation regard code status . patinet try bipap
past unable tolerate , outpatient
neurologist never mention intubation tracheostomy . Mr.
[ * * know lastname 94714 * * ] state new thought
be entirely certain wife would want
point .
transfer [ * * Hospital Unit Name 153 * * ] , start AC
450x16 , 100 % fio2 , PEEP 5 . abg setting
7.40/57/426/37 fio2 turn 50 % .
Past Medical history :
- ALS diagnose 3y ago - Gtube tube feed ,
difficulty speech
- hypercholesterolemia
-?depression
Social History :
live home husband , three child two live
west coast one live [ * * Location * * ] . never use
tobacco , drink alcohol , drug . work
writer . baseline perform adls , write , use internet chat
grandchild .
Family history :
father MI age 52 , mother decease age [ * * age 90 * * ]
Physical Exam :
96.7 , 78 , 112/64 , 16 , 100 % AC setting
Gen : sedated , unresponsive , intubate
HEENT : PERRL , NCAT
Cor : s1s2 , RRR , r / g /
Pulm : CTAB
Abd : soft , NT , ND , + BS , Gtube c / /
Ext ; c / c / e , bilateral toe skin change c / w venous
stasis , bilateral finger erythematous dry excoriated skin
Neuro : babinski upgoing bilaterally , myoclonus BLE ,
hyperreflexic B patellar , bicep
Pertinent result :
arrival Na 126 , CK 273 - ->115 , mb 14 - ->10 , trop < 0.01 - - >
< 0.01 , bicarb 40 , UA negative
[ * * 2179 - 3 - 23 * * ] 02:44AM blood wbc-10.0 RBC-2.88 * Hgb-9.4 * Hct-27.6 *
MCV-96 MCH-32.7 * mchc-34.1 RDW-13.5 Plt ct-316
[ * * 2179 - 3 - 23 * * ] 02:44AM BLOOD Neuts-78.7 * Bands-0 Lymphs-15.8 *
Monos-3.6 Eos-1.6 Baso-0.3
[ * * 2179 - 3 - 22 * * ] 04:15am blood pt-11.7 PTT-22.6 INR(PT)-1.0
[ * * 2179 - 3 - 23 * * ] 02:44AM blood Glucose-127 * UreaN-24 * Creat-1.3 * Na-145
K-4.5 Cl-107 HCO3 - 31 AnGap-12
[ * * 2179 - 3 - 19 * * ] 05:54am blood ALT-49 * AST-44 * LD(LDH)-267 * AlkPhos-142 *
Amylase-41 TotBili-0.3
[ * * 2179 - 3 - 19 * * ] 05:54am blood Lipase-30
[ * * 2179 - 3 - 5 * * ] 02:50PM blood CK - MB-14 * mb indx-5.1 cTropnT-<0.01
[ * * 2179 - 3 - 5 * * ] 10:15pm blood CK - MB-10 MB Indx-8.7 * cTropnT-0.01
[ * * 2179 - 3 - 23 * * ] 02:44AM blood Calcium-8.9 Phos-3.5 mg-2.4
[ * * 2179 - 3 - 19 * * ] 05:54am blood tsh-3.0
[ * * 2179 - 3 - 18 * * ] 11:55am blood cortsol-23.9 *
[ * * 2179 - 3 - 18 * * ] 12:51pm blood Cortsol-43.3 *
[ * * 2179 - 3 - 18 * * ] 01:48PM blood Cortsol-51.1 *
[ * * 2179 - 3 - 22 * * ] 04:11PM blood Type - art pO2 - 136 * pco2 - 50 * pH-7.45
calHCO3 - 36 * base xs-9
[ * * 2179 - 3 - 22 * * ] 04:11PM blood lactate-1.2
.
[ * * 2179 - 3 - 12 * * ] 10:57 pm blood CULTURE LT PIV .
* * FINAL REPORT [ * * 2179 - 3 - 18 * * ] * *
aerobic BOTTLE ( Final [ * * 2179 - 3 - 15 * * ] ):
report PHONE [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] [ * * 2179 - 3 - 13 * * ] @ 2:35 pm .
STAPH AUREUS COAG + . FINAL sensitivity .
Oxacillin resistant Staphylococci must report
also
RESISTANT penicillin , cephalosporin ,
carbacephem ,
carbapenem , beta - lactamase inhibitor combination .
Rifampin use alone therapy .
sensitivity : MIC express
MCG / ML
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
staph aureus coag +
|
clindamycin----------- = > 8 r
erythromycin---------- = > 8 r
GENTAMICIN------------ < = 0.5
levofloxacin---------- = > 8 r
NITROFURANTOIN-------- < = 16
oxacillin------------- = > 4 r
penicillin------------ = > 0.5 r
RIFAMPIN-------------- < = 0.5
tetracycline---------- < = 1
vancomycin------------ < = 1
ANAEROBIC BOTTLE ( Final [ * * 2179 - 3 - 18 * * ] ): growth .
.
[ * * 2179 - 3 - 13 * * ] 12:20 SPUTUM source : Endotracheal .
* * FINAL REPORT [ * * 2179 - 3 - 15 * * ] * *
GRAM STAIN ( Final [ * * 2179 - 3 - 13 * * ] ):
> 25 PMNs < 10 epithelial cells/100x field .
2 + ( 1 - 5 per 1000X field ): GRAM POSITIVE COCCI .
PAIRS CLUSTERS .
RESPIRATORY CULTURE ( final [ * * 2179 - 3 - 15 * * ] ):
SPARSE growth OROPHARYNGEAL flora .
STAPH AUREUS COAG + . moderate growth .
Oxacillin resistant Staphylococci must report
also
RESISTANT penicillin , cephalosporin ,
carbacephem ,
carbapenem , beta - lactamase inhibitor combination
Rifampin
use alone therapy .
sensitivity : MIC express
MCG / ML
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
staph aureus coag +
|
clindamycin----------- = > 8 r
erythromycin---------- = > 8 r
GENTAMICIN------------ < = 0.5
levofloxacin---------- = > 8 r
NITROFURANTOIN-------- < = 16
oxacillin------------- = > 4 r
penicillin------------ = > 0.5 r
RIFAMPIN-------------- < = 0.5
tetracycline---------- < = 1
vancomycin------------ < = 1
.
[ * * 3 - 15 * * ] echo : 1.the left atrium normal size .
2.there mild symmetric left ventricular hypertrophy . left
ventricular cavity size normal . regional left ventricular
wall motion normal . overall left ventricular systolic
function normal ( lvef>55 % ) .
3 . right ventricular chamber size normal .
4.the aortic valve leaflet ( 3 ) appear structurally normal
good leaflet excursion . aortic regurgitation see .
5.the mitral valve leaflet mildly thicken . mitral
regurgitation see .
6.there pericardial effusion .
.
[ * * 2179 - 3 - 5 * * ] EKG : sinus rhythm . slight st segment elevation lead
II , III aVF may represent active inferior ischemic
process . followup clinical correlation suggest .
previous tracing available comparison
.
[ * * 2179 - 3 - 12 * * ] EKG : atrial fibrillation rapid ventricular
response , rate 160 . non - specific repolarization change .
compare previous tracing [ * * 2179 - 3 - 5 * * ] normal sinus rhythm
abbreviate p - r interval give way atrial
fibrillation rapid ventricular response
.
[ * * 3 - 21 * * ] CXR : continue dense opacification
retrocardiac region consistent left low lobe collapse
small left effusion . patchy area increase
opacity right low lung leave mid lung may
represent early infiltrate volume loss .
significant change compare film two day ago .
right subclavian line unchanged .
.
[ * * 2179 - 3 - 22 * * ] Renal US : mildly echogenic otherwise
normal - appear kidney may secondary medical renal
disease . 1.1 x 0.9 cm echogenic focus left kidney may
represent cholesterol deposit versus nonobstructe kidney
stone .
Brief Hospital Course :
# hypercarbic resp failure : feel likely ALS
induce muscular weakness combine possible acute PNA give
LLL consolidation CXR . intubate repiratory
failure , treat possible pneumonia . able
tolerate wean ventilator , therefore require
tracheostomy long term ventilator support . await
trach placement , Ms. [ * * know lastname 94714 * * ] also develop ventilator
associate pneumonia . grow MRSA sputum blood ,
treat course vancomycin . Zosyn add 5
day vancomycin repeat L lung collapse
thick mucous plugging , want cover pneumonia
well . subsequent surveillance culture clean . Zosyn
later switch Cefepime [ * * 1 - 7 * * ] worsen renal failure
attribute Zosyn . complete 8 day course
antibiotic . tracheostomy go well , start
/ exsufflator well aid clear
secretion / mucous prevent recurrent lung colapse .
.
# fib : Ms. [ * * know lastname 94714 * * ] several episode atrial
fibrillation RVR , setting l lung collapse .
initially start beta blocker good response .
multiple episode start amiodarone
anticoagulation heparin . case convert
sinus rhythm . shortly start heparin ,
episode guaiac positive stool , small amount
melena . heparin stop , restart
remain sinus rhythm , concern risk
GI bleeding high risk stroke . PEG
lavage , OB negative . also need colonoscopy
outpatient evaluate cause melena .
subtle st change inital ekg , rule mi
enzyme .
.
# hypotension : Ms [ * * know lastname 94714 * * ] hypotensive intial
presentation , respond well fluid bolus .
cortisol stimulation test normal response . become clear
respond sedation benzodiazepine
prolong hypotension ( well increase delerium
agitation ) , therefore stop , put
allergy list . cessation benzodiazepine , blood
pressure much stable , require boluse .
never require pressor .
.
# al : feel likely progression ALS ,
diaphragmatic weakness CO2 retention . respiratory
mechanic repeatedly asesse , show would
able come vent . therefore trach place
thoracic surgery ( ip unable place due
anatomy ) .
.
# hyponatremia : Mrs [ * * know lastname 94714 * * ] hyponatremic admission . Tis
resolve hydration , indicate likely
hypovolemic total body sodium deplete .
problem duration stay .
.
# Diarrhea : new [ * * 2179 - 3 - 24**]/ Slight increase WBC 15 .
Afebrile . abdominal pain . course antibiotic
vent associated PNA . antibiotic stop today . also
tube feed . C. Diff possibility give recent abx
may also relate tube feed . C.Diff pende .
point reasonable follow fever curve stool output .
C.Diff lab follow . [ * * Month ( ) 116 * * ] consider empiric treatment
c. diff flagyl febrile diarrhea persist .
.
# hypernatremia - likely releate low volume . increase
free water tube feed 100cc q4hr 150cc q4h .
chenistry panel check [ * * 2179 - 3 - 26 * * ] make sure Na
remain stable .
.
# conjunctivitis : Ms. [ * * know lastname 94714 * * ] bilateral conjunctivitis
admission . resolve 7 day course erythromycin eye
cream .
.
# skin change : Ms [ * * know lastname 94715 * * ] intitial present chief
complaint erythema hand foot . dermatology
consult , say likely erythromyalgia .
treatment sarna lotion aspirin , improvement
occur less month . treat sarna
ASA throughout stay . additionally burn
inside thigh hot tea spill home prior
admission . per dermatology recs , area treat
antibiotic cream xeroform dressing , heal cleanly
without infection .
.
# FEN : Ms. [ * * know lastname 94714 * * ] peg admission
able take po intake time secondary progression
ALS . continue NPO , tubefeed per nutrition .
monitor & replete electrolyte lyte . keep
euvolemic .
# Renal Failure : Pt 's Creatinine increase admission
0.7 1.3 .
BUN remain around 20 .urine lyte consistent
ATN > Reanla failure attribute ATN d/2 Zosyn . although
chenge Cefepime , improvement . Renal US
show obstruction .
Pt 's creatinitne remain near 1.3.plan keep pt
hydrated , avoid nephrotoxin follow creatinine
outpatient .
.
# PPX : Ms. [ * * know lastname 94714 * * ] treat SC heparin , protonix ,
bowel regimen . constipation , bowel
regiman increase good result .
.
# access : maintain piv throughout
hospitalization . shortly discharge PICC line place
lose peripheral access .
.
# code status : per discussion Ms [ * * know lastname 94714 * * ] husband
full code throughout stay .
medication admission :
Elavil ( stop week ago )
discharge medication :
1 . Docusate Sodium 150 mg/15 mL Liquid Sig : [ * * 12 - 7 * * ] po BID ( 2 time
day ) .
2 . Camphor - Menthol 0.5 - 0.5 % Lotion Sig : one ( 1 ) Appl Topical
TID ( 3 time day ) .
3 . Metoprolol Tartrate 25 mg Tablet Sig : 1.5 tablet po BID ( 2
time day ) .
4 . Heparin ( Porcine ) 5,000 unit / mL Solution Sig : one ( 1 )
Injection TID ( 3 time day ) .
5 . senna 8.6 mg Tablet Sig : 1 - 2 tablet po BID ( 2 time day ) .
6 . Bisacodyl 10 mg Suppository Sig : [ * * 12 - 7 * * ] Suppositorys Rectal
DAILY ( Daily ) .
7 . aspirin 81 mg Tablet , Chewable Sig : one ( 1 ) Tablet , Chewable
po DAILY ( Daily ) .
8 . Lansoprazole 30 mg Capsule , Delayed Release(E.C. ) Sig : one
( 1 ) Capsule , Delayed Release(E.C. ) PO BID ( 2 time day ) .
9 . olanzapine 5 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need .
Disp:*60 Tablet(s ) * Refills:*0 *
10 . Acetaminophen 325 mg Tablet Sig : one ( 1 ) Tablet PO Q4 - 6h
( every 4 6 hour ) need .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 672 * * ] hospital
discharge Diagnosis :
Amiotrophic Lateral Sclerosis
Hypercarbic Respiratory Failure
Atrial Fibrillation
Recurrent Pneumonia - Ventilator Associated Pneumonia
Renal Failure
discharge condition :
good , afebrile , cough , fever , tracheostomy good
condition .
Discharge instruction :
please continue use exsuflator need . please come back
ED new episode worsen cough , fever
productive sputum .
.
Pleae take medication prescribe .
.
note diarrhea morning prior
discharge , please call [ * * Hospital1 18 * * ] check result c.
diff stool culture [ * * 2179 - 3 - 25 * * ] , consider c. diff study
diarrhea continue .
Followup Instructions :
PCP : [ * * Name10 ( NameIs ) * * ] , [ * * first Name3 ( LF ) 2946 * * ] S. [ * * telephone / Fax ( 1 ) 2936 * * ]
.
recent onset diarrhea . please call [ * * Hospital1 18 * * ] microbiology lab
( [ * * telephone / Fax ( 1 ) 94716 * * ] follow result c. diff toxin assay .
.
please check cbc chem 7 [ * * 2179 - 3 - 26 * * ] . new onset
hypernatremia [ * * 2179 - 3 - 24 * * ] . free water increase tube feed
[ * * 2179 - 3 - 24 * * ] .
[ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 2437 * * ] MD [ * * MD Number(1 ) 2438 * * ]
complete by:[**2179 - 3 - 24 * * ]
|
[
"486",
"5845",
"2760",
"4589",
"2724",
"2859"
] |
Admission Date : [ * * 2196 - 9 - 27 * * ] Discharge Date : [ * * 2196 - 10 - 17 * * ]
Date Birth : [ * * 2151 - 3 - 3 * * ] sex :
Service : SURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 1384 * * ]
Chief Complaint :
ESLD
Major Surgical Invasive Procedure :
[ * * 2196 - 9 - 27 * * ] liver transplant
history Present Illness :
45 history EtOH cirrhosis , MELD 28 child class
c cirrhosis recently admit [ * * Hospital1 18 * * ] last month fever ,
anemia , ascite ARF . brief , recent hospital
course , treat c.perfringen bacteremia
treat Zosyn . Paracentesis perform
reveal
spontaneous peritonitis . egd evaluation show Grade
varix . renal failure issue respond octreotide
midodrine . resume diuretic last Cr normalize
baseline ( 1.0 ) .
admit preparation liver transplant . deny
change health since previous admission . afebrile still
rather lethargic home . tolerate regular diet . normal bowel
habit , describe often loose . abdominal tenderness
tender paracentesis site . food since
midnight .
Past Medical history :
EtOH cirrhosis
EtOH Abuse
Gout
/ p appendectomy several yrs ago
h / HTN normotensive med
[ * * 2196 - 9 - 27 * * ] liver transplant
Social History :
live wife son 10 14 yo . work energy
broker . deny drug tobacco use . Quit drink 6 week ago
Family history :
adopt family hx unknown
Physical Exam :
98.9 91 128/77 18 98ra
Gen : AAOX3 , NAD
HEENT : scleral icterus , MMM , EOMi , NCAT
Skin : Jaundice
Cardio : RRR
Pulm : CTAB
Abd : soft , obese , umbilical hernia note , tender paracentesis
site , distend / ascite , spider angiomas
Ext : 3 + pitting edema b / l LE
Neuro : focal deficit
CXR :
EKG : sinus rhythm . non - specific anterior ST - wave change .
delay precordial r wave transition
Labs :
135 97 11 estGFR : > 75
---|----|---- < 104
4.3 28 1.0
Ca : 9.7 Mg : 1.7 p : 3.4
ALT : 16 AST : 48 AP : 92 tbili : 18.6 Alb : 4.0
7.7 > 8.2 < 149
25.1
PT : 27.2 PTT : 55.8 INR : 2.7
Fibrinogen : 59
recent workup :
Liver / RUQ US ( [ * * 2196 - 8 - 26 * * ] ): 1 ) cirrhosis ascite . 2 ) New ,
partially occlusive main portal vein thrombosis extend
left portal vein . please note , study limit
right portal vein , splenic vein , portal venous confluence
well visualize . 3 ) distend gallbladder without sign
acute cholecystitis . finding may due fast state
EGD ( [ * * 2196 - 8 - 26 * * ] ): varix low third esophagus
gastroesophageal junction , Linear non bleeding erosion 35 cm .
Erythema , abnormal vascularity mosaic appearance
whole
stomach compatible portal hypertensive gastropathy .
otherwise normal egd second part duodenum
TTE [ * * 8 - 30 * * ] : EF > 60 %
pertinent result :
[ * * 2196 - 10 - 17 * * ] 04:53AM blood WBC-9.5 RBC-2.90 * Hgb-8.7 * Hct-27.0 *
MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4 * Plt ct-334
[ * * 2196 - 10 - 13 * * ] 09:32AM blood pt-11.7 PTT-23.6 INR(PT)-1.0
[ * * 2196 - 9 - 30 * * ] 02:52AM blood Fibrino-180
[ * * 2196 - 9 - 27 * * ] 05:00am blood glucose-104 UreaN-11 Creat-1.0 Na-135
K-4.3 Cl-97 HCO3 - 28 angap-14
[ * * 2196 - 9 - 28 * * ] 04:16PM blood glucose-114 * UreaN-30 * Creat-2.3 * Na-142
K-4.6 cl-104 HCO3 - 28 angap-15
[ * * 2196 - 9 - 30 * * ] 10:50pm blood Glucose-122 * UreaN-70 * Creat-4.6 * na-137
K-5.8 * Cl-97 HCO3 - 26 AnGap-20
[ * * 2196 - 10 - 2 * * ] 06:10AM blood glucose-137 * urean-87 * Creat-5.2 * Na-135
K-5.2 * Cl-93 * HCO3 - 26 AnGap-21 *
[ * * 2196 - 10 - 7 * * ] 05:07AM blood Glucose-147 * UreaN-94 * Creat-3.6 * na-130 *
K-4.2 cl-94 * HCO3 - 24 AnGap-16
[ * * 2196 - 10 - 17 * * ] 04:53AM blood Glucose-93 UreaN-69 * Creat-2.0 * Na-132 *
K-5.2 * cl-100 HCO3 - 21 * AnGap-16
[ * * 2196 - 9 - 27 * * ] 05:00am blood ALT-16 AST-48 * alkphos-92 TotBili-18.6 *
[ * * 2196 - 10 - 17 * * ] 04:53AM blood ALT-33 AST-31 alkphos-276 * TotBili-1.6 *
[ * * 2196 - 10 - 17 * * ] 04:53AM BLOOD Calcium-8.7 Phos-4.7 * Mg-1.5 *
Brief Hospital course :
[ * * 2196 - 9 - 27 * * ] , undergo deceased donor liver transplant .
Surgeon dr.[**first name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] . two 19 - french [ * * Doctor Last Name 406 * * ] drain
place posterior liver behind portal structure .
please refer operative note complete detail . aggressive
blood product resuscitation anesthesiology staff well
administration protamine perform . induction
immunosuppression start intraop ( solumedrol ) .
Postop , transfer sicu management
receive blood product maintain hemodynamic stability per
protocol . lft initially increase expect . hepatic duplex
reveal inadequate flow demonstrate within right posterior
portal vein could technical nature versus
small amount thrombus . patency appropriate direction
flow within hepatic artery , hepatic vein , left
main portal vein see . Splenomegaly note . repeat
study [ * * 10 - 1 * * ] reveal patency appropriate direction flow
within hepatic portal venous system . high flow
velocity main portal vein , aliasing
expect region anastomosis note .
notation fatty infiltration liver . lft trend
( ast 580 , alt 530 , alk phos 130 , t.bili 6.6 ) . JP output
remain high average 900 - 1100ml per day . lft start
trend postop day 4 5 . jp output appear foamy .
[ * * 10 - 4 * * ] , ERCP perform note common bile duct mild
narrowing bile duct anastomosis , minimal associate
proximal ductal
dilatation . filling defect cbd
intrahepatic duct .
evidence bile leakage . plastic biliary stent
place . post procedure , amylase lipase wnl . JP
drain output continue high average much
2200ml / day . iv fluid replacement albumin administer
per output . lateral JP remove [ * * 10 - 5 * * ] . medial JP
continue drain much 1800ml per day . IV lasix give
anasarca several day . teds stocking apply
improvement edema . Weight decrease 90.4 Kg [ * * 10 - 16 * * ]
117.4 [ * * 9 - 26 * * ] . medial JP remove [ * * 9 - 14 * * ] . site
remain dry suture .
note , alk phos continue rise 518 . Repeat ERCP do
[ * * 10 - 13 * * ] . obstruction biliary stent .
stent exchange . alk phos continue increase .
[ * * 10 - 14 * * ] , liver biopsy perform note rejection . mark
bile ductular proliferation associate neutrophilic
inflammation , focal ductal dilation , mark cholestasis , bile
plug formation portal tract edema ; rare foci mild portal
mononuclear inflammation scatter eosinophil ;
endothelialitis diagnostic involvement acute cellular
rejection identify . steatosis viral inclusion see .
Rare peri - venular lipofuscin - laden macrophage , suggestive
resolve reperfusion injury . ERCP , LFTS trend
( ast 31 , alt 33 , alk phos 276 , t.bili 1.6 ) . postop pyloric
feeding tube replace [ * * 10 - 6 * * ] remove
ERCP .
experience ATN likely intraop hemodynamic . Creatine
1.0 [ * * 9 - 27 * * ] . start rise postop high
5.2 postop day 5 . gradually , creatinine improve .
Creatinine decreaed 1.8 [ * * 10 - 13 * * ] , start trend
2.0 likely Prograf trough elevate .
level increase 14.1 [ * * 10 - 16 * * ] . Prograf dose adjust
0.5 mg [ * * hospital1 * * ] [ * * 10 - 16 * * ] 1 mg [ * * hospital1 * * ] . immunusuppression consist
cellcept 1gram [ * * hospital1 * * ] well tolerate . solumedrol
taper per transplant protocol prednisone . Prograf
start postop day 1 adjust per trough level .
Diet slowly advanced , poorly tolerate patient
appetite . postpyloric feeding tube place tube
feeding start ( novasource renal ) . oral intake slowly
increase , insufficient support caloric need .
[ * * 10 - 10 * * ] Dermatology biopsie l thumb chronic
non - healing , bleed punctate lesion ( start [ * * 4 - 21 * * ] ) . Biopsy
report note many feature suggestive lichen simplex
chronicus / prurigo nodularis , mild atypia
present favor reactive context . central
ulceration could secondary excoriation ; alternatively ,
may represent channel transepidermal elimination
foreign body setting perforate disorder
( although clinical history suggestive latter ) .
underlie pyogenic granuloma entirely exclude
basis sample ; clinical suspicion persist , deep
sampling may helpful definitive diagnostic
evaluation . bleeding stop site remain clean
dry .
PT work extensively hospital course
deconditione . experience fall onto right hip(slippe
transfer bed ) . pain hip flexion
pain exam greater trochanter . xray hip
negative . require contact guard rolling walker time
discharge , ready discharge home . Rehab
recommend [ * * hospital1 * * ] accept . transfer
[ * * 10 - 17 * * ] .
medication admission :
Folic Acid 1 , Thiamine HCl 100 , Ursodiol 300 '' ' , Ranitidine
HCl 150 '' , lactulose , Furosemide 20 , Spironolactone 100 , Zofran
4 , Maalox , Rifaximin 200 '' '
Discharge medication :
1 . Insulin Regular Human 100 unit / mL Solution Sig : follow
slide scale Injection four time day .
2 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
3 . Miconazole Nitrate 2 % Powder Sig : one ( 1 ) Appl Topical TID
( 3 time day ) .
4 . Valganciclovir 450 mg Tablet Sig : one ( 1 ) Tablet PO EVERY
day ( every Day ) .
5 . Mycophenolate Mofetil 500 mg Tablet Sig : two ( 2 ) Tablet PO
BID ( 2 time day ) .
6 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
7 . Trimethoprim - Sulfamethoxazole 80 - 400 mg Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) .
8 . fluconazole 200 mg Tablet Sig : two ( 2 ) Tablet PO Q24H ( every
24 hour ) .
9 . oxycodone 5 mg Tablet Sig : one ( 1 ) Tablet po Q4H ( every 4
hour ) need pain .
10 . Camphor - Menthol 0.5 - 0.5 % Lotion Sig : one ( 1 ) Appl Topical
TID ( 3 time day ) need itching .
11 . furosemide 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
12 . tacrolimus 0.5 mg Capsule Sig : one ( 1 ) Capsule po Q12H
( every 12 hour ): please fax prograf trough level
[ * * telephone / Fax ( 1 ) 697 * * ] .
Call [ * * telephone / Fax ( 1 ) 673 * * ] dose adjustment , attn [ * * First Name8 ( NamePattern2 ) 1022 * * ] [ * * last Name ( NamePattern1 ) * * ] , RN
coordinator .
13 . prednisone 5 mg Tablet Sig : 3.5 tablet po DAILY ( Daily ):
follow taper schedule per [ * * Hospital1 18 * * ] Transplant .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 7 * * ] & Rehab Center - [ * * hospital1 8 * * ]
discharge Diagnosis :
etoh cirrhosis / p liver transplant [ * * 2196 - 9 - 27 * * ]
bile duct narrow , / p stent
malnutrition
leave thumb bleeding / p biopsy : pyogenic granuloma
ATN , resolve
discharge condition :
good
Discharge instruction :
please call [ * * Hospital1 18 * * ] Transplant Office [ * * telephone / Fax ( 1 ) 673 * * ] fever ,
chill , nausea , vomiting , inability take
medication , jaundice , abdominal distension , increase abdominal
pain , edema , dizziness , incision redness / bleeding / drainage
concern
continue tube feeding order ( Novasource renal 45cc / hr
continuously via feeding tube )
Labs every Monday Thursday 9 cbc , chem 10 , lft ,
albumin trough prograf level result fax'd [ * * Hospital1 18 * * ]
Transplant Office [ * * telephone / Fax ( 1 ) 697 * * ] attention [ * * First Name8 ( NamePattern2 ) 1022 * * ] [ * * last Name ( NamePattern1 ) * * ] , RN
coordinator [ * * telephone / Fax ( 1 ) 10575 * * ]
[ * * Month ( ) 116 * * ] shower , heavy lifting / strain
Followup Instructions :
Provider : [ * * First Name11 ( Name Pattern1 ) 674 * * ] [ * * last Name ( namepattern4 ) 675 * * ] , MD phone:[**telephone / fax ( 1 ) 673 * * ]
Date / Time:[**2196 - 10 - 20 * * ] 3:00
Provider : [ * * Name10 ( NameIs ) * * ] , [ * * Name11 ( NameIs ) 156 * * ] transplant SOCIAL WORK Date / Time:[**2196 - 10 - 27 * * ]
11:30
Provider : [ * * First Name11 ( Name Pattern1 ) 674 * * ] [ * * last Name ( namepattern4 ) 675 * * ] , MD phone:[**telephone / fax ( 1 ) 673 * * ]
Date / Time:[**2196 - 10 - 27 * * ] 1:20
complete by:[**2196 - 10 - 17 * * ]
|
[
"5845",
"2761",
"4280",
"2749"
] |
Admission Date : [ * * 2151 - 6 - 14 * * ] Discharge Date : [ * * 2151 - 9 - 18 * * ]
Date Birth : [ * * 2151 - 6 - 14 * * ] Sex : F
Service : Neonatology
history : 1320 g female , twin , bear via c - section
37 - year - old g4 , P [ * * 1 - 27 * * ] mother 32 1/7 week IUGR
twin B. history decrease Doppler flow twin
B. Maternal lab include blood type O+ , antibody negative ,
rpr nonreactive , hepatitis B surface antigen negative ,
rubella immune , GBS unknown . infant emerge vigorous
apgar 8 8 . receive blow - O2
routine stimulation suctioning .
ADMISSION PHYSICAL examination : vital sign : Weight 1320 g
( 25th percentile ) ; length 41.5 ( 25th 50th percentile ) ;
head circumference 29.25 ( 25th percentile ) ; temperature 97 ;
heart rate 170 ; respiratory rate 36 ; blood pressure 43/34
( 34 ) ; O2 saturation 89 % blow - O2 . general : alert ;
pink ; cry . heent : anterior fontanelle open flat ;
mucous membrane moist ; palate intact . lung : decrease air
movement throughout , prolong expiratory phase .
cardiovascular : regular rate rhythm ; murmur ; 2 +
femoral pulse . gi : soft ; masse . GU : normal premature
female external genitalia . musculoskeletal : Hips
clavicle intact . neurologic : move extremity .
discharge PHYSICAL examination : Weight 3835 g ; head
circumference 36.0 cm ; length 52 cm .
SUMMARY HOSPITAL course system :
1 . respiratory . upon admission , baby start
nasal CPAP . need intubate day life 1
remain intubate day life 3
transition back nasal CPAP . day life 4 ,
transition room air room air
since time . apnea prematurity
treat caffeine . discontinue day
life 14 . issue since time .
2 . cardiovascular . birth , normal blood
pressure never require pressor fluid bolus .
murmur stable .
3 . fluid , Electrolytes , Nutrition . baby start
n.p.o . IV fluid . UVC
several day receive several day parenteral
nutrition . day life 3 , start feed ,
advance tolerate . many problem
p.o . feed . secondary difficulty p.o .
feed take enough , receive jejunostomy tube .
currently , p.o . ad . lib . feed day
night , start 10 p.m. go till 6 a.m. ,
receive J tube continuous feed 100 ml / kg 8
hour .
4 . gi . baby find hyperbilirubinemia day
life 2 peak 6.8/0.2 . receive several
day phototherapy , phototherapy stop
day life 5 bilirubin
issue . day life 12 , start iron 2
mg / kg / day , continue today . baby
find severe reflux work
GI [ * * hospital3 1810 * * ] , [ * * Location ( un ) 86 * * ] . start
multiple medication , continue today
Prilosec , Reglan , Zantac , Maalox . secondary ,
endoscopy [ * * 2151 - 9 - 10 * * ] .
negative esophagitis although pathology
biopsy still pende . NJ tube place see
would improve feeding also improve
irritability , arching , reflux - relate
behavior . , jejunostomy tube place
[ * * 2151 - 9 - 14 * * ] . need follow Dr. [ * * last Name ( STitle ) 79 * * ]
[ * * Hospital * * ] clinic [ * * hospital3 1810 * * ] , [ * * Location ( un ) 86 * * ] .
5 . Hematology . birth , CBC do baby
hematocrit 41.2 283 platelet . late
hematocrit 31.1 day life 91 .
6 . infectious disease . birth , rule - sepsis workup
do . baby white count 7 51
neutrophil 2 band . 48 hour ampicillin
gentamicin , discontinue . postop day
# 1 , [ * * 2151 - 9 - 15 * * ] , spike fever 101.3
sepsis workup do . reassuring
negative . receive 48 hour ampicillin
gentamicin issue .
7 . neurology . baby always normal neurologic
exam 2 normal head ultrasound - late
[ * * 2151 - 7 - 20 * * ] .
8 . Sensory .
a. Audiology . hearing screen perform
automate auditory brain stem response , baby
pass .
b. Ophthalmology . baby 2 ophthalmologic
exam . eye recently examine [ * * 2151 - 7 - 26 * * ] , reveal mature retinal vessel . follow -
exam 6 month recommend .
condition DISCHARGE : good .
discharge disposition : home .
PRIMARY CARE PEDIATRICIAN : [ * * last Name ( un ) * * ] -[**First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 437 * * ] Pediatric
Associates [ * * Location ( un ) 3786 * * ] ( phone number [ * * telephone / Fax ( 1 ) 45614 * * ] ) .
CARE recommendation :
1 . feed discharge - please continue Neocate 24 feed
p.o . ad . lib . day J tube feed 100
ml / kg 8 hour night .
2 . Medications - Prilosec 1 mg / kg / dose b.i.d . ; Reglan 0.1
mg / kg q.i.d . ; Zantac 10 mg p.o . b.i.d . ; Maalox 2.5 ml q
p.o . feed ; iron sulfate 2 mg / kg / day .
3 . iron vitamin supplementation .
a. iron supplementation recommend preterm
low birth weight infant 12 month correct
age .
b. infant feed predominantly breast milk
receive vitamin supplementation 200 iu ( may
provide multivitamin preparation ) daily 12
month correct age .
4 . car seat position screen test pass prior
discharge .
5 . state newborn screening status - baby 3 state
newborn screen - [ * * 2151 - 6 - 17 * * ] ; [ * * 2151 - 6 - 28 * * ] ; [ * * 2151 - 7 - 26 * * ] - normal .
6 . immunization receive - baby receive
immunization prior discharge .
7 . immunization recommendation :
a. Synagis RSV prophylaxis consider
[ * * Month ( ) * * ] [ * * Month ( ) 958 * * ] infant meet
follow 4 criterion : 1 ) bear less 32 week ; 2 )
bear 32 35 week 2 following :
daycare RSV season , smoker household ,
neuromuscular disease , airway abnormality , school-
age sibling ; 3 ) chronic lung disease ; 4 )
hemodynamically significant congenital heart disease .
b. Influenza immunization recommend annually
fall infant reach 6 month
age . age ( first 24 month
child 's life ) , immunization influenza
recommend household contact - - home
caregiver .
c. infant receive rotavirus vaccine .
American Academy Pediatrics recommend initial
vaccination preterm infant follow
discharge hospital clinically
stable least 6 week , few 12 week
age .
FOLLOW - APPOINTMENT schedule recommended :
1 . baby follow - appointment primary
care pediatrician [ * * last Name ( LF ) 766 * * ] , [ * * 2151 - 9 - 20 * * ] .
2 . follow - appointment need make [ * * hospital1 62374 * * ] GI , Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 79 * * ] , 2 week discharge .
discharge diagnosis :
1 . prematurity 32 1/7 week ' gestation .
2 . Twin gestation .
3 . rule sepsis .
4 . respiratory distress syndrome .
5 . severe gastroesophageal reflux .
6 . status post J tube placement .
review : [ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 53043 * * ] , [ * * MD Number(1 ) 53044 * * ]
dictate By:[**First Name3 ( LF ) 72788 * * ]
medquist36
: [ * * 2151 - 9 - 20 * * ] 14:06:19
: [ * * 2151 - 9 - 20 * * ] 15:21:09
Job # : [ * * Job Number 72789 * * ]
|
[
"7742",
"769",
"V290"
] |
Admission Date : [ * * 2150 - 12 - 24 * * ] Discharge Date : [ * * 2150 - 12 - 26 * * ]
Date Birth : [ * * 2092 - 10 - 10 * * ] sex : F
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 898 * * ]
Chief Complaint :
Dyspnea
Major Surgical Invasive Procedure :
none
history Present Illness :
58f breast cancer , HTN , CHF , PAF / p PVI present
shortness breath , increase past day . note
symptom become gradually , increase dyspnea
exertion productive cough develop
palpitation , increase dyspnea relate . pulse
fast irregular . come emergency department
find rapid atrial fibrillation ; chest x - ray
reveal pneumonia . recieve levofloxacin IV
diltiazem ED admit .
Past Medical History :
1 . PAF / p pulm vein isolation , w/ recurrence / p radiation ,
amiodarone .
2 . CHF diastolic EF 62 % MRI [ * * 3 - 6 * * ]
3 . breast cancer stage II status post right mastectomy
status post six month tamoxifen therapy , / p XRT
4 . Hypertension .
5 . Hyperlipidemia .
Social History :
Patient married live husband . deny
smoking alcohol use .
Family history :
NC
Physical Exam :
99.4 , bp 134/86 , hr 122 , rr 18 , spo2 96 % 2L nc
gen- pleasant f , look age , mild distress , non - toxic
heent- anicteric , op clear mmm
neck- jvd / lad / thyromegaly
cv- tachy , irreg irreg , / r / g
pul- move air well , slight bibasilar rale r > l
abd- soft , not , nd , nab
extrm- cyanosis / edema , warm / dry
nails- club , pitting / color change / indentation
neuro- a&ox3 , focal cn / motor deficit
pertinent result :
[ * * 2150 - 12 - 24 * * ] 10:00PM blood wbc-6.5 rbc-4.33 hgb-13.0 Hct-36.7
MCV-85 # MCH-29.9 mchc-35.4 * # RDW-14.7 Plt ct-150
[ * * 2150 - 12 - 26 * * ] 06:00AM blood Glucose-91 UreaN-11 Creat-0.8 na-139
K-4.3 Cl-105 HCO3 - 25 angap-13
[ * * 2150 - 12 - 24 * * ] 10:00PM blood CK(CPK)-54 TotBili-0.6
[ * * 2150 - 12 - 24 * * ] 10:00PM blood CK - MB - NotDone cTropnT-<0.01
[ * * 2150 - 12 - 26 * * ] 06:00AM blood ck(cpk)-81
[ * * 2150 - 12 - 26 * * ] 06:00AM blood CK - MB - NotDone cTropnT-<0.01
[ * * 2150 - 12 - 25 * * ] 06:40AM blood ALT-31 AST-18 alkphos-76 TotBili-0.5
[ * * 2150 - 12 - 25 * * ] 06:40AM blood tsh-4.6 *
Brief Hospital Course :
58f breast cancer , htn , chf , paf / p pvi admit
pneumonia afib rapid ventricular response
.
Afib -- Mrs. [ * * know lastname * * ] maintain amiodarone home sinus
rhythm . feel pneumonia likely culprit
exacerbation back fibrillation . see
EP staff feel would well loading dose
amiodarone 400 mg twice daily three day ; would
return usual dose 200 mg daily . begin
good response . Sinus rhythm quickly - instated .
symptom dyspnea palpitation seem improve
reversion sinus . discharge one day
loading - dose amidodarone leave sinus rhythm , rate
generally 70 's .
.
Pneumonia -- although clinically mild , feel sufficient
cause loss sinus rhythm . O2 requirement
treat course levofloxacin . time
discharge , afebrile decrease cough sputum
production . Micro datum unreveale .
medication admission :
Pantoprazole 40 mg daily
Amiodarone 200 mg daily
Metoprolol 25mf twice daily
Warfarin 2 mg mon - fri 1 mg sat - sun
ASA 325 mg daily
Discharge medication :
1 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
2 . Metoprolol Tartrate 25 mg Tablet Sig : three ( 3 ) Tablet PO BID
( 2 time day ) .
3 . Levofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet PO Q24H ( every
24 hour ) 4 day .
Disp:*4 Tablet(s ) * Refills:*0 *
4 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
5 . warfarin 1 mg Tablet Sig : one ( 1 ) Tablet PO SAT - SUN ( ) .
6 . warfarin 2 mg Tablet Sig : one ( 1 ) Tablet PO MON - FRI ( ) .
7 . amiodarone 200 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) 1 day : take 2 pill twice day Saturday
Sunday , return 200 mg day .
Disp:*4 Tablet(s ) * Refills:*0 *
discharge Disposition :
Home Service
Facility :
[ * * Location ( un ) 86 * * ] VNA
Discharge Diagnosis :
atrial fibrillation rapid ventricular response
Pneumonia
Secondary :
1 . PAF / p pulm vv isolation , w/ recurrence / p radiation ,
amiodarone .
2 . CHF , one episode post cardioversion , diastolic EF 55 % 2/04
3 . breast cancer stage II status post right mastectomy
status post six month tamoxifen therapy , / p XRT
4 . hypertension
5 . hyperlipidemia
discharge condition :
Good , sinus rhythm , improved symptom
discharge instruction :
admit pneumonia rapid heart rate ;
heart rate control temporarily increase dose
amiodarone , give antibiotic pneumonia .
.
call pcp return ed fever / chill , chest pain ,
shortness breath , lightheadedness , loss conciousness ,
concern symptom .
.
take 400 mg amiodarone twice day Saturday Sunday ,
return usual dose 200 mg day Monday .
Followup Instructions :
please see primary care doctor next 1 - 2 week ; call
[ * * telephone / Fax ( 1 ) 2740 * * ] make appointment .
.
Provider : [ * * last Name ( NamePattern4 ) 105871 * * ] NP / DR [ * * last Name ( STitle ) * * ] phone:[**telephone / fax ( 1 ) 612 * * ]
Date / Time:[**2151 - 3 - 4 * * ] 8:00
.
Provider : [ * * Name10 ( NameIs ) 326 * * ] [ * * Name11 ( NameIs ) * * ] DX RM2 RADIOLOGY phone:[**telephone / Fax ( 1 ) 327 * * ]
Date / Time:[**2151 - 3 - 9 * * ] 11:00
.
Provider : [ * * Name10 ( NameIs ) 251 * * ] [ * * last Name ( NamePattern4 ) 677 * * ] , M.D. phone:[**telephone / fax ( 1 ) 2934 * * ]
Date / Time:[**2151 - 3 - 19 * * ] 3:15
|
[
"486",
"4019",
"2724",
"2859"
] |
Admission Date : [ * * 2115 - 1 - 11 * * ] Discharge Date : [ * * 2115 - 1 - 19 * * ]
Date Birth : [ * * 2033 - 12 - 10 * * ] sex :
Service : MEDICINE
allergy :
iodine
attending:[**first Name3 ( LF ) 7881 * * ]
Chief Complaint :
chest pain
Major Surgical Invasive Procedure :
Cardiac Catheterization
history Present Illness :
81 year old man CAD / p cabg [ * * 2103 * * ] LIMA
LAD , SVG PDA , SVG OM , HTN , IDDM , PVD / p bilateral
LE bypass , CRI , admit [ * * Hospital3 417 * * ] Hospital [ * * 1 - 7 * * ]
shortness breath chest pain x one week . initially think
rest angina . rule mi , ekg change . transfer
cath .
hold area pt chest pain , ekg change . underwent
difficult catheterization today(receive large amount
radiation)which demonstrate severe native three vessel disease .
left main heavily calcify 80 % distal stenosis .
left anterior descend receive blood LIMA graft .
left circumflex demonstrate 90 % ostial lesion . RCA
diffusely diseased . LIMA - LAD graft patent . SVG - OM
patent ; SVG - RPDA patent 85 % mid rca lesion . attempt
pci today due excessive radiation dose dye dose . Pt
schedule plan pci SVG - rpda possible LMCA
intervention Monday .
Past Medical History :
HTN
IDDM
CAD / p cabg [ * * 2103 * * ] LIMA LAD , SVG PDA , SVG
OM ( [ * * 2103 * * ] )
PVD / p bilateral LE bypass
COPD
carotid disease
CRI
BPH / p TURP
nephrolithiasis
history thrombocytopenia
Social History :
social history significant 50 pack year smoking history ;
quit ' [ * * 03 * * ] , ETOh drug use . life home wife ,
independent ADLs .
Family history :
NC
Physical Exam :
GEN : elderly male , NAD
HEENT : NC / , EOMI , PERRL , / p clear , MMM
Neck : JVP+9 , supple
CV : RRR , / r / g
lung : CTA bilaterally
Abd : Obese , soft , NT , ND
Ext : WWP , edema
Neuro : A&O x3
Pertinent result :
[ * * 2115 - 1 - 11 * * ] 09:15pm glucose-208 * UREA N-45 * CREAT-1.9 * SODIUM-136
POTASSIUM-5.1 chloride-107 total CO2 - 21 * ANION GAP-13
[ * * 2115 - 1 - 11 * * ] 09:15pm CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.2
[ * * 2115 - 1 - 11 * * ] 09:15pm wbc-4.1 RBC-3.07 * HGB-10.1 * HCT-29.7 * MCV-97
MCH-32.9 * # mchc-34.0 RDW-15.7 *
[ * * 2115 - 1 - 11 * * ] 09:15pm PLT COUNT-96 *
[ * * 2115 - 1 - 11 * * ] 06:16PM GLUCOSE-369 * UREA N-45 * CREAT-1.8 * SODIUM-134
POTASSIUM-5.3 * chloride-105 TOTAL CO2 - 20 * anion gap-14
[ * * 2115 - 1 - 11 * * ] 06:16PM estGFR - use
c.cath [ * * 1 - 11 * * ]
comment :
1 . selective cornary angiography right dominant system
reveal
diffuse three vessel coronary artery disease . LMCA
unable
engage selectively despite use 4 french JL4 , JL4.5 , JL5 .
five
french JL5 , JL4.5 , AL1 , AL2 , AL3 also unsucessful .
LMCA
heavily calcify ostial plaque .
80 % distal
LMCA lesion involve origin LAD , ramus ,
[ * * Month / Day ( 4 ) * * ] .
LAD functional ostial stenosis ( extend distal
LMCA ) ;
signficiant proximal stenosis ; minimal flow mid
LAD .
overall , LAD able well visualize
difficulty engage LMCA . [ * * Month / Day ( 4 ) * * ] 90 % stenosis
origin
extend distal lmca . av groove [ * * Month / Day ( 4 ) * * ] supply
diffusely disease OM1 ( 70 % stenosis ) LPL . ramus
well see ostial 80 % stenosis . heavily
calcify
plaque aorta origin RCA . RCA heavy
calcification proximally 70 % 90 % stenosis . mid
vessel
50 % stenosis . distal rca tortuous vessel
supply
long low acute marginal lateral branch supply
inferior septum . native av groove RCA heavily calcify
subtotally occlude take - large low .
2 . venous conduit angiography reveal SVG OM ( engage
5
french AL2 ) patent thoughout touch onto
low
pole OM communicate native AV groove [ * * Name ( NI ) * * ] .
SVG - rPDA ( engage 5 french MPA ) ostial 30 % mid
85 %
stenosis ; graft retrogradely fill severely diffusely
disease
distal av groove RCA give septal collateral LAD .
3 . Nonselective arterial conduit angiography reveal patent
LIMA
30 % ostial stenosis touch small calibur ,
heavily
calcife LAD ( well image ) .
4 . leave subclavian angiography reveal heavily calcife
vessel
proximal 50 % stenosis . left subclavian stenosis prevent
advancement 4 french [ * * Female First Name ( un ) 899 * * ] catheter despite use angle
glide
wire , slip catheter , Amplatz stiff wire . 4 french
Berenstein
ultimately advance subclavian distal LIMA
angle
glide wire .
5 . leave ventriculography perfome secondary renal
insufficency .
6 . Limited hemodynamic demonstrate systemic systolic
hypertension
central aortic pressure 167/68 ( systolic / diastolic
mmHg ) .
severe diastolic dysfunction LVEDP 32 mmHg .
gradient across aortic valve pullback .
FINAL DIAGNOSIS :
1 . three vessel coronary artery disease .
2 . severe diastolic ventricular dysfunction .
.
[ * * 1 - 14 * * ] cardiac cath :
1 . plan intervention 90 % body SVG - PDA lesion
direct stenting Vision 3.5x18 mm stent .
2 . Limited hemodynamic BP 142/59 hr 55
significant
ventricular ectopy .
3 . Access via 6f long sheath RFA .
FINAL DIAGNOSIS :
1 . succesful direct stenting SVG - PDA graft bare metal
stent .
Brief Hospital course :
.
# . cad : patient present OSH [ * * 1 - 7 * * ] shortness
breath chest pain . transfer [ * * Hospital1 18 * * ]
cardiac cathterization . diagnostic procedure [ * * 2115 - 1 - 11 * * ]
complicated require signficant amount dye radiation ,
therefore , intervention plan another day .
demonstrate severe native 3vd , patent LIMA - LAD , SVG - OM , 90 % [ * * Date Range * * ]
ostial lesion , diffusely disease RCA 85 % lesion patent
SVG - RPDA . receive Reopro post cathterization develop
hematoma require pressure dress . patient develop
refractory chest pain without ECG change
intervention could perform , transfer CCU
monitoring management .
CCU , give Argatroban ACS ( report concern
: HIT ) . cardiac cathterization [ * * 2115 - 1 - 14 * * ]
intervention stenting SVG - RCA . sheath pull
Argatroban patient develop significant
hematoma require 2 unit prbc transfusion . next day ,
patient develop stutter chest pain plan make
take back cath lab possible intervention left
main RCA . transition nitro gtt isosorbide
chest pain . start argatroban prior
procedure . undergo third catheterization [ * * 1 - 17 * * ]
stente L. Subclavian . subsequently remain chest
pain free . continue aspirin , Plavix , statin ,
Toprol . event occur , chest pain resolve
send home medication .
.
# . systolic Heart Failure : echo perform show EF
60 % . Patient continue Lasix beta blocker
increase .
.
# . rhythm : patient normal sinus rhythm
hospital stay , however CCU episode
bradycardia beta blocker hold . subsequently
resume prior discharge .
.
# . Diabetes - Patient place insulin slide scale
place back home glyburide prior discharge .
.
# CRI - Baseline 2.2 OSH . initially increase first
catheterization subsequently improve post - cath
hydration IVF . creatinine monitor remain
stable throughout rest hospitalization .
medication renally dose receive pre-
post - cath hydration procedure .
.
# Hematuria - Pt gross blood foley think
relate traumatic insertion . foley subsequently
flushed clot . evidence
hematuria intervention take .
.
# BPH - Patient continue home hytrin
.
# Thrombocytopenia - Patient know chronic thrombocytopenia .
unclear baseline , OSH platelet
low 100s . HIT Ab send negative .
Heparin hold throughout stay platelet remain
stable 80 low 100s . intervention take .
.
# Chronic Anemia - Pt Procrit q week ( tue ) . receive 2 unit
prbc CCU hematoma HCt subsequently
remain stable . receive Procrit
hospitalization resume per regular
schedule upon discharge .
.
# Sciatica - Patient continue home Neurontin .
medication admission :
ASA 325 mg daily
Nexium 40 mg daily
Toprol XL 25 mg daily
MVI
Neurontin 300nmg daily
Hytrin 2 mg po QHS
Lasix 40 mg daily
glyburide 5 mg daily
Iron 325 mg daily
Procrot q week ( tue )
Discharge medication :
1 . aspirin 325 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
2 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
3 . Atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
5 . gabapentin 300 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
6 . Terazosin 1 mg Capsule Sig : two ( 2 ) Capsule po HS (
bedtime ) .
7 . Hexavitamin Tablet Sig : one ( 1 ) Cap po DAILY ( Daily ) .
8 . ferrous Sulfate 325 mg ( 65 mg Iron ) Tablet Sig : one ( 1 )
Tablet PO DAILY ( Daily ) .
9 . nexium 40 mg Capsule , Delayed Release(E.C. ) Sig : one ( 1 )
Capsule , Delayed Release(E.C. ) po day .
10 . glyburide 5 mg Tablet Sig : one ( 1 ) Tablet po day .
11 . Procrit Injection
12 . Toprol XL 25 mg Tablet Sustained Release 24 hr Sig : one ( 1 )
Tablet Sustained Release 24 hr po day .
13 . Nitroglycerin 0.4 mg Tablet , Sublingual Sig : one ( 1 )
Sublingual every 5 minute three time need pain :
Tkae every 5 minute three dose ; work call
doctor go ER .
discharge Disposition :
Extended Care
Facility :
Baypointe - [ * * Hospital1 1474 * * ]
discharge diagnosis :
Primary
CAD / p 3 pci
.
Secondary
HTN
IDDM
COPD
PVD
CRI
BPH
Thrombocytopenia
Discharge condition :
improve
Discharge instruction :
admit hospital chest pain .
undergo 3 cardiac catheterization stent place
block vessel heart . complication
one procedure bruising swell
groin resolve .
.
change make medication .
start Lipitor , Plavix . medication keep
.
.
chest pain , shortness breath ,
nausea , vomiting , palpitation , lightheadedne , bleed
groin , concern symptom , please call doctor
return ER .
.
please follow
Followup Instructions :
please follow cardiologist Dr [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] 2
week .
please call make appt PCP [ * * last Name ( namepattern4 ) * * ] [ * * 4 - 8 * * ] week .
|
[
"5849",
"4111",
"4019",
"496",
"4280"
] |
Admission Date : [ * * 2179 - 9 - 22 * * ] Discharge Date : [ * * 2179 - 10 - 14 * * ]
Date Birth : [ * * 2125 - 3 - 18 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 1406 * * ]
Chief Complaint :
vf arrest
Major Surgical Invasive Procedure :
[ * * 2179 - 10 - 7 * * ] : MV repair / MAZE/ leave atrial appendage resection
[ * * 2179 - 10 - 13 * * ] : AICD placement
history Present Illness :
54 year old male known pmh present / p
ventricular fibrillation arrest [ * * 2179 - 9 - 22 * * ] . Red
Sox game sister walk car
stop smoke cigarette collapse . pass
physician initiate CPR within 3 - 5 minute per sister 's
report . find ventricular fibrillation
shock 5 time , give 3 mg epinephrine , 2 mg magnesium
torsade rhythm . eventually spontaneous return
circulation breathing . intubate
field route [ * * Hospital1 18 * * ] . transfer ED
CCU put arctic sun protocol .
unresponsive sedated eventually extubate [ * * 9 - 25 * * ]
agitated uncooperative .
history ETOH heavy smoker . Cardiac cath
[ * * 2179 - 9 - 29 * * ] reveal coronary disease 3 + mitral
regurgitation . evaluate mitral valve repair .
Past Medical History :
unknown , go doctor least 20 year .
Social History :
live : sister
Occupation : work [ * * last Name ( un ) * * ] chemical pipefitte
tobacco:1.5 ppd many year , current
ETOH : beer per night , several weekend
family history :
family history early mi , arrhythmia , cardiomyopathy ,
sudden cardiac death ; otherwise non - contributory .
Physical Exam :
Pulse:108 Resp : 20 O2 sit :
B / p right : 93/81 leave :
height : 6'3 " Weight : 60.7 kgs
General :
skin : Dry [ x ] intact [ x ]
HEENT : PERRLA [ x ] EOMI [ x ] ngt place tube feed .
Neck : Supple [ x ] full rom [ x ]
chest : lung clear bilaterally [ x ]
heart : rrr [ ] Irregular [ x ] Murmur III / VI holo diastolic
murmur
Abdomen : Soft [ x ] non - distended [ x ] non - tender [ x ] bowel sound
+ [ x ]
extremity : Warm [ x ] , well - perfuse [ x ] Edema varicosity :
None [ ]
Neuro : A+Ox3 unable swallow still impulsive
restrain .
pulse :
Femoral right : cath site leave : 2 +
dp right : 2 + leave : 2 +
PT [ * * Name ( NI ) 167 * * ] : 2 + leave : 2 +
Radial Right : 2 + leave : 2 +
Carotid Bruit right : leave :
pertinent result :
[ * * 2179 - 10 - 12 * * ] 04:40AM blood WBC-12.4 * RBC-3.24 * Hgb-10.5 * Hct-31.2 *
MCV-96 MCH-32.5 * MCHC-33.8 RDW-14.4 Plt Ct-242
[ * * 2179 - 10 - 11 * * ] 06:05am blood WBC-15.0 * RBC-3.33 * Hgb-10.6 * Hct-32.4 *
MCV-97 MCH-32.0 mchc-32.9 RDW-14.4 Plt ct-213
[ * * 2179 - 10 - 12 * * ] 04:40AM blood pt-14.0 * INR(PT)-1.2 *
[ * * 2179 - 10 - 11 * * ] 06:05am blood pt-12.9 INR(PT)-1.1
[ * * 2179 - 10 - 12 * * ] 04:40AM blood glucose-104 * UreaN-14 creat-0.7 na-137
K-3.6 Cl-99 HCO3 - 31 AnGap-11
[ * * 2179 - 10 - 11 * * ] 06:05am blood Glucose-91 urean-14 Creat-0.6 na-134
K-3.7 Cl-96 HCO3 - 31 AnGap-11
[ * * 2179 - 10 - 12 * * ] 04:40AM blood WBC-12.4 * RBC-3.24 * Hgb-10.5 * Hct-31.2 *
MCV-96 MCH-32.5 * MCHC-33.8 RDW-14.4 Plt Ct-242
[ * * 2179 - 10 - 13 * * ] 04:40AM blood PT-16.6 * inr(pt)-1.5 *
[ * * 2179 - 10 - 13 * * ] 04:40AM blood urean-14 creat-0.7 Na-133 K-4.2 cl-100
[ * * 2179 - 10 - 14 * * ] 04:20AM blood WBC-14.4 * RBC-3.32 * Hgb-10.4 * hct-31.5 *
MCV-95 MCH-31.4 mchc-33.1 RDW-14.5 Plt Ct-307
[ * * 2179 - 10 - 14 * * ] 04:20AM blood UreaN-16 Creat-0.7 Na-132 * K-4.2 Cl-94 *
CT HEAD W / contrast Study Date [ * * 2179 - 9 - 22 * * ]
finding : hemorrhage , edema , mass effect ,
evidence acute vascular territorial infarction .
shift normally midline structure [ * * Doctor Last Name 352**]-white matter
differentiation well preserve . size configuration
ventricle appear normal . osseous structure intact .
opacification bilateral maxillary sinus . ethmoid
air cell demonstrate mucosal thickening . trace fluid
within mastoid air cell bilaterally . left
occipital posterior scalp hematoma .
IMPRESSION :
1 . acute intracranial process .
2 . leave occipital scalp hematoma , without fracture .
Intra - op TEE [ * * 2179 - 10 - 7 * * ]
Pre - CPB :
mild spontaneous echo contrast see body left
atrium .
overall leave ventricular systolic function mildly depressed
( lvef= 40 - 45 % ) . mild global free wall hypokinesis .
1 + AI .
simple atheroma descending thoracic aorta .
mitral valve show characteristic myxomatous deformity .
moderate / severe posterior leaflet mitral valve
prolapse . moderate severe ( 3 + ) mitral regurgitation see .
pericardial effusion .
Post - cpb :
patient infuson Epi NTG , AV - Paced .
mitral ring good position leak MR .
residual area 2.8 cm2 .
Biventricular systolic fxn mildly improve .
TR remain 1 + , AI remain 1 + . Aorta intact .
Brief Hospital Course :
54 year old male know past medical history admit
VF arrest Red Sox game . undergo cpr
field along defibrillation transition atrial
fibrillation . admit [ * * Hospital1 18 * * ] CCU
initiate Arctic Sun cool protocol cardiac arrest .
initial echocardiogram show severe mitral valve prolapse
regurgitation flail mitral valve , likely
precipitant vf arrest . patient extubate
successfully approximately 48 hour rewarme . upon
admission , start empiric antibiotic therapy
possible aspiration pneumonia cefepime , vancomycin
metronidazole . take operate [ * * 2179 - 10 - 7 * * ]
underwent leave side maze procedure Mitral Valve repair ( see
operative note full detail ) . overall patient tolerate
procedure well post - operatively transfer
CVICU stable condition recovery invasive monitoring .
Vancomycin use surgical antibiotic prophylaxis , give
length preoperative stay . POD 1 find patient
extubate , alert oriented breathe comfortably .
patient neurologically intact hemodynamically stable ,
wean inotropic vasopressor support . Amiodarone
start atrial fibrillation . beta blocker initiate
patient gently diurese toward preoperative weight .
Intra - operatively , patient find osteoporotic
appear sternum . [ * * Month / Day / Year 6091 * * ] consult
recommend outpatient follow follow recovery cardiac
surgery . patient continue exhibit dysphagia ,
dobhoff tube place feed purpose . Coumadin
start atrial fibrillation . patient transfer
telemetry floor recovery . Chest tube
pace wire discontinue without complication .
patient evaluate physical therapy service
assistance strength mobility . dual chamber ACID
place [ * * 2179 - 10 - 13 * * ] without complication . interrogate
[ * * 10 - 14 * * ] follow appointment device clinic
arrange . repeat video swallow study clear
nectar thick ground diet tube feed cycle .
Dobhoff tube remove day discharge patient
instruct speech swallow team aspiration
precaution . follow outpatient video
swallow study ( schedule ) diet advancement . start
ACE - EF 35 % blood pressure tolerate . INR
2.3 day discharge give 1 mg
Coumadin plan INR draw [ * * 10 - 15 * * ] result
call [ * * Hospital3 271 * * ] [ * * telephone / Fax ( 1 ) 2173 * * ]
Coumadin dose instruction . INR goal [ * * 2 - 3 * * ] atrial
fibrillation . time discharge POD 7 patient
ambulate freely , wound heal well staple
place pain control oral analgesic
tolerate ground diet . patient discharge home
service good condition appropriate follow
instruction follow appointment arrange .
medication admission :
none
Discharge medication :
1 . furosemide 20 mg Tablet [ * * Month / Day ( 3 ) * * ] : one ( 1 ) Tablet po day
7 day .
Disp:*7 Tablet(s ) * Refills:*0 *
2 . potassium chloride 20 meq Tab Sust . Rel . Particle / Crystal [ * * Month / Day ( 3 ) * * ] :
one ( 1 ) Tab Sust . Rel . Particle / Crystal PO Q12H ( every 12 hour )
7 day .
Disp:*7 Tab Sust . Rel . Particle / Crystal(s ) * Refills:*0 *
3 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) [ * * Month / Day ( 3 ) * * ] : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
disp:*100 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
4 . nicotine 14 mg/24 hr patch 24 hr [ * * Month / Day ( 3 ) * * ] : one ( 1 ) patch 24 hr
Transdermal DAILY ( Daily ) .
disp:*30 Patch 24 hr(s ) * Refills:*1 *
5 . thiamine HCl 100 mg Tablet [ * * Month / Day ( 3 ) * * ] : one ( 1 ) Tablet PO DAILY
( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
6 . folic acid 1 mg Tablet [ * * Month / Day ( 3 ) * * ] : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
7 . calcium carbonate 200 mg ( 500 mg ) Tablet , Chewable [ * * Month / Day ( 3 ) * * ] : one
( 1 ) Tablet , Chewable po BID ( 2 time day ) .
8 . cholecalciferol ( vitamin D3 ) 400 unit Tablet [ * * Month / Day ( 3 ) * * ] : 2.5 tablet
po DAILY ( Daily ) .
9 . lansoprazole 30 mg Tablet , Rapid Dissolve , DR [ * * last Name ( STitle ) * * ] : one ( 1 )
Tablet , Rapid Dissolve , DR [ * * last Name ( STitle ) * * ] DAILY ( Daily ) .
disp:*30 Tablet , Rapid Dissolve , DR(s ) * Refills:*2 *
10 . metoprolol tartrate 25 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet PO BID
( 2 time day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
11 . amiodarone 200 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet po BID ( 2 time
day ) 30 day : take x 30 day per cardilogist
instruction .
Disp:*60 Tablet(s ) * Refills:*0 *
12 . warfarin 5 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet po ( )
1 dose : take instruct cardiologist INR goal
2.0 - 3.0 .
Disp:*60 Tablet(s ) * Refills:*0 *
13 . clindamycin HCl 300 mg Capsule [ * * last Name ( STitle ) * * ] : one ( 1 ) Capsule po twice
day 2 day .
Disp:*4 capsule(s ) * Refills:*0 *
14 . lisinopril 2.5 mg Tablet [ * * last Name ( STitle ) * * ] : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*1 *
discharge Disposition :
Home Service
Facility :
[ * * hospital3 * * ] VNA
Discharge Diagnosis :
mitral regurgitation/ Atrial fibrillation
discharge condition :
alert orient x3 nonfocal
ambulate steady gait
incisional pain manage
incision :
Sternal - heal well , erythema drainage
Leg 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
Provider : [ * * Name10 ( NameIs ) 6091 * * ] [ * * First Name11 ( Name Pattern1 ) 3972 * * ] [ * * last Name ( namepattern4 ) 3973 * * ] , MD phone:[**telephone / fax ( 1 ) 1803 * * ]
Date / Time:[**2179 - 11 - 29 * * ] 2:30
Provider : [ * * Name10 ( NameIs ) * * ] [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 722 * * ] , DPM phone:[**telephone / fax ( 1 ) 543 * * ]
Date / time:[**2179 - 10 - 29 * * ] 9:10
surgeon : Dr [ * * last Name ( STitle ) * * ] [ * * 2179 - 10 - 27 * * ] 1:00 pm
Cardiologist : [ * * last Name ( LF ) 171 * * ] , [ * * first Name3 ( LF ) * * ] [ * * 2179 - 11 - 8 * * ] 1:20 pm
EP Device Clinic 1 week [ * * telephone / Fax ( 1 ) 62 * * ] [ * * 10 - 19 * * ] 11:30
Primary Care Dr. [ * * last Name ( STitle ) * * ] [ * * 4 - 5 * * ] week
video swallow follow 2 week - schedule
Labs : PT / INR Coumadin ? ? ? ? ? ? indication Atrial Fibrillation
Goal INR 2/0 - 3.0
first draw [ * * 2179 - 10 - 15 * * ]
result dr[**name ( NI ) 87655 * * ] office phone [ * * telephone / Fax ( 1 ) 1989 * * ] NP [ * * First Name8 ( NamePattern2 ) * * ]
[ * * last Name ( NamePattern1 ) * * ] [ * * telephone / Fax ( 1 ) 87656 * * ]
* * please call cardiac surgery office question
concern [ * * telephone / Fax ( 1 ) 170 * * ] . answer service contact call
person hour * *
complete by:[**2179 - 10 - 14 * * ]
|
[
"5070",
"5119",
"2762",
"7907",
"2761",
"5849",
"4240",
"3051",
"2768",
"4019"
] |
Admission Date : [ * * 2111 - 9 - 29 * * ] Discharge Date : [ * * 2111 - 10 - 5 * * ]
Date Birth : [ * * 2050 - 1 - 9 * * ] sex :
Service : CARDIOTHORACIC
allergy :
Ampicillin / Amoxicillin / Ativan
attending:[**first Name3 ( LF ) 165 * * ]
Chief Complaint :
fatigue
Major Surgical Invasive Procedure :
OP CABGx2(LIMA - LAD , SVG - om)[**10 - 1 * * ]
history Present Illness :
61 yo 2 month decline energy malaise
walk home , unable sleep trip / lose balance
fall bath tub develop SOB . OSH , find
r ptx rib fx . also find pulmonary edema
elevated trop . know CAD , uncerwent repeat cath
show significant CAD . tansferred [ * * Hospital1 18 * * ] eval .
Past Medical history :
Acute chronic systolic heart failure
DM
HTN
[ * * Hospital1 18048 * * ]
ESRD - HD ( MWF ) - last dialysis [ * * 11 - 8 * * ] ; [ * * 11 - 11 * * ]
Thrombectomy L arm fistula [ * * 12 - 22 * * ]
Hypercholesterolemia
GIB [ * * 10 - 20 * * ] prepyloric area EGD ( ? [ * * 12 - 19 * * ] NSAIDS )
Gastritis [ * * 12 - 22 * * ] ( EGD )
Anemia
Hip surgery [ * * 6 - 21 * * ] - coumadin
Prostate adenocarcinoma
Chronic low back pain
Social History :
Occasional EtOH , tobacco , drug
family history :
mother : [ * * Name ( NI ) 18048 * * ]
Physical Exam :
Obese NAD
Neuro A&O , forgetful train though , wander , grip strenth L
[ * * 3 - 21 * * ] , R [ * * 2 - 19 * * ] PERRL
CV RRR 2/6 SEM
Resp crackle thoughout right , leave clear
GI obese , soft / NT
right groin macerate / fungal infection
pertinent result :
[ * * 2111 - 10 - 4 * * ] 08:20AM blood wbc-8.0 rbc-2.74 * Hgb-8.4 * Hct-24.9 *
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4 * Plt ct-130 *
[ * * 2111 - 10 - 3 * * ] 08:35AM blood wbc-7.9 rbc-3.03 * Hgb-9.4 * Hct-27.5 *
MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9 * Plt ct-127 *
[ * * 2111 - 10 - 4 * * ] 08:20am blood Plt ct-130 *
[ * * 2111 - 10 - 3 * * ] 08:35AM blood Plt ct-127 *
[ * * 2111 - 10 - 1 * * ] 01:33pm blood PT-19.9 * PTT-39.1 * INR(PT)-1.9 *
[ * * 2111 - 10 - 4 * * ] 08:20AM blood Glucose-155 * urean-38 * creat-6.8 * #
na-129 * K-4.4 cl-89 * HCO3 - 30 angap-14
[ * * 2111 - 10 - 3 * * ] 08:35AM blood Glucose-123 * UreaN-22 * Creat-5.2 * Na-135
K-4.2 cl-92 * HCO3 - 31 AnGap-16
[ * * Hospital1 18 * * ] echocardiography REPORT
[ * * know lastname * * ] , [ * * know firstname * * ] [ * * Hospital1 18 * * ] [ * * Numeric Identifier 21518 * * ] ( Complete )
do [ * * 2111 - 10 - 1 * * ] 10:54:10 FINAL
refer Physician [ * * Name9 ( PRE ) * * ] Information
[ * * Name9 ( PRE ) * * ] , [ * * first Name3 ( LF ) * * ]
Division Cardiothoracic [ * * Doctor First Name * * ]
[ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) * * ]
[ * * Hospital Unit Name 4081 * * ]
[ * * Location ( un ) 86 * * ] , [ * * Numeric Identifier 718 * * ] status : Inpatient DOB : [ * * 2050 - 1 - 9 * * ]
Age ( year ): 61 Hgt ( ): 70
BP ( mm Hg ): 137/74 Wgt ( lb ): 235
HR ( bpm ): 68 BSA ( m2 ): 2.24 m2
Indication : intraoperative tee CABG
ICD-9 Codes : 410.91 , 440.0
Test Information
Date / Time : [ * * 2111 - 10 - 1 * * ] 10:54 Interpret MD : [ * * Name6 ( MD ) 3892 * * ]
[ * * Name8 ( MD ) 3893 * * ] , MD
Test Type : TEE ( Complete ) son[**name ( NI ) 930 * * ] : [ * * initial ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 5740 * * ] , MD
Doppler : full Doppler color Doppler Test Location :
Anesthesia West cardiac
contrast : None Tech Quality : Adequate
tape # : 2007aw2- : machine : 2
Echocardiographic measurement
result measurement Normal Range
leave Ventricle - Septal Wall Thickness : * 1.3 cm 0.6 - 1.1 cm
leave Ventricle - Inferolateral Thickness : * 1.2 cm 0.6 - 1.1 cm
leave Ventricle - Diastolic Dimension : * 5.9 cm < = 5.6 cm
leave Ventricle - Ejection Fraction : 40 % > = 55 %
leave Ventricle - Peak Resting LVOT gradient : 3 mm hg < = 10 mm
Hg
Aorta - Annulus : 2.3 cm < = 3.0 cm
Aorta - Sinus Level : 3.4 cm < = 3.6 cm
Aorta - Sinotubular Ridge : 2.4 cm < = 3.0 cm
Aorta - Ascending : * 3.6 cm < = 3.4 cm
Aorta - Descending Thoracic : * 2.9 cm < = 2.5 cm
Aortic Valve - Peak Velocity : 1.7 / sec < = 2.0 / sec
Aortic Valve - Peak Gradient : 11 mm hg < 20 mm Hg
Aortic Valve - Mean Gradient : 7 mm Hg
Aortic valve - LVOT pk vel : 0.[**age 90 * * ] / sec
Aortic valve - LVOT diam : 2.1 cm
Aortic Valve - valve Area : * 2.0 cm2 > = 3.0 cm2
finding
LEFT ATRIUM : Mild LA enlargement . spontaneous echo contrast
thrombus LA / LAA RA / RAA . four pulmonary
vein identify enter left atrium .
right ATRIUM / INTERATRIAL SEPTUM : normal RA size . dynamic
interatrial septum . ASD 2d color Doppler .
LEFT VENTRICLE : mild symmetric LVH . mildly dilate LV cavity .
moderate regional LV systolic dysfunction . mildly depressed
LVEF .
right ventricle : Normal RV chamber size free wall motion .
AORTA : normal aortic diameter sinus level . focal
calcification aortic root . mildly dilate ascending aorta .
simple atheroma aortic arch . mildly dilate descend aorta .
simple atheroma descend aorta .
AORTIC VALVE : three aortic valve leaflet . moderately thicken
aortic valve leaflet . . Trace AR .
MITRAL VALVE : mildly thicken mitral valve leaflet . mild
mitral annular calcification . trivial MR .
TRICUSPID VALVE : normal tricuspid valve leaflet trivial
TR .
PULMONIC VALVE / PULMONARY ARTERY : pulmonic valve well see .
PERICARDIUM : 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 .
REGIONAL LEFT VENTRICULAR WALL MOTION :
N = Normal , H = Hypokinetic , = akinetic , = Dyskinetic
Conclusions
PRE - revascularization :
1 . left atrium mildly dilate . atrial septal defect
see 2D color Doppler .
2 . mild symmetric left ventricular hypertrophy .
leave ventricular cavity mildly dilate . moderate
severe regional left ventricular systolic dysfunction
inferior , septal anterior wall . overall left ventricular
systolic function mildly depressed ( lvef= 40 % ) .
3 . right ventricular chamber size free wall motion
normal .
4 . simple atheroma aortic arch . descending
thoracic aorta mildly dilate . simple atheroma
descending thoracic aorta .
5 . three aortic valve leaflet . aortic valve
leaflet moderately thicken focal calcification
leave coronary cusp cause aorto sclerosis . aortic
valve stenosis . trace aortic regurgitation see .
6 . mitral valve leaflet mildly thicken . trivial
mitral regurgitation see .
7 . pericardial effusion .
Post revascularization :
Pt phenylephrine infusion intrinsic sinus rhythm :
1 . normal Rv function . LVEF 40 %
2 . new regional wall motion abnormalite , valve list
pre - revascularization .
3 . thoracic aortic contour intact
CHEST ( portable AP ) [ * * 2111 - 10 - 2 * * ] 4:28 pm
CHEST ( portable AP )
Reason : r / ptx
[ * * Hospital 93 * * ] MEDICAL condition :
61 year old man / p cabg ct removal
reason examination :
r / ptx
history : status post CABG chest tube removal ; assess
pneumothorax .
finding : comparison study [ * * 9 - 21 * * ] , endotracheal
tube , Swan - Ganz catheter , nasogastric tube
remove . leave chest tube also remove
evidence pneumothorax . probably residual
atelectatic change left base well right
upper zone , decrease .
Brief Hospital course :
admit cardiac surgery . see renal
continue HD . take operating room [ * * 10 - 1 * * ]
undergo OPCABG x 2 . transfer ICU
critical stable condition . give vancomycin
perioperative prophylaxis house preoperatively .
extubate morning POD # 1 . continue hd postop .
transfer floor POD # 1 . start
renagel per renal . well postoperatively ready
discharge rehab POD # 4 .
medication admission :
crestor 40 ' , colace 150 " , zoloft 100 ' , lisinopril 40 ' , norvasc
10 ' , asprin 81 ' , thiamin 100 ' , plavix 75 ' , protonix 40 ' , toprol
xl 200 ' , ambien 10 ' , folate 1 " , sensipar 180 ' , lovaza 1 " "
discharge medication :
1 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
2 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
3 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : 1 - 2 tablet po
Q4H ( every 4 hour ) need pain .
4 . sevelamer 800 mg Tablet Sig : one ( 1 ) Tablet PO TID W / MEALS ( 3
TIMES DAY MEALS ) .
5 . rosuvastatin 20 mg Tablet Sig : two ( 2 ) Tablet PO DAILY
( Daily ) .
6 . sertraline 50 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ) .
7 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
8 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
9 . thiamine HCl 100 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
10 . Folic Acid 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
11 . Cinacalcet 30 mg Tablet Sig : six ( 6 ) Tablet PO DAILY
( Daily ) .
12 . Toprol XL 50 mg Tablet Sustained Release 24 hr Sig : one ( 1 )
Tablet Sustained Release 24 hr po day .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital 38 * * ] Rehab [ * * Location ( un ) 1110 * * ]
discharge Diagnosis :
CAD / p CABG
Acute chronic systolic heart failure
ESRD HD(L AV fist ) , CAD / p MI , HTN , ^lipids , DM2 , / p L
THR , prostate CA / p cryo / lupron , h / gastric ulcer
discharge condition :
good .
Discharge instruction :
call fever , redness drainage incision weight
gain 2 pound one day five one week .
Shower , bath , lotion , cream powder incision .
lifting 10 pound drive follow
surgeon .
Followup Instructions :
Dr. [ * * last Name ( STitle ) 20764 * * ] 2 week
Dr. [ * * First Name ( STitle ) * * ] 4 week
[ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] MD [ * * MD Number(2 ) 173 * * ]
complete by:[**2111 - 10 - 5 * * ]
|
[
"5856",
"5180",
"4280",
"412",
"2724"
] |
Admission Date : [ * * 2173 - 10 - 1 * * ] Discharge Date : [ * * 2173 - 10 - 20 * * ]
Date Birth : [ * * 2133 - 4 - 7 * * ] sex :
Service : PLASTIC
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 26411 * * ]
Chief Complaint :
perineal infection
Major Surgical Invasive Procedure :
[ * * 2173 - 10 - 1 * * ] radical debridement scrotum , perineum
abdoman .
history Present Illness :
HPI : pt 40ym history diabete
transfer [ * * hospital 8641 * * ] Hospital Mediflight
present scrotal pain swell 2 day
incision drainage small scrotal abscess find
exam c / w Fournier 's Gangrene subcutaneous gas
CT . pt report wait ED [ * * Location ( un ) 8641 * * ] 3
hour early afternoon erythema scrotum
swelling progress low abdominal region .
transfer [ * * Hospital1 18 * * ] , note afebrile
course hour become diaphoretic ill appearing . pt
deny SOB < CP , neurological sx , urinary sx , GI sx .
PMH : DM , HTN , chronic back pain
PSH : Vasectomy
Med : Atenolol 50 " , oxycontin 40 " , ASA 81 ' , Metformin 1000 '
: NKDA
Soc : live [ * * last Name ( un ) 53428 * * ] , NH . Wife [ * * Doctor First Name 803 * * ] reach
[ * * telephone / Fax ( 1 ) 79837 * * ]
Labs : CH 7
129 94 25 306 agap=18
3.3 20 1.3
CBC- 11.5 / 34.1 / 142
PT : 15.1 PTT : 26.2 INR : 1.3
OSH CT Abd : scrotal air track anteriorly posteriorly
additional gas buttock
PE :
VS : 100.4 96 100/56 21 94
Diaphoretic
rrr
CTAB
Abdomen soft , NT , NT , erythema track right inguinal
crease , within marker , crepitus palpable leave inguinal
crease
Phallus circumcise mild , ecchymosis base
Scrotum size grapefruit , ecchymotic , crepitus present ,
focal area dark purple break skin midline , testes
non - palpable
Perineum indurate without crepitus , bleed perineal
wound
Anus without crepitus ,
Past Medical history :
DM , HTN , chronic back pain
Vasectomy
Social History :
live [ * * last Name ( un ) 53428 * * ] , NH . Wife [ * * Doctor First Name 803 * * ] reach
[ * * telephone / Fax ( 1 ) 79837 * * ]
Physical Exam :
Day Discharge
Gen : acute distress
card : RRR
Pulm : lung clear Auscultation
Abdomen : soft non - tender
Wound : well - approximate , healing , drain maintain suction
clear serosanguinous drainage . skin graft 100 % take .
mild maceration / irritation skin medial bilateral thigh
secondary moisture friction .
pertinent result :
[ * * 2173 - 9 - 30 * * ] 10:30PM NEUTS-89.1 * lymphs-7.5 * MONOS-2.9 EOS-0.5
BASOS-0.1
[ * * 2173 - 9 - 30 * * ] 10:30PM WBC-11.5 * RBC-5.24 HGB-11.8 * HCT-34.1 *
MCV-65 * MCH-22.5 * MCHC-34.6 RDW-13.9
[ * * 2173 - 10 - 1 * * ] 02:30AM HGB-10.4 * calchct-31
[ * * 2173 - 10 - 1 * * ] 04:25am WBC-12.5 * RBC-4.21 * HGB-9.6 * HCT-29.5 *
MCV-70 * MCH-22.8 * MCHC-32.5 RDW-13.5
[ * * 2173 - 10 - 1 * * ] 11:18AM urine blood - sm NITRITE - NEG protein - neg
glucose-250 KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-5.0
LEUK - NEG
[ * * 2173 - 10 - 1 * * ] 12:47PM urine blood - sm NITRITE - NEG protein - NEG
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-5.0
LEUK - NEG
Brief Hospital course :
Pt life - flight [ * * Hospital1 18 * * ] . Pt diagnose Fournier 's
gangrene , take emergently Urology ER radical
perineal debridement . please see operative note dictate
separately . Pt transfer SICU still intubate IV
insulin , IV antibiotic ( Vanc , Zosyn , Clinda ) , hourly wound
check , pressor / ventilator support . POD2 Pt take back
- debridement wound margin Gen [ * * Doctor First Name * * ] Urology .
SICU , pt relatively uneventful course . see
note .
[ * * 9 - 30 * * ] : transfer [ * * hospital 8641 * * ] Hospital , / p incision drainage
perineal abscess 2 day ago follow increase pain
redness fever , evaluate today find clinical
radiological finding c / w Fournier 's gangrene . transfer
[ * * Hospital1 18 * * ] surgical evaluation treatment . States fever
chill .
[ * * 10 - 1 * * ] : add clindamycin antibiotic coverage , minimally
marching erythema , add propofol sedation . wound swab
day take + enterococcus .
culture neg .
[ * * 10 - 2 * * ] : back debridement right thigh . wean
levo use fluid
[ * * 10 - 3 * * ] : bronchoscopy perform
[ * * 10 - 4**]:ngt placement -- TF start . low grade temp . flexiseal place
[ * * 10 - 5**]:starte insulin gtt refractory blood sugar
setting chronic wound care , lasix gtt albumin
[ * * 10 - 6 * * ] : wean verse / fent , wean vent , start diamox , start
precedex wean extubation
[ * * 10 - 7 * * ] : Extubated . Aggitated , respond haldol prn
[ * * 10 - 9 * * ] : acute event , change po meds , po lasix , increase
ris , PCA oral pain control , / c'ed insulin gtt
Pt transfer urology floor service stable condition .
Wound care , glycemic control , continued antibiotic
provide . Pt take plastic Surgery local flap
closure debride area VAC placement bolster skin graft
testicle . patient well floor . keep
bed rest POD1 - 5 strict restriction abduct
leg . addition , continue IV antibiotic per ID
recommendation . POD 5 VAC dressing take
skin graft 100 % take . day discharge POD 7 ,
patient well . afebrile vital sign stable ,
pain well control oral regimen ,
clear home physical therapy , drain output
decrease appropriately . per ID recs , patient
require additional IV antibiotic therapy .
medication admission :
Atenolol 50 " , oxycontin 40 " , ASA 81 ' , Metformin 1000 '
discharge medication :
1 . ascorbic Acid 500 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2
time day ) .
2 . zinc Sulfate 220 mg Capsule Sig : one ( 1 ) Capsule po DAILY
( Daily ) .
3 . Morphine 30 mg Tablet Sustained Release Sig : two ( 2 ) Tablet
Sustained Release po Q12H ( every 12 hour ) .
disp:*24 Tablet sustained release(s ) * Refills:*0 *
4 . metformin 500 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
5 . Alprazolam 0.25 mg Tablet Sig : two ( 2 ) Tablet po QHS (
day ( bedtime ) ) .
6 . hydromorphone 2 mg Tablet Sig : 1 - 2 tablet po Q3H ( every 3
hour ) need pain .
disp:*50 Tablet(s ) * Refills:*0 *
7 . tizanidine 2 mg Tablet Sig : two ( 2 ) Tablet PO Q6H ( every 6
hour ) need .
8 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
Disp:*60 Capsule(s ) * Refills:*2 *
9 . aspirin 81 mg Tablet , Chewable Sig : one ( 1 ) Tablet , Chewable
po DAILY ( Daily ) .
10 . Atenolol 50 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
11 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
12 . Duricef 500 mg Capsule Sig : one ( 1 ) Capsule po twice day
10 day .
Disp:*20 Capsule(s ) * Refills:*0 *
13 . Insulin NPH Human Recomb 100 unit / mL Suspension Sig : Sixteen
( 16 ) unit Subcutaneous twice day : take breakfast
Bedtime . take [ * * 2 - 28 * * ] dose eat . .
Disp:*2 vial * Refills:*2 *
14 . diabetic supply
1/2 cc 30gauge insulin syrinx prn
Glucometer testing strip PRN
Discharge Disposition :
Home Service
Facility :
rockinham VNA
discharge Diagnosis :
Fournier 's Gangrene
discharge condition :
hemodynamically stable , tolerate oral intake , ambulate ,
void without difficulty , pain control oral regiman
discharge instruction :
return ER :
* vomit keep fluid
medication .
* shake chill , fever great 101.5 ( F )
degree 38 ( c ) degree , increase redness , swell
discharge incision , chest pain , shortness breath ,
anything else trouble .
* serious change symptom , new symptom
concern .
* please resume regular home medication take new
med order .
* drive operate heavy machinery take
narcotic pain medication . may constipation take
narcotic pain medication ( oxycodone , percocet , vicodin ,
hydrocodone , dilaudid , etc . ) ; continue drinking
fluid , may take stool softener , eat food
high fiber .
med
take medication order .
drain
vna help dress change
wound check well drain care . important
keep good record drain output bring record
return clinic .
Followup Instructions :
please call dr.[**name ( NI ) 29526 * * ] office ( [ * * telephone / Fax ( 1 ) 26412 * * ]
followup appointment 1 week .
please call dr.[**name ( NI ) 11306 * * ] office ( [ * * telephone / Fax ( 1 ) 8791 * * ] followup
appointment .
F / u PCP regard insulin regimen blood
glucose control
complete by:[**2173 - 10 - 20 * * ]
|
[
"4019"
] |
Admission Date : [ * * 2171 - 8 - 17 * * ] Discharge Date : [ * * 2171 - 8 - 21 * * ]
Date Birth : [ * * 2134 - 4 - 7 * * ] Sex : F
Service : Transplant Surgery Service
CHIEF COMPLAINT : Fever , chill , nausea , vomiting ,
dysuria .
history PRESENT ILLNESS : patient 37 - year - old
female postop pancrea transplant [ * * 2171 - 8 - 7 * * ] , live
unrelated renal transplant [ * * 2170 - 8 - 14 * * ] . present
36 hour history increase fever chill , nausea
vomit . patient report shake home .
Temperature 101.7 . patient note foul
smell urine . upon admission patient agitated
tachycardic heart rate 120 . vital sign
normal .
PAST MEDICAL HISTORY : IDDM , status post live unrelated
renal transplant [ * * 2170 - 8 - 14 * * ] .
medication HOME :
1 . Prograf 3 mg po b.i.d .
2 . CellCept 1 gram b.i.d .
3 . Valcyte 900 mg day .
4 . Prednisone 4 mg daily .
5 . bactrim single strength 1 daily .
6 . Nystatin 5 ml PO QID .
7 . Protonix 40 mg po b.i.d .
8 . Os - Cal b.i.d
9 . Fosamax q week .
PHYSICAL EXAMINATION : temperature 102.8 , heart rate 108 ,
blood pressure 136/80 , respiratory rate 18 , 98 % room air .
patient alert orient , agitated . cranial
nerve II XII intact . pupil equal , round
reactive light . lung clear bilaterally . incision
clean dry intact . Abdomen tender approximately around
incision . positive bowel sound . leg - edema .
history BRIEF HOSPITAL COURSE : patient 37 - year-
old female presenting severe nausea vomiting , fever
foul smell urine . lady 's likely diagnosis
pyelonephritis versus UTI superimpose anxiety attack .
patient admit transplant unit start
IV fluid empiric Zosyn . Chest x - ray do
demonstrate pleural effusion . infiltrate . lung
field clear . nasogastric tube insert . correct
position note stomach . patient underwent
supine film abdoman . gas note loop
colon .
patient underwent CT abdoman pelvis without
contrast . demonstrate evidence abscess
benign appear fluid collection along course
right iliac vessel , likely represent lymphocele .
patient admit sicu monitor . white blood
cell count admission 21.1 , hematocrit 31.5 , creatinine
1.2 , day 1 0.9 , amylase 22 , lipase 14 , glucose
91 . ekg reveal sinus tachycardia . ST - wave change .
Urine positive nitrate . WBC 30 , large amount
blood . previously state patient start Zosyn .
Urine blood culture send . blood culture
subsequently negative . Urine culture demonstrate E. coli
100,000 colony , resistant ampicillin Bactrim ,
sensitive cephalosporin , imipenem , Levo ,
meropenem .
hospital 2 , patient temperature 104.5 .
give tylenol aggressive IV hydration . continue
Zosyn Linezolid . white blood cell count increase
30.3 . complain back pain well . temperature
defervesce . patient transfer medical-
surgical unit hospital day 3 . temperature 99 . Abdomen
soft . slowly advanced house diet . IV therapy
decrease . urine output approximately 500 cc per day
clear yellow urine . patient continue feel anxious .
Glucoses normal . Foley catheter remove . patient
follow nephrology throughout hospital course .
Prograf level 7.1 . Prograf adjust accordingly .
Creatinine 1.2 , BUN 13 , amylase 23 , lipase 17
glucose 112 . note , patient complain right hip
pain hospital day 3 . medicate IV Dilaudid
fair relief . patient feel muscle spasm
right hip , erythematous swelling . physical therapy
consult . localize inflammation note . concern
trochanteric bursitis . patient independent
mobility . independent transfer , stair ,
hallway ambulation . Outpatient PCA recommend .
patient 's antibiotic switch ceftriaxone IV .
patient discharge home hospital day 5 . give
prescription Keflex 1 week Macrobid . Urine
output approximately 1.5 liter per day . Glucose
remain within normal range . afebrile .
discharge medication :
1 . Prednisone 4 mg po daily .
2 . Valcyte 900 mg po daily .
3 . Nystatin 5 mg PO QID .
4 . bactrim single strength 1 po daily .
5 . CellCept 1 gram po b.i.d .
6 . Prograf 3 mg po b.i.d .
7 . Protonix 40 mg PO daily .
8 . Aspirin 81 mg , enteric coat , one po daily .
9 . hydrocodone/ acetaminophen 5/325 mg 1 tab po p.r.n . q4
hour .
10 . Keflex 500 mg PO QID x 10 day .
11 . Macrodantin 100 mg cap 1 po daily .
discharge diagnosis :
1 . Status post pancrea transplant [ * * 2171 - 8 - 7 * * ] .
2 . Status post live unrelated renal transplant [ * * 2170 - 8 - 14 * * ] .
3 . urinary tract infection .
4 . Urosepsis .
patient instruct follow Dr. [ * * First Name ( STitle ) * * ]
[ * * Name ( STitle ) * * ] [ * * 2171 - 8 - 26 * * ] . also follow [ * * first Name4 ( NamePattern1 ) * * ]
[ * * last Name ( NamePattern1 ) * * ] social service well Dr. [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ]
[ * * 2171 - 9 - 6 * * ] .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) * * ] , MD , phd [ * * Numeric Identifier 8353 * * ]
Dictated By:[**Name8 ( MD ) 4664 * * ]
medquist36
: [ * * 2171 - 11 - 12 * * ] 16:00:13
: [ * * 2171 - 11 - 13 * * ] 02:12:59
Job # : [ * * Job number 41013 * * ]
cc:[**Name8 ( MD ) * * ]
[ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , MD
|
[
"5990"
] |
Admission Date : [ * * 2136 - 7 - 14 * * ] Discharge Date : [ * * 2136 - 7 - 17 * * ]
Date Birth : [ * * 2059 - 8 - 27 * * ] sex : F
Service : SURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 3223 * * ]
Chief Complaint :
76f / p fall
Major Surgical Invasive Procedure :
none
history Present Illness :
76f / p fall ; patient originally see outside hospital ,
transfer [ * * Hospital1 18 * * ] .
Past Medical history :
hypertension
bilateral total hip replacement
Social History :
EtOH use
family history :
unknown
Physical Exam :
AXO person , place , event
CN 2 - 12 intact
RRR
CTA b / l
+ bs , not , nd , soft
pelvic instability
gross abn extremity
rectal guaiac neg , mass
LE palp distal pulse
pertinent result :
[ * * 2136 - 7 - 14 * * ] 02:00AM blood ASA - NEG Ethanol-46 * Acetmnp - NEG
Bnzodzp - NEG Barbitr - NEG Tricycl - NEG
[ * * 2136 - 7 - 14 * * ] 07:50AM blood calcium-8.0 * phos-2.9 mg-1.1 *
[ * * 2136 - 7 - 15 * * ] 02:40am blood Calcium-7.3 * phos-2.1 * Mg-3.3 *
[ * * 2136 - 7 - 14 * * ] 02:00AM blood CK - MB-3 cTropnT-<0.01
[ * * 2136 - 7 - 14 * * ] 07:50AM blood CK - MB-3 cTropnT-<0.01
[ * * 2136 - 7 - 14 * * ] 02:00AM blood ck(cpk)-104
[ * * 2136 - 7 - 14 * * ] 07:50AM blood ck(cpk)-106
[ * * 2136 - 7 - 14 * * ] 02:00AM blood glucose-109 * UreaN-9 Creat-0.7 na-142
K-3.5 Cl-102 HCO3 - 21 * angap-23 *
[ * * 2136 - 7 - 14 * * ] 07:50AM blood glucose-188 * UreaN-7 Creat-0.7 Na-142
K-3.2 * Cl-102 HCO3 - 21 * angap-22 *
[ * * 2136 - 7 - 15 * * ] 02:40AM blood glucose-116 * UreaN-10 Creat-0.7 na-142
K-4.1 cl-111 * HCO3 - 21 * angap-14
[ * * 2136 - 7 - 14 * * ] 02:00AM blood PT-12.6 PTT-21.0 * INR(PT)-1.1
[ * * 2136 - 7 - 14 * * ] 02:00AM blood Hypochr - NORMAL Anisocy-1 + Poiklo-1 +
Macrocy-3 + Microcy - NORMAL Polychr - OCCASIONAL Ovalocy-1 +
[ * * 2136 - 7 - 14 * * ] 02:00AM blood Neuts-90.6 * Bands-0 Lymphs-5.6 * Monos-3.6
eos-0.1 baso-0
[ * * 2136 - 7 - 14 * * ] 02:00AM blood WBC-13.7 * RBC-3.81 * Hgb-14.5 hct-42.1
MCV-110 * MCH-38.1 * MCHC-34.5 RDW-15.9 * Plt ct-407
[ * * 2136 - 7 - 15 * * ] 02:40am blood WBC-5.4 RBC-2.92 * Hgb-11.2 * Hct-32.3 *
MCV-111 * MCH-38.5 * MCHC-34.8 RDW-16.1 * Plt ct-284
[ * * 2136 - 7 - 16 * * ] 09:05AM blood Hct-37.8
[ * * 2136 - 7 - 14 * * ] 01:20AM URINE bnzodzp - NEG barbitr - neg opiate - NEG
cocaine - neg amphetm - neg mthdone - NEG
[ * * 2136 - 7 - 14 * * ] 01:20AM URINE Hours - RANDOM
[ * * 2136 - 7 - 14 * * ] 01:20AM URINE RBC-[**2 - 12 * * ] * WBC-[**2 - 12 * * ] Bacteri - MOD Yeast - NONE
Epi-1
[ * * 2136 - 7 - 14 * * ] 01:20AM URINE blood - LGE Nitrite - NEG Protein - TR
Glucose - NEG Ketone - TR Bilirub - NEG Urobiln - NEG ph-5.0 Leuks - NEG
[ * * 2136 - 7 - 14 * * ] 01:20AM urine Color - Yellow Appear - Clear Sp [ * * last Name ( un ) * * ] -1.005
AP CXR : 1 . compression deformity several low
thoracic vertebral body , uncertain chronicity .
2 . widen ascending aortic contour , may
represent aneurysmal dilatation .
AP Pelvis : bilat THR , Fx
CT c - spine : Marked osteopenia degenerative change see ,
without definite fracture subluxation identify
CT head : bilateral area intraparenchymal ( hemorrhagic
contusion ) subarachnoid hemorrhage
EKG : sinus tachycardia . leave ventricular hypertrophy . Diffuse
ST - wave change may secondary leave ventricular
hypertrophy . previous tracing available comparison
Brief Hospital course :
Patient admit intraparenchymal subarachnoid
hemorrhage , poorl control hypertension .
hospital course ( system ):
Neuro : Patient 2 CT head do , without interval change ,
mental status improve hospital course . Patient
also develop focal neurologic deficit .
treat dilantin seizure prophylaxis 7 - day
course , also receive valium DT prophylaxis .
CV : Patient treat metoprolol lisinopril
hypertension , bp maintain 160 SBP throughout
hospital course . Patient also ekg show
sinus tachycardia [ * * 7 - 14 * * ] ; hr decrease within normal
limit discharge .
Resp : Patient treat incentive spirometry
hospital course , respiratory status good throughout
hospital stay .
GI : patient receive colace hospital course ,
tolerate regular diet throughout ; also receive protonix
GI prophylaxis .
GU : patient foley place hospital
course ; / c'd without incident , patient able
urinate .
FEN : Patient receive thiamine , folate mulivitamin
admission EtOH use risk Wernicke - Korsakoff
syndrome .
Heme : issue
ID : issue
Medications admission :
norvasc
zestril
Discharge medication :
1 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
2 . Metoprolol Tartrate 50 mg Tablet Sig : one ( 1 ) Tablet PO three
time day : hold SBP < 100 HR < 55 .
3 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
4 . Multivitamin Capsule Sig : one ( 1 ) Cap po DAILY ( Daily ) .
5 . Lorazepam 0.5 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need .
6 . Phenytoin Sodium Extended 100 mg Capsule Sig : one ( 1 ) Capsule
po TID ( 3 time day ) 4 day .
7 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 979 * * ] - [ * * Location ( un ) 246 * * ]
discharge Diagnosis :
1 ) subarachnoid hemorrhage
2 ) frontal intraparenchymal hemorrhage
* 3 ) hypertension ( poorly control admission )
discharge condition :
stable
Discharge instruction :
suffer intraparenchymal hemorrhage
subarachnoid hemorrhage follow fall . return
headache , nausea / vomiting , difficulty breathing , chest pain ,
decrease sensation motor function , symptom
concern .
Followup Instructions :
follow - Trauma Clinic 2 week ( [ * * telephone / Fax ( 1 ) 6439 * * ] )
follow - neurosurgery 2 week ( [ * * telephone / Fax ( 1 ) 1669 * * ] )
follow - PCP regard BP control
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 520 * * ] MD , [ * * MD Number(3 ) 3226 * * ]
complete by:[**2136 - 7 - 17 * * ]
|
[
"2768",
"4019"
] |
Admission Date : [ * * 2115 - 1 - 20 * * ] Discharge Date : [ * * 2115 - 1 - 31 * * ]
Service : NEUROLOGY
allergy :
Percocet / Penicillins / Atropine / Keflex / Bactrim / Inderal /
Levaquin / Reglan / Ciprofloxacin Hcl / Doxycycline /
Azithromycin
attending:[**doctor last Name 15044 * * ]
Chief Complaint :
prolong r side shake
Major Surgical Invasive Procedure :
intubation
history Present Illness :
Briefly , pt [ * * age 90 * * ] year old woman PMH notable breast
CT
[ * * 2081 * * ] ( / p r mastectomy ) , pancreatic CA [ * * 2094 * * ] ( / p whipple 's ) ,
colon CA / c'ed [ * * 1 - 2 * * ] , / p total colectomy , transfer
ICU present partial status epilepticus .
accord daughter , recent colectomy
complication post - operative ileus , overall decrease po 's
weight loss . nursing home relatively
stable day prior admission tired
take po 's . night nursing aid note
L face , arm , leg twitching , unclear true LOC
associate . twitching begin around midnight
continue morning bring [ * * Hospital1 18 * * ]
evaluation .
ED note talk coherently
twitching , O2 sat low 90 ' 2L NC .
give total 4 mg ativan 1 gm dilantin bolus
stop shaking , however become sedate
require intubation .
admit ICU management .
Past Medical History :
1 . pancreatic cancer status post Whipple procedure [ * * 2094 * * ]
2 . multiple duodenal stricture ulcer
3 . adhesion status post lysis radiation pancrea .
4 . status post transverse colectomy radiation - induce injury
colon .
5 . status post appendectomy [ * * 2041 * * ] .
6 . status post cholecystectomy gangrenous cholecystitis [ * * 2105 * * ]
7 . status post gastrojejunostomy .
8 . macular degeneration reportedly legally blind left eye
9 . status post total abdominal hysterectomy bilateral
salpingo - oophorectomy .
10 . breast cancer status post modify radical mastectomy
[ * * 2081 * * ]
11 . Hypertension .
12 . history Methicillin resistant Staphylococcus aureus
infection .
13 . multiple fall .
14 . status post ileocolectomy colon cancer [ * * 1 - 2 * * ]
15 . osteoarthritis
16 . report history hepatitis [ * * 2064 * * ]
17 . status post partial hysterectomy [ * * 2061 * * ]
18 . status post ventral incision hernia repair [ * * 2095 * * ]
Social History :
nursing home resident , formerly lawyer , per
daughter cognitively baseline intact , write
life memoir recent surgery , leave quite ill .
Family history :
Noncontributory
Physical Exam :
exam admission floor ( ICU )
limit pt 's mental status .
Gen : sleeping , arousable follow command , breathing
comfortably , heart rrr 2/6 SEM LSB , lung crackle
L mid base anteriorly , abd soft , non distended , incision
site C / / I. Peripheral pulse easily palpable
Neuro :
follow command , intermittently wiggle toe ,
unclear
command
CN : r pupil 3 - -2 , L pupil surgical , + OC 's purposeful
EOM 's , face symmetric , tongue midline , + gag
: move 4 extremity vigorously mild painful stimulus ,
move LUE less other .
: localize pain 4
r : RUE LUE 1 + throughout , patellae 1 + bilaterally , 5 beat
ankle clonus non sustain bilaterally , toe bilaterally ,
+ jaw jerk , -[**doctor last Name * * ]
pertinent result :
[ * * 2115 - 1 - 20 * * ] 11:54AM TYPE - ART TIDAL vol-500 O2 - 100 PO2 - 437 *
PCO2 - 33 * PH-7.40 total CO2 - 21 BASE XS--2 AADO2 - 252 REQ O2 - 49
intubated - intubated
[ * * 2115 - 1 - 20 * * ] 11:54AM O2 sat-100
[ * * 2115 - 1 - 20 * * ] 09:51AM CEREBROSPINAL FLUID ( CSF ) PROTEIN-49 *
glucose-64 LD(LDH)-50
[ * * 2115 - 1 - 20 * * ] 09:51AM CEREBROSPINAL FLUID ( CSF ) WBC-3 RBC-1550 *
POLYS-73 LYMPHS-26 MONOS-1
[ * * 2115 - 1 - 20 * * ] 09:51AM CEREBROSPINAL FLUID ( CSF ) WBC-8 RBC-2550 *
polys-67 lymphs-30 MONOS-3
[ * * 2115 - 1 - 20 * * ] 08:30AM URINE COLOR - Straw APPEAR - Clear SP [ * * last Name ( un ) 155**]-1.015
[ * * 2115 - 1 - 20 * * ] 08:30AM URINE blood - TR NITRITE - NEG protein - TR
GLUCOSE - NEG KETONE-15 BILIRUBIN - NEG UROBILNGN - NEG PH-6.5
LEUK - NEG
[ * * 2115 - 1 - 20 * * ] 08:30AM URINE RBC-0 - 2 WBC-0 - 2 BACTERIA - none yeast - NONE
EPI-0
[ * * 2115 - 1 - 20 * * ] 07:38am TYPE - ART PO2 - 301 * PCO2 - 39 PH-7.42 total
CO2 - 26 BASE XS-1 INTUBATED - INTUBA
[ * * 2115 - 1 - 20 * * ] 07:38am GLUCOSE-112 * LACTATE-3.3 * NA+-131 * K+-4.4
CL--99 *
[ * * 2115 - 1 - 20 * * ] 07:38AM HGB-11.5 * calcHCT-35 O2 SAT-99 CARBOXYHB-0.4
MET hgb-0.7
[ * * 2115 - 1 - 20 * * ] 07:38am freeCa-1.10 *
[ * * 2115 - 1 - 20 * * ] 07:20AM GLUCOSE-93 UREA N-15 CREAT-1.1 sodium-136
POTASSIUM-5.5 * CHLORIDE-97 TOTAL CO2 - 26 anion GAP-19
[ * * 2115 - 1 - 20 * * ] 07:20AM ALT(SGPT)-9 AST(SGOT)-31 amylase-141 * TOT
BILI-0.5
[ * * 2115 - 1 - 20 * * ] 07:20AM WBC-7.8 RBC-3.95 * # hgb-11.8 * # HCT-36.7 MCV-93
MCH-30.0 mchc-32.3 RDW-14.1
[ * * 2115 - 1 - 20 * * ] 07:20AM neuts-82.0 * LYMPHS-14.9 * MONOS-2.7 EOS-0.3
BASOS-0.2
[ * * 2115 - 1 - 20 * * ] 07:20AM PLT COUNT-472 * #
Brief Hospital course :
ICU / Floor course system :
Neuro :
1 . first time seizure - episode think focal
status , stop never recurrent
seizure - like activity . think perhaps seizure
secondary severe electrolyte abnormality setting
poor nutrition post operatively . continue
dilantin , initially 100 mg IV TID , level
persistently supratherapeutic upon transfer floor
dilantin hold day level check . [ * * 1 - 29 * * ]
level finally within low - therapeutic range ( 4.4 ,
correct albumin approximately 9 ) restart
100 mg qday . think intrinsic slow clearance
dilantin , none medication know
decrease dilantin clearance . upon discharge level 3.7 .
level follow 2x / week .
neurologic workup seizure include LP
unremarkable MRI show enhance lesion , one small
area DWI right thalamus without FLAIR correleate unclear
significance . radiology report diffuse meningeal uptake ,
likely / p LP effect . EEG perform .
2 . Encephalopathy - Pt initially encephalopathic ,
think due infection well dilantin toxicity .
pneumonia treat dilatnin level reduce ,
become markedly awake lucid , discharge
conversant easily follow command .
ID :
1 . aspiration pneumonia - LLL infiltrate CXR ,
leukocytosis
13 K , low grade temp ( 98.8 ax ) , start levofloxacin
flagyl complete 10 day course . wbc 6 upon
discharge lung exam much improve . blood
urine culture negative date .
Pulm :
intubate [ * * 1 - 20 * * ] airway protection
multiple sedate medication receive seizure .
easily extubate 6 pm [ * * 1 - 21 * * ] . [ * * 1 - 24 * * ] episode
acute respiratory distress , CXR lung exam
consistent pulmonary edema give IV lasix
excellent response . start maintenance dose
lasix remainder stay discontinue
upon discharge .
Heme :
admission , hct drop 36->29 , repeat 32
appear iron deficiency anemia chronic disease ,
however borderline low B12 folate . Stool
guiaic 's negative . hct stay around 28 - 29
remainder stay .
pain :
continue fentanyl patch ( OA ) prevent withdraw , prn
tylenol .
FEN :
Pt po'e due encephalopathy . upon transfer ,
nutrition consult plan PICC placement TPN make .
PICC place able place peripherally ,
therefore start [ * * Month / Year ( 2 ) 32813 * * ] . electrolyte follow
daily initial hyponatremia resolve . also initially
hypomagnesemia , hypocalcemia , hypokalemia ,
stabilize [ * * Month / Year ( 2 ) 32813 * * ] . [ * * 1 - 28 * * ] pass
speech / swallow evaluation oral diet start .
tolerate well upon discharge [ * * Month / Day ( 4 ) 32813 * * ] discontinue
plan augment oral nutrition well possible .
daughter meet medial nutrition group prior
discharge . electrolyte follow weekly . also
restart pancrease eat full
diet .
PPx :
stroke ppx , initially give ASA , due decrease
hct recent surgery , upon transfer ASA / c'ed . DVT
prophylaxis receive heparin [ * * last Name ( LF ) 32813 * * ] , [ * * first Name3 ( LF ) * * ] give
SC heparin , start back SC heparin upon discharge .
GI prophylaxis receive pepcid , switch
back home regimen protonix upon discharge .
Code : intially DNR DNI , much discussion
daughter PCP [ * * last Name ( namepattern4 ) * * ] . [ * * First Name ( STitle ) * * ] decision make
make DNR / DNI .
Dispo : transfer back nursing home much
improve condition [ * * 2115 - 1 - 31 * * ] .
medication admission :
1 . Zestril 10 mg daily
2 . Protonix 40 mg daily
3 . pancrease 3 packet per meal
4 . fentanyl patch 25mcg / hr every 72 hour .
5 . ocuvite twice daily
Discharge medication :
1 . multi - vitamin Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
2 . Ocuvite Tablet Sig : one ( 1 ) Tablet po day .
disp:*30 Tablet(s ) * Refills:*2 *
3 . Heparin Sodium 5,000 unit/0.5 ml Syringe Sig : one ( 1 )
Injection three time day .
Disp:*qs * Refills:*2 *
4 . Dilantin 100 mg qday
5 . Protonix 40 mg qday
6 . fentanyl patch
7 . Zestril 10 mg qday
8 . Multivitamin
Discharge Disposition :
Extended Care
Facility :
[ * * hospital3 2732 * * ] & Retirement Home - [ * * Location ( un ) 55 * * ]
discharge diagnosis :
partial seizure
Pneumonia
discharge condition :
improve
Discharge instruction :
please return ED pt develop worsen respiratory
distress seizure - like activity .
take complete diet restart
pancrease
dilantin level electrolyte follow weekly .
check albumin dilantin level .
Followup Instructions :
Dr. [ * * Name ( NI ) * * ] , pt schedule
|
[
"5070",
"2761",
"4280",
"2768",
"2859",
"4019"
] |
Admission Date : [ * * 2114 - 11 - 18 * * ] Discharge Date : [ * * 2114 - 11 - 19 * * ]
Date Birth : sex :
service :
DIAGNOSIS : right temporal intracranial mass .
history PRESENT illness : 53 - year - old
gentleman present vertigo ring ear
headache since [ * * Month ( ) 359 * * ] . c - scan MRI
without gadolinium outside hospital ,
diagnose 3 - cm x 3 - cm intracranial right temporal
mass . refer [ * * Hospital1 188 * * ] evaluation .
history PRESENT illness : patient history
headache , ring ear , vertigo since [ * * Month ( ) * * ]
early [ * * Month ( ) 359 * * ] . history nausea , vomiting ,
visual disturbance , diplopia , seizure .
evidence weakness tingling numbness anywhere .
admission , patient find mass edema
around bleed surround tumor .
admit Intensive Care Unit blood - pressure
control
anti - seizure medication therapy close monitoring .
workup reveal leave lung mass adrenal mass ;
preliminary diagnosis carcinoma lung extensive
metastasis make . workup require .
patient express explicit desire home [ * * Holiday * * ] Eve
[ * * Holiday * * ] intention stay
hospital [ * * Holiday * * ] day . therefore , start
high - dose Decadron anti - edema measure .
discharge home high - dose Decadron .
followup . we schedule CT guide lung biopsy
[ * * 3 - 22 * * ] [ * * Hospital Unit Name 1825 * * ] 9:30 .
also continue Decadron 8 mg p.o . q.6h . two day
6 mg Decadron q.6h . two day follow 4 mg
Decadron q.6h . meet Dr. [ * * last Name ( STitle ) 724 * * ] Dr. [ * * First Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ]
Brain [ * * Hospital 341 * * ] Clinic [ * * 2114 - 11 - 26 * * ] .
base tissue diagnosis , patient
eyelid surgery chemotherapy chemotherapy
radiotherapy , decide . patient also
give strict instruction contact we early date
change mental status
severity headache .
allergy : patient allergic lipitor SULFA .
new allergy DILANTIN document .
discharge medication :
1 . Zantac 150 mg p.o.b.i.d .
2 . Depakote 350 mg p.o . three time day .
3 . Decadron start 8 mg , taper 4 mg p.o .
q.6h . followup plan make .
patient also note past medical history
coronary artery disease three - vessel stenting
angioplasty ; hypertension ; diabete mellitus ,
take Insulin .
discharge condition : patient awake , alert , oriented ,
localize sign , focal lesion . patient
fully aware risk discharge .
patient willing go home .
dr.[**last Name ( STitle ) * * ] , [ * * first Name3 ( LF ) * * ] 14 - 120
dictated By:[**Last Name ( STitle ) 22910 * * ]
medquist36
: [ * * 2114 - 11 - 21 * * ] 10:43
: [ * * 2114 - 11 - 21 * * ] 12:44
JOB # : [ * * Job Number 24026 * * ]
|
[
"3051",
"4019"
] |
Admission Date : [ * * 2175 - 8 - 10 * * ] Discharge Date : [ * * 2175 - 8 - 22 * * ]
Date Birth : [ * * 2148 - 2 - 15 * * ] sex : F
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 6565 * * ]
Chief Complaint :
right flank pain , fever
Major Surgical Invasive Procedure :
embolization bleed artery IR
history Present Illness :
27 F 2 day right flank pain , sharp , worsen
deep breath . similar pain past . associated fatigue
fever x 2 day . dysuria , hematuria urinary
symptom . chronic tingling right foot ( since
diagnose cord compression many month back . headache .
ER course - give Abx . temp 103.9
ROS :
constitutional : Fatigued , weight loss past 5 week . fever
associate chill . also anorexic .
Neuro : confusion , numbness extremity , dizziness
light - headedness , vertigo , weakness extremity , confusion ,
tremor . Parasthesias -
Psychiatric : depression , suicidal ideation
eye : blurry vision , diplopia , loss vision , photophobia .
wear glass .
ENT : dry mouth , oral ulcer , bleed nose , gum , tinnitus ,
sinus pain , sore throat
Cardiac : chest pain , DOE , syncope , PND , orthopnea ,
palpitation , peripheral edema
Pulmonary : shortness breath , hemoptysis , pleuritic pain .
chronic coung many week
GI : nausea vomiting . diarrhea , constipation ,
hematemesis , melena , hematochezia . abd pain .
heme : easy bleeding , bruising , lymphadenopathy
GU : dysuria , hematuria , increased frequency , urgency
incontinence
Endocrine : lose hair since start chemo . skin change , heat
cold intolerance
skin : rash pruriti
Musculoskeletal : myalgia , arthralgias , back pain
Allergy : seasonal allergies- NKDA .
.
[ x ] system negative detailed review except
note .
Past Medical History :
- Hepatocellular carcinoma - metastasis bone , lung , abdomen
-Had receive weekly 5 - fu leucovorin
progress weekly doxorubicin . previously
treat gemcitabine , Cisplatin , Avastin .
- Pulmonary embolism svc clot - anticoagulation .
-r ovarian cyst - affirm increase abdominal girth [ * * 2168 * * ] ,
feel increase bloating , present ED find
right ovarian cyst , resect .
- [ * * 2155 * * ] ( 7yrs old ) hospitalize 6 month fever / cough ,
weakness , unclear source infection , require blood
transfusion .
- Gyn- menstrual period past year
Social History :
Social history : life sister brother . recently
relocate [ * * Country 3587 * * ] [ * * 12 - 21 * * ] - speak Creole Portugese .
Denies stds , deny etoh , ivdu , smoking .
Family history :
1 sister age 27 , question r leg mass resect 4 yr ago .
Brother liver problem child .
Father - HTN
deny cancer history
Physical Exam :
VS 99.6 p 123 / min , BP 104/68 RR 16 100 % RA
Gen - thin female appear chronically sick . acute
distress .
Eyes - pale , jaundice
ENT - moist mucosa , thrush , ulcer erythema
Neck - supple , LAD , jvp normal
cv - S1 , 2 - normal , murmur rub , gallop . Tachycardia
RS - crackle wheeze
Abd - rt UQ abd pain , RT distenstion . liver edge palpable .
Rt CVA tenderness
Extremeties - edema
skin - rash
GU - catheter
Neuro - Alert orient x3 , Cr n [ * * 3 - 27 * * ] normal . Motor - [ * * 5 - 20 * * ] UE
LE bilaterally equal , prox distal . sensory normal
crude touch bilaterally . Plantars flexor bilaterally .
pronator drift . fluent speech .
Psychiatric - anxious . calm . depress
Heme / lymph - cerv LAD , thyroid normal .
pertinent result :
CXR - IMPRESSION : acute cardiopulmonary process . multiple
pulmonary masse present lung base well evaluate
CT examination [ * * 2175 - 7 - 26 * * ]
CT abdomen , pelvis - IMPRESSION :
1 . significant interval worsening metastatic disease
describe .
2 . interval increase size left adnexal dermoid .
3 . unchanged appearance osseous metastasis
.
.
Brief Hospital Course :
# acute blood loss anemia / hemoperitoneum : likely bleed
hepatic tumor , however , angio identify obviously
bleeding lesion , embolization perform initially . Pt
increase abdominal distension pain ; repeat CT scan
show demonstrable change hemoperitoneum , could
rule continue ooze liver lesion . r hepatic
artery therefore embolize Gel - foam prevent
/ future bleeding . follow procedure , patient
stable hematocrit , require additional transfusion .
.
# fever : clinical sign would indicate current
infection , pt w/o cough , SOB , dysuria , diahrea . serial
blood culture without crowth . fever believe
secondary either diffuse cancer blood peritoneum .
.
# pain : Pt swtiche PCA MS contin w/ diluadid prn .
patient significantly uncomfortable admission , pain
in well control time discharge . pain due
carcinomatosis abdomien .
.
# hepatocellular carcinoma : HepB + , widely metastatic . last
chemo 2 week ago . pt fail multiple
chemotherapeutic regimen , feel would gain advantage
additional treatment . Pt see palliative care ,
assistance appreciate . Patient discharge home
hospice .
medication admission :
LOVENOX 60mg subcutaneously [ * * hospital1 * * ]
Discharge medication :
1 . roxanol Concentrate 20 mg / mL Solution Sig : [ * * 1 - 17 * * ] mL po q 1 hour
need discomfort / respiratory distress .
Disp:*4 syrinx * Refills:*0 *
2 . Wheelchair Misc Sig : one ( 1 ) Miscellaneous day .
Disp:*1 * Refills:*0 *
3 . hospital bed
please provide pt w/ one hospital bed
4 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
Disp:*60 Capsule(s ) * Refills:*2 *
5 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
6 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need .
Disp:*60 Tablet , Delayed Release ( e.c.)(s ) * Refills:*2 *
7 . Morphine 15 mg Tablet Sig : 1 - 2 tablet po Q3 - 4H ( every 3 4
hour ) need Pain .
Disp:*150 Tablet(s ) * Refills:*2 *
8 . Morphine 30 mg Tablet Sustained Release Sig : four ( 4 ) Tablet
Sustained Release po Q12H ( every 12 hour ) .
Disp:*240 Tablet sustained release(s ) * Refills:*2 *
9 . Nystatin 100,000 unit / mL Suspension Sig : five ( 5 ) ML PO QID
( 4 time day ) need .
Disp:*250 ML(s ) * Refills:*1 *
10 . compazine 10 mg Tablet Sig : one ( 1 ) Tablet po every six ( 6 )
hour need nausea .
disp:*50 Tablet(s ) * Refills:*2 *
discharge Disposition :
Home Service
Facility :
VistaCare
discharge diagnosis :
metastatic liver cancer
hemoperitoneum
Discharge condition :
stable
Discharge instruction :
discharge admission due bleed
belly . bleeding one liver tumor .
blood suppy tumor block will not
bleed . bleeding tumor , long
canidate serafinib treatment . unfortuantly
chemotherapy normally use treat liver cancer
prove successful . discharge home ,
arangement make give support remain
comfortable .
Followup Instructions :
call Dr. [ * * last Name ( STitle ) * * ] develop severe abdominal pain , confusion ,
difficulty breathing , vomiting .
[ * * first Name4 ( NamePattern1 ) 2946 * * ] [ * * last Name ( NamePattern1 ) * * ] MD [ * * MD Number(1 ) 3218 * * ]
|
[
"2851"
] |
Admission Date : [ * * 2118 - 12 - 2 * * ] Discharge Date : [ * * 2118 - 12 - 16 * * ]
Date Birth : [ * * 2039 - 1 - 27 * * ] sex :
Service : SURGERY
allergy :
Ativan / Morphine
attending:[**first Name3 ( LF ) 2836 * * ]
Chief Complaint :
weakness , abdominal pain
Major Surgical Invasive Procedure :
none
attempt IV Port placement
history Present Illness :
patient 79y man end ileostomy , well - know
surgery service recently discharge [ * * 11 - 30 * * ] , return
ED 24h peristomal abdominal pain weakness .
pain begin day follow discharge , describe
constant dull pain , non - radiating . also complain
weakness . ostomy - put within normal limit
patient . - put liquid visible blood .
deny dizziness , fever , chill . one episode emesis
morning presentation . SBP admission ED
70s .
PMH :
1 . Gout
2 . hypertension
3 . atrial fibrillation
4 . h / spontaneous pneumothorax
5 . ? pulmonary fibrosis
6 . h / rheumatic fever
7 . h / multiple small bowel obstruction
8 . carotid artery stenosis
9 . brain infarct asymptomatic
10 . h / recent c.diff
11 . GERD
12 . chronic renal insufficiency
13 . h / Port - - cath
14 . colonic stricture chronic small bowel obstruction ,
partial .
PSH :
1 . colectomy , ileostomy " gangrene"/diverticulitis/"toxic
megacolon "
2 . ileostomy reversal 2 year ago
3 . lysis adhesion [ * * 2118 - 7 - 5 * * ]
4 . Appendectomy
5 . removal cyst neck
6 . leave hip replacement
7 . removal 2 bur elbow
8 . / p talc pleurodesis ( [ * * Hospital1 112 * * ] )
9 . / p port removal staph sepsis
10 . resection ileocolic anastomosis creation
end - ileostomy ( [ * * 11 - 2 * * ] )
Past Medical history :
PSH :
1 . colectomy , ileostomy " gangrene"/diverticulitis/"toxic
megacolon "
2 . ileostomy reversal 2 year ago
3 . lysis adhesion [ * * 2118 - 7 - 5 * * ]
4 . Appendectomy
5 . removal cyst neck
6 . leave hip replacement
7 . removal 2 bur elbow
8 . / p talc pleurodesis ( [ * * Hospital1 112 * * ] )
9 . / p port removal staph sepsis
10 . resection ileocolic anastomosis creation
end - ileostomy ( [ * * 11 - 2 * * ] )
Social History :
Social history :
Quit smoke 35 year ago . etoh .
Family history :
family history :
Noncontributory
Physical Exam :
VS : 97.5 85 122/56 17 1003L
Gen : acute distress
CV : RRR S1 S2
lung : coarse breath sound bilaterally , rale wheeze
Abd : soft , non - distended , moderate tympany , tender palpation
diffusely primarily around ileostomy site . rebound
guard . Ostomy pink healthy appearing . brown liquid
- put bag .
Ext : warm , well perfuse
Pertinent result :
Admit Labs
CBC : 26/35.9\539
Chem : 128/98/42
---------<239
5.8\13\2.0
Lactate:7.4
tbil:0.5 AST:26 ALT:57 AP:96
.
[ * * 2118 - 12 - 2 * * ] 01:10PM blood wbc-26.3 * # rbc-3.66 * Hgb-11.8 * Hct-35.9 *
MCV-98 MCH-32.1 * MCHC-32.8 RDW-15.1 Plt ct-539 *
[ * * 2118 - 12 - 3 * * ] 04:48am blood WBC-23.5 * RBC-3.47 * Hgb-11.1 * Hct-32.4 *
MCV-94 MCH-32.0 mchc-34.2 RDW-15.5 Plt ct-454 *
[ * * 2118 - 12 - 13 * * ] 05:45am blood WBC-12.6 * RBC-2.92 * Hgb-9.4 * Hct-27.7 *
MCV-95 MCH-32.2 * mchc-34.0 RDW-16.4 * Plt Ct-422
[ * * 2118 - 12 - 11 * * ] 04:25am blood PT-27.8 * inr(pt)-2.8 *
[ * * 2118 - 12 - 2 * * ] 01:10PM blood glucose-239 * UreaN-42 * Creat-2.0 * Na-128 *
K-5.8 * Cl-98 HCO3 - 13 * angap-23 *
[ * * 2118 - 12 - 3 * * ] 04:48am blood glucose-132 * UreaN-37 * Creat-1.5 * Na-132 *
K-5.5 * Cl-102 HCO3 - 18 * angap-18
[ * * 2118 - 12 - 13 * * ] 05:45am blood Glucose-106 * UreaN-18 Creat-1.1 Na-131 *
K-4.8 cl-101 HCO3 - 22 angap-13
[ * * 2118 - 12 - 5 * * ] 03:54AM blood ALT-27 AST-18 LD(LDH)-151 AlkPhos-54
Amylase-36 totbili-0.5
[ * * 2118 - 12 - 13 * * ] 05:45am blood Calcium-7.9 * Phos-3.8 Mg-1.9
[ * * 2118 - 12 - 7 * * ] 04:30AM blood TSH-13 *
[ * * 2118 - 12 - 7 * * ] 04:30AM blood Free T4 - 0.91 *
[ * * 2118 - 12 - 6 * * ] 06:15AM blood Digoxin-0.7 *
[ * * 2118 - 12 - 2 * * ] 01:28PM blood lactate-7.4 *
[ * * 2118 - 12 - 3 * * ] 05:04AM blood lactate-3.0 *
[ * * 2118 - 12 - 5 * * ] 04:17AM blood lactate-0.6
.
[ * * 2118 - 12 - 5 * * ] 11:08 MRSA SCREEN source : Nasal swab .
MRSA SCREEN ( final [ * * 2118 - 12 - 6 * * ] ):
POSITIVE METHICILLIN resistant STAPH AUREUS .
.
Radiology Report CT PELVIS W / CONTRAST Study Date [ * * 2118 - 12 - 2 * * ]
2:10 pm
impression :
1 . significant small bowel dilation fecalization
proximal
right mid abdominal anastomosis concern massive
impaction . stricture stoma exclude . small
amount free intra- abdominal air pneumatosis several
loop ileum deep within pelvis concern
ischemic process .
2 . unchanged aneurysm ( x2 ) infrarenal abdominal aorta .
.
Brief Hospital course :
patient 79yM w/ end ileostomy present w/ abdominal
pain weakness , find small foci free air
pneumatosis ileum proximal ostomy .
admit surgery start IVF resuscitation
dehydration , weakness elevated Lactate . CT scan
do show fecal impaction disimpacte
emergency room . also demonstrate small foci free
air possible pneuomotosis proximal illeum . currently
report
significant improvement abdominal pain since
disimpaction .
Vascular consult due history superior mesenteric
artery
stent mesenteric ishemia resection ileocolic
anastomosis creation end - ileostomy . present
increase watery ostomy output parastomal abdominal pain .
Review CT scan show stent patent
unlikely mesenteric ischemia .
leukocytosis : start Zosyn 1 week course
WBC defervesce . c.diff negative .
Hyponatremia / Hyperkalemia : improve hydration
Hypotension / Hemodynamic Instability : Dehydrated improve
hydration .
diet advanced eat well . ostomy output
1 - liter / day . order Opium Tincture
Psyllium 1.7 g wafer . abdomen soft nontender
nondistended .
IV Port attempt , successful . need continue
close monitoring I&O 's .
medication admission :
protonix 40 ' , amiodarone 200 '' , digoxin 0.125 ' , lopressor
12.5 '' ' , Tylenol prn , imodium 2 mg tab '' ' , coumadin ( afib ,
3mg / ) , levothyroxine 50mcg PO daily
Discharge medication :
1 . Metoprolol Tartrate 25 mg Tablet Sig : 0.5 Tablet po BID ( 2
time day ) .
2 . amiodarone 200 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
3 . Digoxin 125 mcg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
4 . warfarin 2 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ):
Monitor INR .
5 . psyllium 1.7 g Wafer Sig : one ( 1 ) wafer po QID ( 4 time
day ) .
6 . Levothyroxine 50 mcg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
7 . Opium Tincture 10 mg / mL Tincture Sig : three ( 3 ) Drop PO TID
( 3 time day ): 0.3ml. titrate accord stool consistency .
avoid constipation .
8 . pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) po day .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 672 * * ] hospital
discharge Diagnosis :
abdominal pain
weakness
Leukocytosis
Elevated Lactate 7.4
Hyponatremia / Hyperkalemia
hypotension
Hemodynamic Instability
dilate loop small bowel fecalization distal ileum
Acute Renal Failure
discharge condition :
good
Discharge instruction :
admit dehydration , weakness hemodynamic
instability .
please call doctor return er
follow :
* experience new chest pain , pressure , squeeze
tightness .
* new worsen cough wheezing .
* vomit keep fluid
medication .
* getting dehydrate due continued vomiting , diarrhea
reason .
* sign dehydration include dry mouth , rapid heartbeat
feel dizzy faint stand .
* see blood dark / black material vomit
bowel movement .
* skin , white eye become yellow .
* pain improve within 8 - 12 hour go
within 24 hour . call return immediately pain
get bad change location move chest
back .
* shake chill , fever great 101.5 ( F )
degree 38(c ) degree .
* serious change symptom , new symptom
concern .
.
* take new med order .
* drive operate heavy machinery take
narcotic pain medication . may constipation take
narcotic pain medication ( oxycodone , percocet , vicodin ,
hydrocodone , dilaudid , etc . ) ; continue drinking
fluid , may take stool softener , eat food
high fiber .
* continue increase activity daily
* continue Ostomy care
Followup Instructions :
please follow - Dr. [ * * First Name ( STitle ) * * ] [ * * 2 - 27 * * ] week . call [ * * telephone / Fax ( 1 ) 2998 * * ]
schedule appointment .
complete by:[**2118 - 12 - 15 * * ]
|
[
"5849",
"2760",
"2762",
"2767",
"5859",
"2449",
"2749"
] |
Admission Date : [ * * 2120 - 11 - 9 * * ] Discharge Date : [ * * 2121 - 1 - 9 * * ]
Service : [ * * hospital1 * * ]
history PRESENT ILLNESS : patient 83 year - old
female history rectal cancer admit
[ * * Hospital1 69 * * ] [ * * 2120 - 11 - 9 * * ] low
anterior resection rectal cancer ileostomy
omental flap placement stump . initially course
complicate necrosis omental pouch
prolong postoperative ileus . multiple CT scan
abdoman reveal evidence obstruction ileus
think secondary inflammation irritation
necrotic omentum . [ * * 12 - 18 * * ] , patient find
less responsive increase respiratory effort .
arterial blood gas reveal ph 7.22 , CO2 100 PA2
84 3 liter oxygen . point patient
intubate hypercarbic respiratory failure
transfer Medical Intensive Care Unit .
respiratory standpoint , patient extubate
following day , require reintubation three day
secondary increase secretion need constant
pulmonary toilet . patient remain difficult wean .
attribute volume overload secondary diastolic
dysfunction well component chronic obstructive
pulmonary disease . sputum culture [ * * 12 - 18 * * ] subsequently
grow MRSA patient treat ten day course
Vancomycin . patient finally extubate [ * * 1 - 5 * * ]
extensive diuresis . gastrointestinal standpoint
CT abdomen [ * * 12 - 16 * * ] reveal communication
Hartmann 's pouch peritoneal cavity abdominal
fluid collection . per Surgery Service collection
note drain rectal stump
recommend surgical management .
infectious disease standpoint four four blood
culture bottle [ * * 12 - 5 * * ] [ * * 12 - 6 * * ] grow coag negative
staphylococcus , treat Vancomycin .
surveillance culture [ * * 12 - 28 * * ] reveal growth date .
mention previously , patient sputum [ * * 12 - 18 * * ] ,
grow MRSA . blood culture [ * * 12 - 18 * * ] subsequently grow
[ * * Female First Name ( un ) * * ] [ * * Female First Name ( un ) 29361 * * ] , patient complete fourteen day
course Fluconazole [ * * 1 - 4 * * ] . lastly , sputum [ * * 1 - 4 * * ]
grow Pseudomonas . Infectious Disease Service
consult believe patient colonize ,
particularly since currently evidence
pneumonia .
cardiac standpoint concern volume
overload secondary diastolic dysfunction . patient
echocardiogram [ * * 12 - 19 * * ] , reveal left ventricular
ejection fraction 55 % unremarkable chamber size
thickness . also concern coronary artery
disease . patient reportedly cardiac
catheterization outside hospital 30 % leave
anterior descend coronary artery 50 % right coronary
artery . several episode atypical chest pain
stay rule myocardial infarction
multiple time . MICU stay patient
frequent episode paroxysmal atrial fibrillation .
treat Amiodarone Lopressor good effect .
nutrition standpoint patient initially
total parenteral nutrition , discontinue
[ * * first name5 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 29361 * * ] fungemia . patient since
tube feed via nasogastric tube goal .
psychiatric standpoint patient profoundly
depressed follow Psychiatry Service .
episode self extubation attempt .
point feel suicide risk .
try Celexa Ritalin without benefit .
currently Wellbutrin .
PAST MEDICAL history : 1 . rectal carcinoma status post
radiation therapy chemosensitization low anterior
resection [ * * 2120 - 11 - 15 * * ] . 2 . Hypertension question
diastolic dysfunction . 3 . Coronary artery disease
30 % leave anterior descend coronary artery , 50 % right
coronary artery . 4 . Status post cholecystectomy .
allergy : Penicillin , Erythromycin intravenous contrast
( tolerate contrast ) .
medication TRANSFER : Lopressor 50 mg po b.i.d . ,
Wellbutrin 100 mg po t.i.d . , Lasix 80 mg po b.i.d . , Prevacid
30 mg po q.d . , amiodarone 400 mg po q.d . , Atrovent , Colace
100 mg po b.i.d . , Reglan 10 mg po q.i.d . , heparin subQ ,
tylenol prn .
SOCIAL history : live husband .
positive tobacco history .
PHYSICAL EXAMINATION : patient temperature 99.9 .
blood pressure 129/34 . Heart rate 78 . respiratory
rate 30 . sate 100 % 4 liter oxygen nasal
cannula . general , patient sad , conversant
old female acute distress . Neck examination
jugulovenous pressure approximately 8 cm water .
neck supple without lymphadenopathy . cardiovascular
examination regular rate rhythm . murmur , rub
gallop . respiratory examination , patient decrease
breath sound bilaterally well soft bibasilar rale .
Abdomen examination patient positive bowel sound .
abdomen soft , nontender , nondistended . colostomy
site clean intact . extremity warm without
club , cyanosis edema . 2 + dorsalis pedi
pulse bilaterally .
LABORATORY : patient white blood cell count
11.6 , hematocrit 32.2 , platelet count 376 , sodium 137 ,
potassium 4.8 , chloride 88 , CO2 41 , BUN 15 , creatinine 0.4 ,
calcium 9.1 , mag 1.8 , phosphate 4.3 . study , patient
chest x - ray [ * * 1 - 6 * * ] , reveal interval
improvement upper zone redistribution small left
pleural effusion residual leave low lobe collapse
questionable consolidation retrocardiac region think
secondary atelectasis . CT abdoman
[ * * 12 - 25 * * ] , reveal collection fluid air within
abdoman consistent abdominal abscess .
CT adomen [ * * 12 - 16 * * ] , reveal collection
fluid air within abdoman identifiable
Hartmann 's pouch . tte [ * * 12 - 19 * * ] . find
ejection fraction 60 % . left atrium mildly
dilate . left ventricular thickness cavity size
normal . right ventricular thickness size
normal . find moderate mitral annular
calcification 1 + mitral regurgitation .
microbiologic datum , sputum culture [ * * 1 - 4 * * ] grow
Pseudomanas . [ * * 12 - 28 * * ] MRSA , [ * * 12 - 22 * * ] MRSA [ * * 12 - 18 * * ] MRSA . blood
culture [ * * 12 - 28 * * ] growth time two set . [ * * 12 - 18 * * ] one
four [ * * first name5 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 29361 * * ] , [ * * 12 - 6 * * ] two two coag negative
staph . [ * * 12 - 5 * * ] two two coag negative staph . [ * * 11 - 27 * * ]
growth time two .
HOSPITAL COURSE : patient transfer General
Medicine Service [ * * 1 - 6 * * ] management .
1 . Pulmonary : patient daily chest physical therapy
aggressive pulmonary toilet . encourage
use incentive spirometer . decide treat
patient course Ciprofloxacin Pseudomonas
sputum . discuss treatment infectious
disease fellow think need double
cover pan sensitive Pseudomonas sputum .
patient 's respiratory status continue improve daily
basis . oxygen saturation improve dramatically
point require 3 4 liter nasal cannula
maintain appropriate oxygen saturation .
2 . infectious disease : mention previously
treat patient empirically Pseudomonas pneumonia
Ciprofloxacin . clear evidence
pneumonia , give history tenuous status opt
treat empirically single [ * * Doctor Last Name 360 * * ] .
infectious disease standpoint patient well .
overt sign infection . follow
blood culture carefully additional growth
date surveillance culture . white blood cell
count fever curve remain within normal limit .
3 . Gastrointestinal : patient note
abdominal collection drain rectal stump .
follow Surgery Service stay
believe need surgical
management . abdominal examination remain benign .
4 . Cardiovascular : cardiovascular standpoint
evidence acute ischemia , however ,
stay Medical Intensive Care Unit patient
several episode paroxysmal atrial fibrillation .
continue Amiodarone Lopressor . despite
several episode stay general
medicine floor . time remain hemodynamically
stable ventricular response rate 150s .
respond quite well low dose intravenous Lopressor
convert sinus rhythm almost instantaneous . think
atrial fibrillation secondary
patient 's general medical problem . toward end
hospital stay patient remain normal sinus rhythm .
despite opt continue Amiodarone
Lopresor . stay Medical Intensive Care
Unit , patient feel diastolic dysfunction ,
note fluid sensitive responsive
Lasix . time arrive medical floor feel
euvolemic .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( NamePattern1 ) 1211 * * ] , M.D. [ * * MD Number(1 ) 1212 * * ]
dictate by:[**last Name ( NamePattern1 ) 11732 * * ]
medquist36
: [ * * 2121 - 3 - 18 * * ] 17:00
: [ * * 2121 - 3 - 19 * * ] 05:41
JOB # : [ * * Job Number 36073 * * ]
|
[
"496",
"4280"
] |
Admission Date : [ * * 2117 - 7 - 18 * * ] Discharge Date : [ * * 2117 - 7 - 29 * * ]
Date Birth : [ * * 2047 - 11 - 12 * * ] sex :
Service : MEDICINE
history PRESENT ILLNESS : patient 69 year - old
male history coronary artery disease status post
myocardial infarction transfer [ * * Hospital1 346 * * ] percutaneous angioplasty
seven minute episode ventricular tachycardia without
intervention . patient find bed wife ,
choke unresponsive mid afternoon day
admission . wife call daughter turn
activate Emergency Medical System . patient
find v fibrillation treat epinephrine ,
atropine Dopamine . take [ * * hospital 35774 * * ] Hospital
give Lidocaine Amiodarone .
Electrocardiogram notable ST depression V4 5
6 lead junctional rhythm . transfer
[ * * Hospital1 69 * * ] emergent cardiac
catheterization . Cardiac catheterization notable
mild moderate left anterior descend coronary artery
stenosis stenting first diagonal perform .
transfer floor sedate intubate .
PAST MEDICAL history : Significant hypertension ,
life long , coronary artery disease , questionable myocardial
infarction [ * * 2108 * * ] , percutaneous transluminal coronary
angioplasty [ * * 2116 - 6 - 14 * * ] , leave anterior descend coronary
artery 95 % stenosis , OMI 90 % stenosis , obtuse marginal one
stent diabete apparently diet control .
allergy : know drug allergy .
FAMILY history : significant coronary artery disease .
patient 's father die age 57 acute myocardial
infarction .
social history : patient 80 pack year history
smoking [ * * 2115 * * ] . ethanol . engineer
marry child .
medication admission : Zocor 40 day , Plendil 5
day , atenolol 25 day Vaseretic dose
unknown .
PHYSICAL EXAMINATION : Temperature 99.8 . heart rate 66 .
blood pressure 124/61 . patient intubate AC
600 tidal volume 14 respiration FIO2 40 % PEEP 5 .
physical examination intubate , sedated , spontaneous
monoclonic jerk . HEENT pupil small , minimally reactive
light . gag reflex . cardiovascular regular rate
rhythm . murmur . Pulmonary clear auscultation
anteriorly . Abdomen nondistended , soft . extremity
positive pulse four extremity . patient
paroxysmal monoclinic jerk . neurological examination eye
open spontaneously . tracking . rove eye movement .
response verbal painful stimulus . cranial nerve
examination pupil 2 mm light reaction appreciate except
possible minimal change left pupil . corneal reflex
bilaterally . blink light bilaterally . slide
eye movement , response _ _ _ _ _ _ _ _ test .
gag obtainable . Motor increase tone throughout normal
bulk intermittent myoclonic movement four
extremity increase frequency patient
stimulate . drawer , flexor extensor response
pain . patient protect face arm drop
towards . Reflexes 3 + brachial radiali bicep
tricep reflexe , leave right arm . 3 + tricep
reflexe bilaterally , 2 + patella reflexe bilaterally 4 +
ankle reflexe bilaterally . plantar movement .
patient positive [ * * Doctor Last Name * * ] sign bilaterally upper
extremity three four beat clonu ankle .
LABORATORY : white blood cell count 10.0 , hematocrit 41.5 ,
platelet 165 , sodium 145 , K 3.3 , chloride 105 , bicarb 19 ,
BUN 20 , creatinine 1.6 , glucose 237 . arterial blood gas pH
7.3 , PCO2 46 , PO2 292 , calcium 8.4 , total bilirubin 0.4 , CPK
44 , alkaline phosphatase 83 , troponin less 0.4 .
HOSPITAL COURSE : immediately upon admission neurological
consult obtain indicate wide spread severe anoxic
brain damage . CT scan head do show
small subcortical hemorrhage left frontal lobe
multiple lacunar infarct , chronic reduce
great white matter visibility consistent global
ischemic change . give patient 's history start
amiodarone prevent arrhythmias . also
hypertensive start Lopressor , aspirin , Plavix ,
statin , Captopril . since admission patient start
spike low grade fever start Flagyl
Levofloxacin empiric treatment possible infection .
since beginning [ * * Hospital 228 * * ] hospital stay
multiple meeting patient 's family undertake
primary care team neurology team attempt
explain poor prognosis , accord neurology
give patient 's status 93 % improvement 7 % slight
improvement severe neurologic damage , 0 % moderate
complete improvement patient 's neurological status .
patient 's family voice understanding
current situation decide proceed tracheostomy
PEG tube placement maintain patient full code .
[ * * 7 - 23 * * ] tracheostomy tube perform bedside
interventional pulmonology without complication . PEG
tube placement perform GI [ * * 7 - 27 * * ] . patient
extubate [ * * 7 - 28 * * ] early a.m. remain
stable next 24 hour flow oxygen 35 % .
cardiovascular status remain stable high normal blood
pressure cardiac rhythm significant intermittent
atrial fibrillation spontaneous conversion sinus
bradycardia without require intervention . infectious
disease wise remain afebrile since initiation
antibiotic treatment . neurological status remain
unchanged . patient vegetative state time
discharge .
patient discharge [ * * hospital3 * * ] Hospital
Naddick long term care management diagnosis
acute myocardial infarction status post ventricular
fibrillation anoxic brain injury . discharge
medication insulin slide scale per flow sheet ,
calcium gluconate 500 po t.i.d . , Lansoprazole oral solution
30 mg nasogastric q.d . , heparin 5000 unit subq q 12 , aspirin
325 mg po q day , Metoprolol 75 mg nasogastric b.i.d .
hold systolic blood pressure less 100 heart
rate less 60 , Captopril 75 mg po t.i.d . hold
systolic blood pressure less 90 . Saliva substitute 1
3 milliliter po q 1 2 hour prn , Metronidazole 500 mg
intravenous q 8 last dose [ * * 8 - 1 * * ] . Acetaminophen 325/650
po q 4 6 hour prn fever pain , Levofloxacin 500 mg
po q 24 hour last dose give [ * * 8 - 1 * * ] .
Simvastatin 40 mg po q day Plavix 75 mg po q.d . last dose
[ * * 2117 - 8 - 18 * * ] . Aspirin 325 mg po q day Atropine
sulfate 0.5 mg intravenous prn symptomatic bradycardia
hypertension . discharge tube feeding diet .
staff [ * * hospital3 * * ] Hospital Naddick
schedule primary care physician follow
patient .
dr.[**last Name ( STitle ) * * ] , [ * * first Name3 ( LF ) * * ] 12 - 222
dictate by:[**doctor First Name 35775 * * ]
medquist36
: [ * * 2117 - 7 - 29 * * ] 12:01
: [ * * 2117 - 7 - 29 * * ] 12:08
JOB # : [ * * Job Number 35776 * * ]
|
[
"5070",
"4019",
"2720"
] |
Admission Date : [ * * 2153 - 2 - 3 * * ] Discharge Date : [ * * 2153 - 2 - 7 * * ]
Date Birth : [ * * 2074 - 10 - 16 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 30 * * ]
Chief Complaint :
hypotension , fever 101
Major Surgical Invasive Procedure :
femoral central line
history Present Illness :
78 yo man c PMH Chronic Liver disease , Hepatoma / p
[ * * first Name3 ( LF ) 54267 * * ] x 2 , COPD , Afib coumadin , USOH
[ * * 2153 - 2 - 3 * * ] begin chill , rigor febrile
home 101 , per pt . go [ * * Location ( un ) * * ] ED find
hypotensive bp low 70 s. Pt deny : cough , SOB ,
dysuria , urinary frequency , diarrhea , abdominal pain , n / v , night
sweat , anorexia . last BM yesterday . [ * * Location ( un ) * * ] : Levaquin , 3
L NS , dopamine 5 mcg / min . Pt arrive [ * * Hospital1 18 * * ] ED c BP near
120/48 hr 80 - 90 . dopamine drip stop . however pt
notice refractory hypotension start Levophed
. [ * * hospital1 * * ] ED , receive IV Vanco , Levoflox , FFP
NS IVF 100cc / hour .
.
MICU course : pt vanc , levo , flagyl unit .
panculture negative date . CXR without infiltrate . Abd u /
negative cholecystitis . abdominal CT r / new liver
abscess consider pt 's PMH negative . Vancomycin
taper [ * * 2 - 6 * * ] ( receive 4 day ) . IV levoflox flagyl
continue . Pt also steroid bronchospasm , COPD
MICU , receive prednisone 60 mg po qd unit ,
bronchodilator . satte 99 - 100 % 2L NC ( baseline
oxygen requirement ) . initially , INR supratherapeutic
4.9 , coumadin hold initially . Coumadin restart
goal INR [ * * 1 - 12 * * ] . foley / c'd continue urinate
well . tolerate regular diet , take med orally .
Past Medical history :
-afib many year coumadin
-htn
-copd
-hepatocellular carcinoma cirrhosis / p [ * * Month / Day ( 3 ) 54267 * * ]
surgery
x 2 , dx'd 2 year ago , folloe Dr. [ * * First Name ( STitle ) * * ] [ * * Hospital1 18 * * ] .
Pt hx liver abscess / p second [ * * first Name9 ( NamePattern2 ) 54267 * * ] [ * * 5 - 13 * * ] .
-prosthetic rigtht eye / p HSV subsequent enucleation
-stent pancrea mass h / obstructive jaundice
-Sarcoidosis / p lung biopsy right
-h / right temporal infarct [ * * 1 - 11 * * ] subtherapeutic INR , Afib MRI ,
[ * * 6 - 13 * * ]
-h / splenic infarct thought [ * * 1 - 11 * * ] subtherapeutic INR , Afib [ * * 6 - 13 * * ]
-last echo [ * * 2152 - 6 - 13 * * ] : EF 55 % , mod - markedly dil atria b / l. dil RV
free wall hypokinesis , RV pressure overload , 1+MR , 4+TR ,
severe pulm artery HTN , Cardiologist [ * * Location ( un ) * * ] Dr. [ * * last Name ( STitle ) 3503 * * ] ,
dry weight 162 lbs .
Social History :
patient live home wife , independent ADLs , 2
daughter , originally [ * * Name ( NI ) 4754 * * ] since [ * * 2103 * * ] , smoke
2ppd x 20 year quit 40 yr ago , etoh , drug . former
construction worker [ * * Location ( un ) * * ] gas co.
Family history :
patient one 11 child . 2 brother 1 sister
stroke , brother age 38 50 . one brother [ * * name2 ( NI ) 499 * * ]
cancer . seizure run family .
Physical Exam :
Physical Exam admission :
vital : 99.7 hr 90 - 110 afib , 88 - 96/58 - 70 , 18 , 95 % 2 Lt
GEN : acute distress , pleasant elderly man
skin : rash , jaundice
[ * * name2 ( NI ) 4459 * * ] : NC / , anicteric sclera , mmm
neck : supple , meningismus , + JVP
CHEST : normal respiratory pattern , CTA bilat anteriorly ,
decrease breath sound basis
CV : irregular irregular rate , murmurs
ABD : soft , nontender , nondistended , + BS , liver edge
palpable , ascite .
EXTREM : edema , 1 + dorsalis pedi pulse , 2 + radial pulse
.
Phys Exam call MICU :
vital : tm : 96.8 tc : 96.6 bp : 111/64 ( 99 - 120/49 - 69 ) p : 81 rr :
19 - 25 O2sat : 98 - 100 % 2L NC . 24 hour / 3090/1310 +1780 . 8
hour / : 1250/2365 -1115 .
General : well appear CM NAD . pleasant cooperative .
sit upright chair talk daughter .
[ * * Name ( NI ) 4459 * * ] : right eye prosthetic , leave eye PERRL , leave eye EOMI .
nasal discharge . MM slightly dry , op clear . poor dentition .
JVD mid neck . cervical LAD .
lung : CTAB
CV : irregularly irregular rhythm . S1 S2 audible .
Abd : Soft , NT , ND , Positive BS , ascite . HSM .
Ext : peripheral edema . cyanosis / club . Ext warm
well perfuse . 2 + dp pulse b / l.
Pertinent result :
[ * * 2153 - 2 - 3 * * ] 08:00PM WBC-12.2 * # RBC-2.92 * HGB-10.3 * HCT-29.8 *
MCV-102 * MCH-35.1 * MCHC-34.5 RDW-16.8 *
[ * * 2153 - 2 - 3 * * ] 08:00PM NEUTS-73 * BANDS-11 * LYMPHS-11 * MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-1 * MYELOS-0
[ * * 2153 - 2 - 3 * * ] 08:00PM HYPOCHROM - NORMAL ANISOCYT - NORMAL
POIKILOCY - NORMAL MACROCYT-1 + MICROCYT - NORMAL POLYCHROM - NORMAL
[ * * 2153 - 2 - 3 * * ] 08:00PM PLT COUNT-163
[ * * 2153 - 2 - 3 * * ] 07:45PM lactate-1.3
[ * * 2153 - 2 - 3 * * ] 08:00PM PT-43.3 * PTT-39.9 * INR(PT)-4.9 *
.
[ * * 2153 - 2 - 3 * * ] : CXR impression : Cardiomegaly congestive heart
failure . bibasilar atelectasis small bilateral pleural
effusion .
.
[ * * 2153 - 2 - 4 * * ] : Abdominal Ultrasound
impression : evidence acute cholecystitis
cholelithiasis . patchy area increase echogenicity
right lobe liver likely represent change associate
prior rf ablation .
.
[ * * 2153 - 2 - 5 * * ] CT TORSO
impression :
1 . bilateral predominantly peripheral ground glass opacity ,
new prior study . etiology uncertain ,
differential diagnosis include include infectious
inflammatory process , cryptogenic organizing pneumonia ,
eosinophilic hypersensitivity pneumonia pulmonary edema
superimpose severe emphysema . clinical correlation
follow indicate recommend .
2 . stable renal cyst .
3 . stable appearance radiofrequency ablation site .
evidence abdominal abscess pseudocyst .
4 . peripheral high attenuation area transiently see ? perfusion
anomaly , describe .
.
CULTURE datum :
[ * * 2153 - 2 - 3 * * ] blood cx X 4 neg
[ * * 2153 - 2 - 4 * * ] blood cx X 4 neg
[ * * 2153 - 2 - 3 * * ] Urine cx growth
[ * * 2153 - 2 - 3 * * ] : UA neg nitr , neg leuk , 0 - 2 WBC , [ * * 2 - 11 * * ] RBC , rare bact ,
0 - 2 epi .
.
Brief Hospital Course :
78 yo man Chronic Liver disease , Hepatoma / p [ * * Month / Day ( 1 ) 54267 * * ]
x 2 , h / liver abscess , COPD , atrial fibrillation coumadin
admit fever hypotension , think septic
secondary unclear etiology-- CXR negative infiltrate
bilateral pleural effusion ( effusion small
diagnostic thoracentesis ) , urinalysis negative , urine cx
negative , blood cx X 4 negative . Pt cover empirically X 4
day Vanco / Levo / Flagyl , / c Vanco [ * * 2153 - 2 - 6 * * ] , continue
Levo / Flagyl complete 7 day course give history liver
abscess past .
.
1 . Hypotension , fever admission think [ * * 1 - 11 * * ]
Septic - picture : clear source . however low bp ,
document fever OSH , hx chill make infection
likely . Pt start Levofloxacin + Vanc ED levophed
trough peripheral IV . vanc , levo , flagyl MICU .
Panculture negative date . CXR without infiltrate . Abd u /
negative cholecystitis . CT torso show ground glass
opacity lung inflamm vs. infectious , bilateral effusion
small tap . intraabd abscess .
- plan continue Levo / Flagyl 2 day complete 7
day course give h / liver abscess past .
.
2 . Cardiovascular :
A. coronary : sign ischemia EKG , enzyme negative .
Aspirin hold beta blocker continue .
B. Pump : sign ischemia ekg enzyme . get 20 mg
IV lasix diuresis , transition 40 mg po lasix transfer
medical floor . note , usually get 80 mg po qd lasix
home . last echo [ * * 6 - 13 * * ] show EF 55 % , severe pulm HTN ,
dil atria b / l , dilate right ventricle pressure overload .
discharge , monitor daily weight call PCP
weight increase 3 lbs , may indicate
heart failure .
C. Rhythm : atrial fibrillation . continue beta
blocker , atenolol , rate control , coumadin
anticoagulation . Goal INR [ * * 1 - 12 * * ] . pt goal INR 1 mg
coumadin po qday .
.
3 . copd : start prednisone 60 mg qday total 5 day ,
complete hospitalization . continue
bronchodilator . Pt satte well 2L NC , baseline oxygen
requirement . satte well ambulate physical
therapy .
.
4 . gi : Pt hx liver disease , hepatocellular carcinoma
status post [ * * Month / Day ( 3 ) 54267 * * ] . lft elevate , afp high , however
stable trend downward . abd pain , nausea , vomiting ,
diarrhea , constipation . intraabdominal abscess see
CT abdoman . stable appearance radiofrequency ablation site
CT Abdomen .
.
5 . HTN : Pt 's blood pressure remain stable ,
require pressor 48 hour , fluid need past 24
hour . take well po . restart beta blocker [ * * last Name ( un ) * * ]
tight hold parameter .
.
6 . code : Pt full code .
medication admission :
1 . aspirin 81 mg Tablet
2 . albuterol - Ipratropium 103 - 18 mcg / Actuation Aerosol
3 . Fluticasone - Salmeterol 100 - 50 mcg / Dose Disk Device Sig :
4 . Atenolol 25 mg Tablet Sig
5 . Losartan Potassium 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
6 . Warfarin Sodium 1 mg Tablet Sig : one ( 1 ) Tablet po
day .
7 . LT4 25 ug QD
8 . Lasix 20 qd
Discharge medication :
1 . Levothyroxine 25 mcg Tablet Sig : 0.5 Tablet PO DAILY ( Daily ) .
disp:*15 Tablet(s ) * Refills:*3 *
2 . Atenolol 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
3 . Levofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet PO Q24H ( every
24 hour ) 2 day .
Disp:*2 Tablet(s ) * Refills:*0 *
4 . warfarin 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ):
need see Dr. [ * * last Name ( STitle ) 8521 * * ] refill monitor
INR lab value / adjust dose . .
disp:*30 Tablet(s ) * Refills:*0 *
5 . Losartan 25 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
6 . furosemide 40 mg Tablet Sig : two ( 2 ) Tablet PO DAILY ( Daily ):
need follow Dr. [ * * last Name ( STitle ) 8521 * * ] refill ,
check electrolyte .
Disp:*60 Tablet(s ) * Refills:*0 *
7 . metronidazole 500 mg Tablet Sig : one ( 1 ) Tablet PO TID ( 3
time day ) 2 day .
Disp:*6 Tablet(s ) * Refills:*0 *
8 . albuterol 90 mcg / Actuation Aerosol Sig : two ( 2 ) puff
Inhalation every 4 - 6 hour need wheezing .
Disp:*1 MDI * Refills:*2 *
9 . Ipratropium Bromide 17 mcg / Actuation Aerosol Sig : two ( 2 )
Puff Inhalation QID ( 4 time day ) .
Disp:*1 MDI * Refills:*2 *
discharge Disposition :
Home Service
Facility :
[ * * Hospital * * ] Home Health Care
discharge Diagnosis :
1 . hypotension
2 . atrial fibrillation
3 . Hypertension
4 . Chronic Obstructive Pulmonary Disease
5 . Hepatocellular carcinoma
6 . history right temporal infarct
7 . history splenic infarct
8 . history sarcoidosis status post lung biopsy right
9 . history prosthetic right eye
discharge condition :
stable , good
Discharge instruction :
experience fever , chill , chest pain , shortness
breath , abdominal pain , nausea , vomiting , please report
emergency room immediately .
please take medication prescribe .
please follow physician . [ * * Name10 ( NameIs ) * * ] information .
Followup Instructions :
appointment Dr. [ * * last Name ( STitle ) 31446 * * ] [ * * Name ( STitle ) 8521 * * ] , 11:00am , [ * * 2 - 14 * * ] , [ * * 2152 * * ] . please call office [ * * telephone / Fax ( 1 ) 54268 * * ] need
reschedule appointment .
complete by:[**2153 - 2 - 7 * * ]
|
[
"0389",
"496",
"4019"
] |
Admission Date : [ * * 2146 - 3 - 28 * * ] Discharge Date : [ * * 2146 - 3 - 31 * * ]
Date Birth : [ * * 2105 - 8 - 20 * * ] sex :
Service : MEDICINE
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 7202 * * ]
Chief Complaint :
chest pain
Major Surgical Invasive Procedure :
Cardiac catheterization [ * * 2146 - 3 - 28 * * ] :
2 Cypher stent right coronary artery
history Present Illness :
patient 40 year old male history 2 ppd x 20
year tobacco history family history heart disease
present [ * * hospital3 * * ] afternoon [ * * 10 - 24 * * ]
substernal chest pressure around 2 pm shovel snow today
around 12:30 - 1 pm . patient return indoor feel [ * * 10 - 24 * * ]
substernal chest pressure associate diaphoresis , shortness
breath leave arm radiation tightness radiate
area clavicle back . report prior
history chest pain . take [ * * hospital6 3105 * * ]
ekg show 1-[**street Address(2 ) 1766 * * ] elevation II , III avF ,
normal axis [ * * Street Address(2 ) 4793 * * ] elevation V3 invert wave
, avl prior ekg comparison . right - sided ekg show
persistent II , III avf st elevation [ * * Street Address(2 ) 4793 * * ] V2 - V6 , TWI
avl. CK 105 .
[ * * hospital3 * * ] , place nitro drip , heparin gtt ,
integrillin give IV morphine aspirin . SBP
123/90 pulse 58 . transfer BIMC
cardiac catheterization .
cath [ * * 2146 - 3 - 28 * * ] show :
right - dominant system
lmca normal
LAD mild disease without lesion
LCX Non - dominant vessel lesion
RCA dominant mid - segment 99 % lesion evident thrombus
RA 19
PCW 31
PA 40
CO 7 CI 3
Cypher x 2 RCA place
Past Medical History :
2 ppd x 20 year tobacco history
h / hernia repair
herniate disc upper spine ( disability )
[ * * Date Range 2320 * * ]
Social History :
patient currently disability . formerly work
warehouse heavy lifting herniate disc
upper spine disability . smoke 2 ppd x 20
year . also drink 6 - 7 beer / week . deny illicit drug
use .
Family history :
Father - Deceased MI age 44
paternal father - MI age 55
Mother - [ * * Name ( NI ) 2320 * * ] , MI x 2
11 brother 3 sister - major medical problem
Physical Exam :
Tc = 97.3 p=74 BP=159/100 rr=16 99 % O2 2liters NC
Gen - NAD , AOX3 , heavy - set male
HEENT - PERLA , EOMI , JVD , carotid bruit bilaterally
Heart - RRR , soft holosystolic murmur Grade II / VI RUSB
Lungs - CTAB ( anteriorly )
Abdomen - Soft , NT , ND hepatosplenomegaly , + BS
Ext - Right groin ooze venous catheter site , +2 d. pedis
bilaterally , C / C / e
pertinent result :
ECHO Study Date [ * * 2146 - 3 - 29 * * ]
conclusion :
left atrium normal size . leave ventricular wall
thickness cavity
size normal . probably mild basal inferior wall
hypokinesis
overall preserve LV ejection fraction ( LVEF>55 % ) . right
ventricular chamber
size free wall motion normal . aortic valve leaflet
( 3 ) appear
structurally normal good leaflet excursion aortic
regurgitation .
aortic valve stenosis . mitral valve appear
structurally
normal trivial mitral regurgitation . estimate
pulmonary artery
systolic pressure normal . pericardial effusion .
IMPRESSION : mild regional LV hypokinesis preserve overall
LVEF c / w CAD .
c.cath Study Date [ * * 2146 - 3 - 28 * * ]
comment :
1 . coronary angiography right dominant system reveal
severe
single vessel coronary artery disease . left main coronary
artery
angiographically apparent flow limit stenosis .
LAD
mild luminal irregularity . LCX non - dominant vessel
without
lesion . RCA dominant vessel 99 % stenosis
mid
vessel evidence thrombus .
2 . Resting hemodynamic perform . Right sided pressure
severely elevate ( mean RA pressure 18 mm Hg ) . Pulmonary
artery
pressure moderately elevate ( PA pressure 50/29 mm
Hg ) . leave
sided filling pressure markedly elevate ( mean PCW
pressure 29
mm Hg ) . central arterial pressure moderately elevate
( aortic
pressure 161/104 mm Hg ) . Cardiac index normal ( 3.2
L / min / m2 ) .
3 . successful pci rca two overlap Cypher DES
( 3.5 x 8
mm 3.0 x 23 mm ) .
FINAL DIAGNOSIS :
1 . one vessel coronary artery disease .
2 . severely elevate leave right sided filling pressure .
3 . successful Primary PCI rca two drug - eluting
stent
acute inferior myocardial infarction .
[ * * 2146 - 3 - 28 * * ] 07:52pm glucose-121 * UREA N-9 CREAT-0.9 sodium-140
potassium-4.6 chloride-102 total CO2 - 30 * ANION GAP-13
[ * * 2146 - 3 - 28 * * ] 07:52pm ALT(SGPT)-142 * AST(SGOT)-107 * ld(ldh)-319 *
ALK PHOS-82 AMYLASE-48 TOT BILI-0.7
[ * * 2146 - 3 - 28 * * ] 07:52pm LIPASE-29
[ * * 2146 - 3 - 28 * * ] 07:52PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-2.4 *
MAGNESIUM-2.1 CHOLEST-228 *
[ * * 2146 - 3 - 28 * * ] 07:52pm % HbA1c-5.7
[ * * 2146 - 3 - 28 * * ] 07:52pm TRIGLYCER-114 HDL CHOL-42 CHOL / HDL-5.4
LDL(CALC)-163 *
[ * * 2146 - 3 - 28 * * ] 07:52PM WBC-11.9 * RBC-5.34 HGB-16.5 HCT-48.8 MCV-91
MCH-30.8 MCHC-33.7 RDW-13.3
[ * * 2146 - 3 - 28 * * ] 07:52pm PLT count-254
[ * * 2146 - 3 - 28 * * ] 07:52pm pt-12.7 PTT-29.1 INR(PT)-1.0
[ * * 2146 - 3 - 28 * * ] 06:31PM TYPE - ART PO2 - 303 * PCO2 - 56 * ph-7.28 * TOTAL
CO2 - 27 BASE XS--1 INTUBATED - INTUBA
[ * * 2146 - 3 - 28 * * ] 06:31PM HGB-16.8 calcHCT-50 O2 SAT-96
Brief Hospital course :
patient 40 year old male history heavy
tobacco use , family history CAD present inferior
MI / p RCA stent x 2
1 . cad
- patient Cypher stent place right coronary
artery event . isolated episode
NSVT post - cath attribute reperfusion .
- patient continue aspirin must take Plavix
next 9 month . place statin close
monitoring LFTS slightly elevate
presentation give history EtOH use . titrate
Toprol XL 50 mg Lisinopril 5 mg .
2 . HTN
- patient originally feel little dizzy lightheade
Lopressor 25 mg TID systolic blood pressure
90 . therefore , change Toprol XL 50 mg without
difficulty . also titrate Lisinopril 5 mg .
3 . CHF
- patient pawp 31 cath lab . CXR show
evidence CHF . give lasix 20 IV x 2 total
auto - diurese , remain euvolemic throughout
rest stay .
- echocardiogram show EF 55 - 60 %
hypokinesis inferior wall . echocardiogram
repeat 4 week post - mi - evaluate residual wall
motion abnormality .
4 . smoking cessation
- patient encourage quit smoking . try
nicotine patch gum past without success . discuss
possibility wellbutrin , however , give alcohol
consumption , feel may risk lower seizure
threshold . patient encourage join group tobacco
cessation therapy appear hesitant . try quit
tobacco admit temptation give
people live home smoke .
medication admission :
aspirin
Discharge medication :
1 . aspirin 325 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
2 . Clopidogrel Bisulfate 75 mg Tablet Sig : one ( 1 ) Tablet PO
DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*9 *
3 . Atorvastatin Calcium 80 mg Tablet Sig : one ( 1 ) Tablet PO
DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
4 . Metoprolol Succinate 50 mg Tablet Sustained Release 24hr Sig :
one ( 1 ) Tablet Sustained Release 24hr po DAILY ( Daily ) .
disp:*30 Tablet Sustained Release 24hr(s ) * Refills:*2 *
5 . lisinopril 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
disp:*30 Tablet(s ) * Refills:*2 *
discharge disposition :
home
discharge Diagnosis :
st elevation inferior myocardial infarction
premature coronary artery disease
Discharge condition :
Stable .
discharge instruction :
must take plavix every day next 9 month .
failure may result another heart attack even
death .
please call 911 return er experience
chest pain .
Followup Instructions :
please call schedule appointment primary care
physician [ * * last Name ( namepattern4 ) * * ] [ * * 1 - 16 * * ] week . liver function test
draw time . need follow
cardiologist 4 week . may repeat echo time
evaluate function heart .
|
[
"4271",
"3051"
] |
Admission Date : [ * * 2167 - 11 - 13 * * ] Discharge Date : [ * * 2167 - 11 - 27 * * ]
Date Birth : [ * * 2167 - 11 - 13 * * ] sex :
Service : NB
history PRESENT ILLNESS : [ * * know lastname 75017 * * ] [ * * know lastname * * ] former 1.135
kilogram produce 31 - 2/7 week gestation pregnancy bear
33 - year - old g1 , P0 1 woman . prenatal screen : blood type
a- , antibody negative , rubella immune , RPR nonreactive ,
hepatitis B surface antigen negative , group beta strep status
unknown . mother 's medical history complicate
pneumonia require initiation steroid . continue
steroid taper pregnancy . develop
gestational diabetes likely secondary steroid
taper . also smoker anxiety disorder .
suffer cerebral vascular accident age 18 .
monitor closely know intrauterine growth
restriction note absent diastolic flow
day delivery . take cesarean section
nonreasurre fetal heart rate tracing . large
amount blood note time delivery . infant
emerge apneic require positive pressure ventilation
blow - O2 . apgar 5 one minute 7 five minute
8 10 minute . admit neonatal
intensive care unit treatment prematurity .
anthropometric measurement time admission
neonatal intensive care unit : Weight 1.135 kilogram , less
10th percentile , length 37 cm 25th percentile , head
circumference 24.6 cm , less 10th percentile .
PHYSICAL EXAMINATION UPON discharge : weight 1.345 kilogram ,
length 39 cm , head circumference 27 cm . general : well
appear preterm male room air . skin warm dry . Color
pink . well perfuse . Head , ear , eye , nose throat ,
anterior fontanel open , level , suture oppose , eye clear ,
palate intact . positive red reflex bilaterally . chest : Breath
sound clear , equal , easy respiration . cardiovascular :
regular rate rhythm . murmur . Normal S1 , S2 , femoral
pulse +2 . positive palmar pulse . Abdomen soft , nontender ,
nondistended . masse . positive bowel sound . cord remnant
dry . extremity : move stable hip . Neuro :
active exam . symmetric tone movement . positive
suck , positive grasp .
HOSPITAL COURSE systems including pertinent LABORATORY
datum :
1 . respiratory : infant require treatment
continuous airway pressure upon admission
neonatal intensive care unit . respiratory distress
resolve wean room air day life # 1 .
continue room air rest neonatal
intensive care unit admission . rare episode
spontaneous apnea bradycardia
monitor treatment provide .
time discharge breathe comfortably room
air 40 - 60 breath per minute oxygen saturation
great 96 % .
2 . cardiovascular : infant maintain normal heart
rate blood pressure . intermittent murmur
note day life 5 6 audible
time discharge . baseline heart rate 130 - 170
beat per minute recent blood pressure 56/28
mmHg , mean arterial pressure 46 mmHg .
3 . fluid , electrolyte , nutrition : infant initial
hypoglycemia require treatment 20 % glucose
water . umbilical venous catheter place
central access . enteral feed start day
life # 2 gradually advanced full volume .
successfully wean high glucose intravenous
solution intravenous fluid 72
hour prior delivery . currently feed 150
ml per kilo per day preemie Enfamil 28 calorie per
ounce formula . serum glucose 57 - 80 mg per
deciliter . time discharge weigh 1.345
kilogram . Serum electrolyte check several time
first week life within normal limit .
4 . infectious disease : due respiratory distress
presentation time birth unknown group
beta strep status mother , infant
evaluate sepsis upon admission neonatal
intensive care unit . white blood cell count
differential within normal limit . blood culture
obtain prior start intravenous ampicillin
gentamycin . blood culture growth 48
hour antibiotic discontinue . Urine CMV
send negative .
5 . hematological : infant blood type o+
direct antibody test negative . hematocrit birth
38 . receive transfusion blood
product . treat supplemental iron .
6 . gastrointestinal : infant require treatment
unconjugate hyperbilirubinemia phototherapy . peak
serum bilirubin occur day life 6.1 mg per
deciliter . treat phototherapy
approximately 96 hour . recent rebound bilirubin
[ * * 2167 - 11 - 20 * * ] 1.6/0.5 mg per deciliter .
7 . neurology : head ultrasound perform day
life # 5 show left germinal matrix hemorrhage .
repeat head ultrasound [ * * 2167 - 11 - 25 * * ] show
previously mention leave germinal matrix hemorrhage
stable increase ventricular size . infant
maintain normal neurological exam
admission .
8 . sensory : Audiology hearing screening yet
perform . recommend prior discharge .
ophthalmology : infant require screen eye
exam retinopathy prematurity start
correct age 33 - 34 week .
9 . Placenta : placental pathology normal .
10 . psychosocial : mother ill postoperatively
cesarean section . remained hospitalize
[ * * 2167 - 11 - 25 * * ] . infant retro
transfer [ * * Hospital * * ] hospital upon request . [ * * Hospital1 35990 * * ] social work involve
mother . contact social worker [ * * Name ( NI ) 4457 * * ]
[ * * Name ( NI ) 36244 * * ] reach [ * * telephone / Fax ( 1 ) 70445 * * ] .
condition DISCHARGE : Stable .
discharge disposition : transfer [ * * Hospital * * ] Hospital
continue level ii care .
primary CARE PHYSICIAN : [ * * last Name ( namepattern4 ) * * ] . [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] , [ * * Hospital 75018 * * ]
Medical Center , [ * * last Name ( un ) 75019 * * ] , [ * * location 56504 * * ]
[ * * Numeric Identifier 75020 * * ] . phone number [ * * telephone / Fax ( 1 ) 56498 * * ] .
CARE recommendation TIME discharge :
1 . feed . Preemie Enfamil 28 calorie per ounce formula
150 ml per kilo per day gavage every 3 hour .
2 . medication . ferrous sulfate 25 mg per mL dilution , 0.1
ml p.o . daily ; vitamin e 5 unit pg daily .
3 . iron vitamin supplementation : iron supplementation
recommend preterm low birth weight infant
12 month correct age . infant feed
predominantly breast milk receive vitamin
supplementation 200 international unit ( may
provide multivitamin preparation ) daily 12
month correct age .
4 . car seat position screening recommend prior
discharge .
5 . state newborn screen send [ * * 11 - 16 * * ]
[ * * 2167 - 11 - 27 * * ] . notification
abnormal result date .
6 . immunization . immunization administer
thus far .
7 . immunization recommend : Synagis RSV prophylaxis
consider [ * * Month ( ) * * ] [ * * Month ( ) 958 * * ]
infant meet follow four criterion :
1 ) bear less 32 week ;
2 ) bear 32 35 week two following :
Daycare RSV season , smoker household ,
neuromuscular disease , airway abnormality , school
age sibling ;
3 ) Chronic lung disease
4)hemodynamically significant congenital heart disease
Influenza immunization recommend annually fall
infant reach 6 month age .
age first 24 month child 's life ,
immunization influenza recommend household
contact home caregiver .
infant receive rotavirus vaccine . American
Academy Pediatrics recommend initial vaccination preterm
infant follow discharge hospital
clinically stable least 6 week few 12 week
age .
discharge diagnosis :
1 . prematurity 31 - 2/7 week ' gestation .
2 . intrauterine growth restriction .
3 . transitional respiratory distress .
4 . suspicion sepsis rule .
5 . apnea prematurity .
6 . unconjugated hyperbilirubinemia .
7 . Profound hypoglycemia .
8 . last germinal matrix IVH .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 48738 * * ] , MD [ * * MD Number(2 ) 55708 * * ]
dictate by:[**last Name ( NamePattern1 ) 43348 * * ]
medquist36
: [ * * 2167 - 11 - 27 * * ] 01:20:30
: [ * * 2167 - 11 - 27 * * ] 12:40:47
Job # : [ * * Job Number 75021 * * ]
|
[
"7742",
"V290"
] |
Admission Date : [ * * 2151 - 10 - 1 * * ] Discharge Date : [ * * 2151 - 10 - 5 * * ]
Date Birth : [ * * 2091 - 12 - 3 * * ] sex : F
Service : MEDICINE
allergy :
Known Allergies / Adverse Drug reaction
attending:[**first Name3 ( LF ) 13256 * * ]
Chief Complaint :
alter mental status
Major Surgical Invasive Procedure :
n /
history Present Illness :
59 yo F w/ PMH alcohol hepatitis C cirrhosis history
varix upper gi bleed present loss consciousne
Guiac positive HCT drop 44 - ->33
setting intoxicate alcohol develop
hematemesis ED .
per ED report , patietn alert orient x3
admission , intoxicated , hypotensive systolic 70 .
give multiple lister fluid develop
hematemesis vomit bright red blood clot .
NG tube place continue vomit blood . start
octerotid PPI drip bolus , give dose
ceftriaxone vancomycin transffuse 2u PRBC .
pressure continue low receive 4th l fluid
prior transfer MICU .
arrival MICU , intubate sedate .
Review system :
unable obatin patient sedate
Past Medical History :
- alcoholic cirrhosis- low grade varices- band ,
bleed past . peripheral edema ( lasix 20 mg daily ) . 1 pint
brandy per day year . try detox .
Denies withdrawal
seizure .
- Chronic Back pain
- Hepatitis C , diagnose ~ 8 year ago , never treat . unknown
get , deny IVDU , transfusion . never liver bx .
- Hypertension
- Alcoholic cirrhosis- low grade varices- band ,
bleed past . peripheral edema ( lasix 20 mg daily ) . 1 pint
brandy per day year . try detox .
Denies withdrawal
seizure .
- Chronic Back pain
- Hepatitis C , diagnose ~ 8 year ago , never treat . unknown
get , deny IVDU , transfusion . never liver bx .
- Hypertension
Social History :
live [ * * Location 686 * * ] 16yo son . [ * * Name ( NI ) * * ] history alcohol
abuse , 10 year . current smoker . deny drug use .
alcohol detox - relape shortly thereafter . drink
[ * * 2 - 8 * * ] 1 pint brandy per day though actively try quit .
Family history :
Mother MI
Sister diabete .
many family member alcohol abuse
Physical Exam :
Exam admission :
General : sedateed intubated , NAD
HEENT : Sclera anicteric . intubate blood ett ,
unable assess JVP
CV : RRR , MRG appreciate
lung : Rhonchrousou breath sound bilaterally
Abdomen : soft , protuberant nondistended . hypoactive bowel
sound .
GU : foley
Ext : warm , well perfuse , 2 + pulse , club , cyanosis
edema
Neuro : sedate inutbate
discharge :
: AF 120s/70s 83 - 97 18 97%RA
Gen : NAD , sit chair comfortable
HEENT : MMM , hallitosis .
CV : RRR , normal S1 / S2 , / r / g.
Pulm : CTAB , wheeze , rhonchi rale .
Abd : soft , non - tender , obese .
Neuro : aao person , place , time , president
Pertinent result :
Labs Admission :
[ * * 2151 - 10 - 1 * * ] 02:15am blood wbc-7.2 # rbc-3.03 * hgb-11.1 * # hct-33.1 *
mcv-109 * MCH-36.7 * mchc-33.5 RDW-16.4 * Plt ct-78 *
[ * * 2151 - 10 - 1 * * ] 02:15am blood neuts-37.2 * Lymphs-54.5 * Monos-5.9
Eos-1.8 Baso-0.7
[ * * 2151 - 10 - 1 * * ] 09:03AM blood PT-22.6 * PTT-34.9 INR(PT)-2.2 *
[ * * 2151 - 10 - 1 * * ] 02:15am blood Glucose-129 * UreaN-18 Creat-1.0 Na-138
K-5.1 Cl-104 HCO3 - 22 AnGap-17
[ * * 2151 - 10 - 1 * * ] 07:40PM blood ALT-28 AST-61 * ld(ldh)-161 AlkPhos-97
TotBili-2.5 *
[ * * 2151 - 10 - 1 * * ] 02:15am blood Calcium-8.1 * Phos-2.4 * Mg-1.5 *
[ * * 2151 - 10 - 1 * * ] 02:15am blood ASA - NEG Ethanol-292 * Acetmnp - NEG
Bnzodzp - NEG Barbitr - NEG Tricycl - NEG
[ * * 2151 - 10 - 1 * * ] 09:13am blood type-[**last Name ( un ) * * ] ph-7.20 *
[ * * 2151 - 10 - 1 * * ] 02:36am blood Lactate-4.8 * K-4.6
[ * * 2151 - 10 - 1 * * ] 09:13am blood freeca-0.86 *
Labs Discharge :
[ * * 2151 - 10 - 5 * * ] 05:01AM blood wbc-4.5 RBC-2.56 * Hgb-8.7 * hct-26.2 *
MCV-102 * MCH-34.0 * MCHC-33.2 RDW-21.8 * Plt Ct-57 *
[ * * 2151 - 10 - 5 * * ] 05:01AM blood Glucose-122 * UreaN-4 * Creat-0.4 Na-136
K-3.5 Cl-107 HCO3 - 27 angap-6 *
[ * * 2151 - 10 - 5 * * ] 05:01AM blood ALT-27 AST-55 * AlkPhos-117 * totbili-1.9 *
[ * * 2151 - 10 - 5 * * ] 05:01AM blood Calcium-7.8 * Phos-3.3 Mg-1.9
imaging :
EGD ( [ * * 2151 - 10 - 1 * * ] ): " source bleeding identify [ * * first Name4 ( NamePattern1 ) * * ]
[ * * last Name ( NamePattern1 ) * * ] tear GE junction , bleed time
endoscopy . intervention do . otherwise grade
varice low third esophagus stigmata
bleeding . moderate amount old blood clot stomach ,
source bleeding identify stomach ;
normal mucosa duodenum otherwise normal EGD third
part duodenum . "
Portable Chest ( [ * * 2151 - 10 - 1 * * ] ): " single frontal view chest
obtain . cardiac mediastinal hilar contour
unremarkable . lung clear focal consolidation ,
pleural effusion pneumothorax . "
Portable Abdomen ( [ * * 2151 - 10 - 1 * * ] ): " gaseous distention loop
small bowel low abdoman , paucity gas remain
throughout abdoman . finding nonspecific ,
exclude partial small - bowel obstruction . evidence
free intraperitoneal air , though image quality limit
assessment . nasogastric tube place . right - side pelvic
catheter consistent central venous access line . "
Brief Hospital Course :
59 year old female history hepatitis C
alcoholic cirrhosis know Grade varix present
ugib secondary [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] tear .
# ugib- patient history esophageal varix
follow Dr. [ * * last Name ( STitle ) * * ] cirrhosis . nadalal
one home medication . develop hematemesis
ED , receive 3L crystalloid 2 unit PRBC .
trasnferre MICU , EGD perform GI
reveal [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] tear esophagus .
monitor MICU HCT remain stable throughout
MICU stay . start sucralfate receive 48 hour
protonix drip . transfer floor , continue
remain hemodynamically stable , although continue
melanic stool . HCT continue remain stable discharge .
send home sucralfate pantoprazole daily , along
iron supplementation setting acute blood loss .
# hypovolemic shock- Patient present hypotension
elevate lactate resolve fluid resusciation
blood product . since egd , remain hemodynamically
stable , lactate trend , require additional
blood product .
# alter mental status- Patient find alter home
intoxicate . positive flapping tremor start
lactulose time transfer MICU . patient
continue CIWA scale floor , require minimal
diazepam symptom .
# cirrhosis- Patient alcoholic / HepC cirrhosis .
follow liver clinic Dr. [ * * last Name ( STitle ) * * ] . still actively
drink per postiive blood alcohol today ED .
MELD score 15 . thormbocytopenia know esophageal
varix . history ascite hepatic
encephalopathy , however flap tremor somnolent
time / c MICU , persistent floor .
treat 4d course ceftriaxone setting GI
Bleed .
# Alcohol abuse- Patient come MICU intoxicate > 200 BAL .
social work consult . patient demonstrate interest
attend AA discharge .
# Hypertension- Patient normotensive MICU admission ,
nadolol restart transfer MICU continue
floor . home lasix lisinopril hold setting
GI bleeding , sign fluid overload day
discharge restart .
# hypokalemia - k around 3.3 - 3.5 . unknown etiology . replete
PO K.
# Depression- Patient restart citalopram
able tolerate po
# Migraines- Fiorecet hold hospital .
patient full code throughout admission .
TRANSITIONAL ISSUES :
Pt need weekly lab follow hypokalemia hematocrit
several week , f / u appt primary care [ * * 10 - 14 * * ] .
f / u appointment GI need repeat egd roughly 3
week per gi recommendation .
medication admission :
preadmission medication list correct complete .
Information obtain webOMR .
1 . furosemide 20 mg PO DAILY
hold sbp<90
2 . spironolactone 50 mg PO DAILY
hold sbp<90
3 . Nadolol 20 mg PO DAILY
hold sbp<90 , hr<60
4 . Acetaminophen - Caff - Butalbital [ * * 2 - 8 * * ] TAB PO Q8H : PRN headache
5 . citalopram 10 mg PO DAILY
6 . FoLIC Acid 1 mg PO DAILY
7 . Multivitamins 1 tab PO DAILY
8 . Thiamine 100 mg PO DAILY
Discharge medication :
1 . Nadolol 20 mg PO DAILY
hold sbp<90 , hr<60
2 . Acetaminophen - Caff - Butalbital [ * * 2 - 8 * * ] TAB PO Q8H : PRN headache
3 . citalopram 10 mg PO DAILY
4 . FoLIC Acid 1 mg PO DAILY
5 . Multivitamins 1 tab PO DAILY
6 . Thiamine 100 mg PO DAILY
7 . Pantoprazole 40 mg PO Q24H
RX * pantoprazole 40 mg 1 tablet(s ) mouth daily Disp # * 31
Tablet refills:*3
8 . Sucralfate 1 gm PO BID
RX * sucralfate 1 gram 1 tablet(s ) mouth twice day Disp # * 31
Tablet Refills:*4
9 . Lactulose 30 ml PO TID
RX * lactulose [ Constulose ] 10 gram/15 ml 15 - 30 mL mouth use
4 time day Disp # * 1000 Milliliter refills:*3
10 . ferrous Sulfate 325 mg PO BID
RX * ferrous sulfate 325 mg ( 65 mg iron ) 1 tablet(s ) mouth
twice day Disp # * 62 Tablet refills:*3
Discharge Disposition :
Home Service
Facility :
[ * * Hospital 119 * * ] Homecare
Discharge Diagnosis :
primary :
[ * * Doctor First Name * * ] -[**doctor last Name * * ] tear
Alcoholic intoxication
secondary :
Hepatitis C Virus
Cirrhosis
Migraines
Hypertension
Chronic low back pain
low extremity edema
Depression
discharge condition :
Mental Status : clear coherent .
Level consciousness : alert interactive .
Activity Status : Ambulatory - Independent .
Discharge instruction :
Dear Ms. [ * * know lastname * * ] ,
recently admit [ * * Hospital1 18 * * ] find
alter mental status . , egd
vomitting blood show change varix ,
evidence tear likely cause
bleeding . change home medication .
imperitive discontinue drink ,
likely cause hospital admission .
pleasure take care patient .
please hesitate contact we question ,
comment concern .
Warm Regards ,
Inpatient Medicine Team
Followup Instructions :
Department : [ * * Hospital3 249 * * ]
: THURSDAY [ * * 2151 - 10 - 14 * * ] 2:10 pm
: Dr. [ * * last Name ( STitle ) * * ] [ * * Name ( STitle ) * * ]
Location : [ * * company 191 * * ] POST [ * * hospital 894 * * ] CLINIC [ * * telephone / Fax ( 1 ) 2010 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) 895 * * ] South [ * * Hospital * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] garage
appointment hospital - base doctor part
transition hospital back primary care provider .
[ * * Name10 ( NameIs ) 616 * * ] visit , see regular primary
care doctor follow .
Department : LIVER CENTER
: FRIDAY [ * * 2151 - 10 - 22 * * ] 11:00
: [ * * First Name11 ( Name Pattern1 ) 640 * * ] [ * * last Name ( namepattern4 ) * * ] , MD [ * * telephone / Fax ( 1 ) 2422 * * ]
building : LM [ * * Hospital Ward Name * * ] Bldg ( [ * * last Name ( NamePattern1 ) * * ] ) [ * * Location ( un ) 858 * * ]
Campus : WEST good parking : [ * * Hospital Ward Name * * ] Garage
Department : RADIOLOGY
: FRIDAY [ * * 2151 - 10 - 22 * * ] 9:00
: ULTRASOUND [ * * telephone / Fax ( 1 ) 590 * * ]
building : CC [ * * Location ( un ) 591 * * ] [ * * Location ( un ) * * ]
Campus : WEST good parking : [ * * Street address(1 ) 592 * * ] garage
|
[
"2851",
"4019",
"311",
"3051",
"2768",
"2875"
] |
Admission Date : [ * * 2200 - 2 - 24 * * ] Discharge Date : [ * * 2200 - 3 - 4 * * ]
Date Birth : [ * * 2123 - 2 - 5 * * ] sex : F
Service : CARDIOTHORACIC
allergy :
Nitroglycerin / Penicillins / Amoxicillin / Norvasc / Celecoxib
/ Adhesive Tape / Lovenox
attending:[**first Name3 ( LF ) 922 * * ]
Chief Complaint :
exertional chest pain
Major Surgical Invasive Procedure :
[ * * 2200 - 2 - 25 * * ] - coronary artery bypass graft three vessel .
( Saphenous vein graft->diagonal artery , first obtuse marginal
artery second obtuse marginal artery .
[ * * 2200 - 2 - 24 * * ] - leave heart Catheterization , coronary angiogram
history Present Illness :
77 year old white female know coronary artery disease ,
undergone stenting LAD circumflex vessel
past . present recurrent angina elsewhere
rule non st myocardial infaction Troponin
1.19 . transfer undergo catheterization
[ * * 2 - 25 * * ] .
Catheterization reveal osteal circumflex subtotal stent
circumflex stenosis . LV function show ~55 % .
refer surgical revascularization .
Past Medical history :
hypertension
hyperlipidemia
noninsulin dependent Diabetes mellitus
moderate aortic stenosis
chronic atrial fibrillation
Congestive heart failure past
Coronary artery disease percutaneous intervention past
Anxiety
Cerbrovascular disease-60 - 70 % bilateral carotid artery
H / breast cancer , / p right lumpectomy radiation
H / cervical cancer , / p hysterectomy radiation
appendectomy
cholecystectomy
H / multinodular goiter
/ P removal pylonidal cyst
/ P bilateral carpal tunnel surgery
/ p bone spur removal
Osteoarthritis
coccyx ulcer - stage IV
Social History :
patient currently live alone . husband alzheimer 's
disease live care facility . one son
handicapped grandson . quit smoking 35 year ago ;
previously 4 ppd . drink alcohol use ilicit
drug .
Family history :
family history negative premature coronary artery disease
sudden death . Mother die complication alcoholism .
Father die pneumonia . Grandmother die colon cancer .
Physical Exam :
admission :
VS - 97.3 , 100/74 , 16 , 95%RA
Gen : WDWN elderly female NAD . orient x3 . mood , affect
appropriate . patient lie supine post - cath .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
Neck : Supple without lymphadenopathy .
CV : irregularly irregular , normal S1 , S2 . [ * * 3 - 31 * * ] holosystolic
murmur loud lusb radiate carotid .
thrill , lift . S3 S4 .
Chest : chest wall deformity , scoliosis kyphosis . Resp
unlabore , accessory muscle use . CTAB , crackle ,
wheeze rhonchi anteriorly .
Abd : soft , NTND . HSM tenderness . abd aorta enlarge
palpation . abdominial bruit .
Ext : c / c / e. femoral bruit .
skin : brown skin change around leave low leg . stasis
dermatitis , ulcer , scar , xanthomas .
.
pulse :
right : Carotid 2 + Femoral 2 + dp 2 +
leave : Carotid 2 + Femoral 2 + dp 2 +
pertinent result :
[ * * 2200 - 2 - 24 * * ] 04:45PM glucose-113 * urea n-11 CREAT-0.5 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2 - 27 anion GAP-11
[ * * 2200 - 2 - 24 * * ] 04:45PM alt(sgpt)-18 ast(sgot)-36 CK(CPK)-166 * ALK
PHOS-58 AMYLASE-16 TOT BILI-0.8
[ * * 2200 - 2 - 24 * * ] 04:45PM ctropnt-0.22 *
[ * * 2200 - 2 - 24 * * ] 04:45PM wbc-6.2 rbc-2.99 * HGB-9.9 * HCT-28.6 * MCV-96
MCH-33.1 * mchc-34.6 RDW-14.7
[ * * 2200 - 2 - 24 * * ] 04:45PM wbc-6.2 rbc-2.99 * HGB-9.9 * HCT-28.6 * MCV-96
MCH-33.1 * mchc-34.6 RDW-14.7
[ * * 2200 - 2 - 24 * * ] 04:45PM PT-17.2 * PTT-31.9 INR(PT)-1.6 *
[ * * 2200 - 2 - 24 * * ] Cardiac Catheterization
1 . coronary angiography right dominant system
reveal three vessel coronary artery disease . LMCA
angiographycally apparent coronary artery disease . LAD
non - obstructed . d1 ostial 80 % lesion . LCx
subtotally occlude - stent restenosis mid stent
ostium
vessel . RCA small caliber , 70 % lesion
proximally .
2 . resting hemodynamic reveal elevate leave side fill
pressure
LVEDP 20 mmHg . normal systemic arterial
systolic
diastolic pressure SBP 109 mmHg DBP 72 mmHg .
3 . peak peak transaortic gradient 5 mmHg
4 . left ventriculography perform .
[ * * 2200 - 2 - 25 * * ] echo
left atrium mildly dilate . left atrium elongate .
right atrium moderately dilate . estimate right
atrial pressure 0 - 10mmhg . leave ventricular wall thickness ,
cavity size regional / global systolic function normal
( LVEF > 55 % ) . right ventricular cavity mildly dilate
normal free wall contractility . ascending aorta mildly
dilate . aortic valve leaflet moderately thicken .
mild aortic valve stenosis ( area 1.2 - 1.9cm2 ) . mild ( 1 + )
aortic regurgitation see . mitral valve leaflet
mildly thicken . mild moderate ( [ * * 12 - 27**]+ ) mitral regurgitation
see . [ due acoustic shadowing , severity mitral
regurgitation may significantly underestimate . ]
tricuspid valve leaflet mildly thicken . moderate
severe [ 3 + ] tricuspid regurgitation see . moderate
pulmonary artery systolic hypertension . pericardial
effusion .
compare prior study ( image review ) [ * * 2199 - 10 - 19 * * ] ,
severity mitral tricuspid regurgitation
increase . estimate pulmonary artery pressure high .
aortic stenosis mild severity .
[ * * 2200 - 3 - 2 * * ] 06:13AM blood wbc-9.7 rbc-3.01 * Hgb-9.6 * Hct-27.8 *
MCV-93 MCH-32.0 mchc-34.6 RDW-16.0 * Plt ct-121 *
[ * * 2200 - 3 - 3 * * ] 05:04AM blood pt-20.6 * INR(PT)-1.9 *
[ * * 2200 - 3 - 2 * * ] 06:13AM blood pt-19.8 * PTT-30.8 INR(PT)-1.9 *
[ * * 2200 - 3 - 1 * * ] 05:30PM blood pt-22.3 * INR(PT)-2.1 *
[ * * 2200 - 3 - 1 * * ] 03:45AM blood pt-20.0 * PTT-35.0 INR(PT)-1.9 *
[ * * 2200 - 2 - 28 * * ] 02:10am blood PT-16.6 * PTT-32.6 INR(PT)-1.5 *
[ * * 2200 - 2 - 27 * * ] 12:58AM blood pt-16.3 * PTT-31.4 INR(PT)-1.5 *
[ * * 2200 - 2 - 26 * * ] 03:09PM blood PT-17.8 * PTT-40.7 * INR(PT)-1.6 *
[ * * 2200 - 2 - 26 * * ] 01:55PM blood pt-18.0 * PTT-34.4 INR(PT)-1.6 *
[ * * 2200 - 2 - 26 * * ] 02:20AM blood pt-17.0 * PTT-53.2 * inr(pt)-1.5 *
[ * * 2200 - 2 - 25 * * ] 05:19PM blood PT-16.8 * PTT-80.5 * INR(PT)-1.5 *
[ * * 2200 - 2 - 25 * * ] 05:10AM blood pt-18.5 * PTT-59.1 * inr(pt)-1.7 *
[ * * 2200 - 3 - 3 * * ] 05:04AM blood UreaN-22 * creat-0.6 na-129 * K-4.0
Brief Hospital course :
Ms. [ * * know lastname 14330 * * ] admit [ * * Hospital1 18 * * ] [ * * 2200 - 2 - 24 * * ] cardiac
catheterization management myocardial
infarction . cardiac catheterization reveal two vessel
disease severe instent restenosis circumflex artery .
give severity disease fact refuse
take plavix , surgical revascularization decide upon .
Ms. [ * * know lastname 14330 * * ] work - usual preoperative manner
include carotid ultrasound show mild right
moderate left internal carotid artery stenosis . Heparin
continue remain without chest pain . wound care
nurse [ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) 4221 * * ] assistance coccyx ulcer
appropriate dressing barrier cream apply .
[ * * 2200 - 2 - 26 * * ] , Ms. [ * * know lastname 14330 * * ] take Operating Room
undergo coronary artery bypass graft three vessel .
please see operative note detail . postoperatively
take intensive care unit monitoring . next
several hour , awake neurologically intact
extubate . beta blockade , aspirin statin resume .
Diuresis towards preoperative weight begin .
coccyx wound treat Aquacel AG daily .
surgical wound clean dry . pace wire ct
remove accord protocol . Bactroban administer
MRSA positive nasal swab . Lopressor digoxin give
advanced rate control chronic atrial fibrillation
diuretic continue , achieve
preoperative weight .
stop [ * * 3 - 3 * * ]
medication admission :
ativan 3 HS , atenolol 25 , lipitor 80 , ASA 325 , digoxin 0.125 ,
lisinopril 40 , colace , coumadin 2.5 , januvia 100 , magnesium
oxide 400 , lasix 40 KCl 10 every day , MVI
discharge medication :
1 . aspirin 81 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
2 . ranitidine HCl 150 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2
time day ) .
3 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
4 . Atorvastatin 80 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
5 . oxycodone - Acetaminophen 5 - 325 mg Tablet Sig : 1 - 2 tablet po
Q4H ( every 4 hour ) need pain .
6 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet po Q4H ( every
4 hour ) need .
7 . Magnesium Hydroxide 400 mg/5 ml Suspension Sig : thirty ( 30 )
ML po HS ( bedtime ) need constipation .
8 . Bisacodyl 10 mg Suppository Sig : one ( 1 ) Suppository Rectal
DAILY ( Daily ) need constipation .
9 . Metoprolol Tartrate 50 mg Tablet Sig : one ( 1 ) Tablet PO BID
( 2 time day ) .
10 . Digoxin 250 mcg Tablet Sig : [ * * 12 - 27 * * ] alter w/ 1 tab Tablet PO
every DAY ( every Day ) .
11 . Clonazepam 1 mg Tablet Sig : one ( 1 ) Tablet po QHS (
day ( bedtime ) ) need insomnia .
12 . Januvia 100 mg Tablet Sig : one ( 1 ) Tablet po day .
13 . warfarin 1 mg Tablet Sig : dose per INR Tablet PO
DAILY ( Daily ): Goal INR [ * * 1 - 28 * * ]
INR 2.6 [ * * 3 - 4**]- coumadin give .
14 . furosemide 10 mg / mL Solution Sig : twenty ( 20 ) mg Injection
Q12H ( every 12 hour ) .
15 . Potassium Chloride 20 meq Tab Sust . Rel . Particle / Crystal
Sig : one ( 1 ) Tab Sust . Rel . Particle / Crystal PO Q12H ( every 12
hour ) .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital1 700 * * ] - [ * * Location ( un ) 701 * * ]
discharge diagnosis :
coronary artery disease
/ p coronary artery bypass
Hyperlipidemia
Hypertension
Atrial fibrillation
non insulin dependent Diabetes mellitus
Anxiety
/ p myocardial infarction
peripheral vascular disease
Cerebrovascular disease
Multinodular goiter
Osteoarthritis
h / cervical cancer
Discharge condition :
deconditione
Discharge instruction :
1 ) monitor wound sign infection . include
redness , drainage increase pain . event
drainage sternal wound , please contact [ * * name2 ( NI ) 5059 * * ]
( [ * * telephone / Fax ( 1 ) 1504 * * ] .
2 ) report fever great 100.5 .
3 ) report weight gain 2 pound 24 hour 5 pound
1 week .
4 ) lotion , cream powder incision
heal . may shower wash incision . gently pat wound
dry . please shower daily . bathing swim 1 month .
Use sunscreen incision expose sun .
5 ) lifting great 10 pound 10 week date
surgery .
6 ) drive 1 month take narcotic pain .
7 ) call question concern .
Followup Instructions :
please follow - Dr. [ * * last Name ( STitle ) 914 * * ] 1 month . ( [ * * telephone / Fax ( 1 ) 1504 * * ]
please follow - Dr. [ * * last Name ( STitle ) * * ] 2 week . [ * * telephone / Fax ( 1 ) 8725 * * ]
please follow - Dr. [ * * last Name ( STitle ) 1057 * * ] [ * * 1 - 29 * * ] week . [ * * telephone / Fax ( 1 ) 14331 * * ]
please call appointment
complete by:[**2200 - 3 - 4 * * ]
|
[
"4280",
"4019",
"4241",
"2724",
"4439"
] |
Admission Date : [ * * 2103 - 5 - 19 * * ] Discharge Date : [ * * 2103 - 5 - 27 * * ]
Date Birth : [ * * 2080 - 7 - 19 * * ] sex : F
Service : MEDICINE
allergy :
Morphine / Dilaudid
attending:[**first Name3 ( LF ) 1055 * * ]
Chief Complaint :
back pain one day
Major Surgical Invasive Procedure :
none
history Present Illness :
Ms. [ * * know lastname 14164 * * ] 22 year - old african - american woman know
[ * * know lastname 14165 * * ] cell disease , present 1 - day history
right - sided posterior chest pain .
note well 4 - day prior admission
develop URI symptom , include headache , rhinorrea ,
generalize fatigue . subsequently develop cough ,
productive small amount dark yellow sputum . yesterday ,
develop right - sided posterior chest pain , pleuritic
nature , bad coughing , deep breathing lie
culprit side . report mild SOB . feel warm
past day , measure temperature . deny
chill . unsure whether receive Pneumovax
Influenza vaccine .
ROS otherwise negative joint pain . gi urinary
complaint . lightheadedness , dizziness .
ed , vital initially 99.4 , hr 80 , BP 119/58 , RR 16 ,
oxygen saturation 95 % 3L , 88 % room air . CXR reveal
RLL infiltrate . give Ceftriaxone 1 gm IV X1
Azithromycin 500 mg PO QD . also give Morphine 1 mg IV
X1 , Benadryl 25 mg X1 , Dilaudid pain control .
Past Medical History :
1 . [ * * know lastname * * ] cell disease , 1 admission per year since [ * * 2100 * * ]
acute pain crisis .
2 . history gonorrhea
3 . prior pneumonia versus acute chest syndrome [ * * 2100 * * ]
4 . history pre - eclampsia first pregnancy
5 . know multiple RBC allo - antibody difficult cross - match
Social History :
live 2 child age 4 2 year - old .
active smoker , smoke 5 cigarette per day . quit
3 year , restart last year . EtOH consumption .
also deny illicit drug use .
Family history :
live [ * * Doctor Last Name * * ] home age 5 onwards . per OMR
record , mother father [ * * name2 ( NI ) 14165 * * ] cell trait .
child [ * * name2 ( NI ) 14165 * * ] cell trait .
Physical Exam :
physical examination admission :
vital : 99.4 , hr 100 , BP 110/55 , RR 20 , Sat 99 % 3 liter
via NC .
GEN : Sleepy . scratch . uncomfortable motion .
HEENT : Anicteric . EOMI . PERRL . Frontal boss .
LN : cervical lymphadenopathy .
RESP : dullness percussion right base . decrease air entry
right base , basilar crackle . bronchial breathing . +
egophony , + whisper pectoriloquy .
CVS : PMI displace . Normal S1 , physiologic splitting S2 .
S3 , S4 . soft , late systolic murmur apex , non - radiating .
GI : BS NA . abdoman soft non - tender .
EXT : strong pedal pulse . pedal edema .
pertinent result :
Relevant laboratory datum admission :
CBC :
WBC 11.1 , Hb 6.9 , Hct 19.9 , Platelet 552
neuts-54 BANDS-1 lymphs-35 monos-7 EOS-2 BASOS-1 ATYPS-0 METAS-0
MYELOS-0 NUC RBCS-1
HYPOCHROM-2 + ANISOCYT-3 + POIKILOCY-3 + MACROCYT-2 + MICROCYT-1 +
POLYCHROM - NORMAL SPHEROCYT-1 + OVALOCYT-1 + TARGET-2 + [ * * name2 ( NI ) * * ] -2 +
chemistry :
Na 138 , K 4.7 , Cl 106 , HCO3 24 , BUN 8 , Creat 0.7 , Glucose 0.7
relevant imagind study :
[ * * 2103 - 5 - 19 * * ] CXR : stable cardiac contour . interval development
patchy opacity right low lobe , pleural effusion .
[ * * 2103 - 5 - 20 * * ] CXR : heart size within normal limit
evidence CHF . consolidation right middle
right low lobe associate small right pleural
effusion , increase compare prior film [ * * 5 - 19 * * ] , 05 . atelectasis left lung base previously
demonstrate . probably associated collapse
right lobe .
IMPRESSION : increase extent right middle lobe right
low lobe consolidation small right pleural effusion . leave
basilar atelectasis .
[ * * 2103 - 5 - 21 * * ] CXR : cardiac silhouette upper limit normal
size slight increase pulmonary vascularity ,
consistent patient 's know [ * * Year / Month / Day 14165 * * ] cell status .
multifocal area consolidation involve right middle
low lobe , progress interval .
also bilateral probable small pleural effusion .
IMPRESSION : worsen multifocal consolidation suggest
multifocal pneumonia . [ * * Year / Month / Day * * ] cell lung differential
diagnosis infectious symptom present .
[ * * 2103 - 5 - 22 * * ] CXR : significant interval change .
[ * * 2103 - 5 - 23 * * ] CXR : increase mild moderate left pleural effusion .
persistent right middle low lobe infiltrate right
pleural effusion , stable .
[ * * 2103 - 5 - 24 * * ] CXR : slight interval improvement right middle lobe
aeration . slight improvement right pleural effusion . stable
leave pleural effusion left low lobe retrocardiac
atelectasis .
[ * * 2103 - 5 - 26 * * ] CXR : improve right middle lobe leave low lobe
opacity . small left - sided pleural effusion
unchanged .
* * * * * * * *
[ * * 2103 - 5 - 22 * * ] echo : left atrium mildly elongate . leave
ventricular wall thickness , cavity size , systolic function
normal ( lvef>55 % ) . regional left ventricular wall motion
normal . right ventricular chamber size free wall motion
normal . aortic valve leaflet ( 3 ) appear structurally normal
good leaflet excursion aortic regurgitation .
mitral valve leaflet mildly thicken . mitral
valve prolapse . trivial mitral regurgitatino .
borderline pulmonary artery systolic hypertension .
pericardial effusion .
Brief Hospital Course :
22 year - old african - american woman [ * * Year / Month / Day 14165 * * ] cell disease
admit respiratory symptom right - side back pain ,
find RLL infiltrate + hypoxemia .
1 ) Pneumonia + /- acute chest syndrome : CXR admission reveal
RLL infiltrate suspicious pneumonia , although acute chest
syndrome rule . examination also remarkable
hypoxemia , saturation low 80 .
empirically start Ceftriaxone Azithromycin coverage
Mycoplasma , Chlamydia , Hemophilus pneumococcus ,
hydrated . afebrile admission , subsequently
develop fever hospital rise WBC 34.6
[ * * 5 - 21 * * ] . also develop worsen hypoxemia [ * * 5 - 21 * * ]
increase SOB setting decrease hematocrit 15.5 ,
14.3 . abg reveal ph 7.41/38/70 . repeat CXR
perform remarkable worsen RML / RLL pneumonia . give
well inability transfuse PRBCs [ * * 3 - 21 * * ]
available cross - match blood ( multiple allo - antibody ) , Ms.
[ * * know lastname 14164 * * ] transfer ICU [ * * 5 - 20 * * ] .
ICU , supportive care provide . continue
Ceftriaxone Azithromycin . Sputum culture return op
flora , without predominance organism ( rule
Chlamydia Mycoplasma ) . blood urine culture return
negative . serial CXRs initially reveal worsen picture ,
interval development LLL infiltrate consistent
multilobar process , bilateral pleural effusion . echo
perform show normal EF>60 % . effusion
ultimately feel likely [ * * 3 - 21 * * ] fluid overload setting
aggressive IVF administration , diurese Lasix
[ * * 5 - 23 * * ] [ * * 5 - 24 * * ] . eventually improve defervesced ,
decrease oxygen requirement improve radiographic
picture . antibiotic change PO Levofloxacin [ * * 5 - 24 * * ] ,
Ceftriaxone / C'd [ * * 5 - 24 * * ] ( receive 6 day ) , Azithromycin
/ C'd [ * * 5 - 25 * * ] ( receive 7 day ) . complete 14 - day
course ( total ) Levofloxacin ( last dose [ * * 2103 - 6 - 1 * * ] ) .
note , effusion persist discharge , stable size .
also persistent leukocytosis WBC 16.2 discharge .
improve time . need follow - imaging
completion antibiotic course document complete
resolution infiltrate / effusion , well repeat WBC .
effusion persist , thoracentesis would indicate
rule parapneumonic effusion . give pneumococcal ,
Meningococcal Hib vaccine prior discharge .
follow - PCP [ * * Name Initial ( PRE ) 176 * * ] 1 week discharge .
2 ) [ * * Name Initial ( PRE ) * * ] cell disease : Hematocrit admission 19.9 ( around
baseline ) , 15.3 [ * * 5 - 20 * * ] 2 + [ * * Month / Year ( 2 ) 14165 * * ] cell
peripheral smear , nadir 14.3 [ * * 5 - 21 * * ] . hematology
service consult . Ms. [ * * know lastname 14164 * * ] multiple allo - antibody
HRB absent rare except African - Americans .
blood bank unable provide match blood .
transfuse 1 unmatched unit [ * * 5 - 22 * * ] pre - medication
Prednisone 60 mg PO QD , without response . transfusion
therefore hold . per hematology , folate increase 5 mg
PO QD . hematocrit slowly trend 22 discharge .
note , ferritin send rule concomitant iron deficiency ,
return elevate 791 . appropriate
reticulocytosis 22 % setting anemia .
follow - Dr. [ * * last Name ( STitle ) * * ] Hematology within 1 week
discharge . treatment hydroxyurea address .
3 ) pain control : pain control achieve Dilaudid IV prn
pre - medication Benadryl . switch PO
OxyContin 10 mg po BID oxycodone breakthrough [ * * 5 - 26 * * ] ,
fair pain control . tylenol around clock Naproxen
also add . discharge
OxyContin / Oxycodone / Naproxen / Tylenol + bowel regimen .
4 ) bacterial vaginosis : Ms. [ * * know lastname 14164 * * ] diagnose bacterial
vaginosis prior admission , treat Flagyl . complete
5 - day course Flagyl hospital , resolution
symptom ( [ * * 5 - 22 * * ] -- > [ * * 5 - 26 * * ] ) .
5 ) oral lesion : hospital , develop oral lesion
suspicious oral HSV . start Valtrex 1 gm PO TID
plan complete 3 day . complete course
- patient ( last dose [ * * 2103 - 5 - 28 * * ] ) .
medication admission :
Folate 2 mg PO QD
Metronidazole ( take intermittently bacterial
vaginosis )
Discharge medication :
1 . Folic Acid 1 mg Tablet Sig : five ( 5 ) Tablet PO DAILY ( Daily ) .
Disp:*150 Tablet(s ) * Refills:*1 *
2 . Colace 100 mg Capsule Sig : one ( 1 ) Capsule po twice day :
please take Oxycontin .
Disp:*60 Capsule(s ) * Refills:*0 *
3 . Levofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet PO Q24H ( every
24 hour ) 5 day : start [ * * 5 - 28 * * ] , last dose [ * * 6 - 1 * * ] .
Disp:*5 Tablet(s ) * Refills:*0 *
4 . Valacyclovir HCl 500 mg Tablet Sig : two ( 2 ) Tablet PO TID ( 3
time day ) need HSV 3 dose : please take 1 pill
tonight , 1 pill tomorrow morning 1 pill tomorrow night . .
Disp:*6 Tablet(s ) * Refills:*0 *
5 . oxycodone HCl 10 mg Tablet Sustained Release 12hr Sig : one
( 1 ) Tablet Sustained Release 12hr po Q12H ( every 12 hour ) .
disp:*25 Tablet Sustained Release 12hr(s ) * Refills:*0 *
6 . oxycodone HCl 5 mg Tablet Sig : one ( 1 ) Tablet PO Q4 - 6h ( every
4 6 hour ) need pain .
Disp:*40 Tablet(s ) * Refills:*0 *
7 . Naproxen 250 mg Tablet Sig : two ( 2 ) Tablet po Q12H ( every 12
hour ) 7 day .
Disp:*28 Tablet(s ) * Refills:*0 *
discharge disposition :
home
discharge Diagnosis :
primary diagnosis :
[ * * Month / Year ( 2 ) * * ] cell disease
Anemia
Pneumonia
RBC antibodie
secondary diagnosis :
bacterial vaginosis
probable oral herpe simplex
Discharge condition :
Patient discharge home stable condition . saturation 94 - 96 %
room air . Hematocrit 22.5 .
Discharge instruction :
please return hospital call PCP develop
worsen respiratory symptom , include increase shortness
breath , increase cough . also return
develop fever .
please continue take Levofloxacin daily , last dose [ * * 6 - 1 * * ] .
treat pneumonia . start [ * * 5 - 28 * * ] .
please note also increase folate 5 mg daily .
please take Oxycontin 10 mg twice daily pain control .
also take oxycodone 5 mg need every 4 6 hour
breakthrough pain .
note give 3 vaccine ( Haemophilus influenza ,
pneumococcal , meningococcal vaccine )
Followup Instructions :
please call PCP ( Dr. [ * * last Name ( STitle ) 14166 * * ] [ * * telephone / Fax ( 1 ) 14167 * * ] schedule
appointment see within 1 week discharge . need
repeat CXR next 2 week .
please call dr.[**name ( NI ) 220 * * ] office ( Hematology ) [ * * telephone / Fax ( 1 ) 9645 * * ] ,
schedule appointment see within 1 - 2 week
discharge .
complete by:[**2103 - 5 - 27 * * ]
|
[
"486",
"5119",
"3051"
] |
Admission Date : [ * * 2151 - 1 - 31 * * ] Discharge Date : [ * * 2151 - 2 - 16 * * ]
Date Birth : [ * * 2096 - 2 - 11 * * ] sex :
Service : MICU
history PRESENT ILLNESS : patient 54 year old man
admit Intensive Care Unit [ * * 2151 - 1 - 31 * * ] , [ * * hospital3 6265 * * ] evaluation hematemesis , melena abdominal
mass . patient well Tuesday
prior admission develop headache
point take Vicodin develop nausea vomiting
abdominal pain . Thursday evening prior admission ,
state pass floor bathroom
fall secondary severe pain . state loss
consciousness fifteen minute . deny head
trauma .
Saturday prior admission , patient state
retch blood . present
Emergency Department [ * * hospital3 3583 * * ] admit
find hematocrit 26.3 , potassium 6.2 ,
also acute renal failure . Abdominal CT indicate
large peripancreatic mass . patient transfer
[ * * Hospital1 69 * * ] evaluation .
transfer , white blood cell count 28 ,
creatinine 3.4 .
PAST MEDICAL history :
1 . history spontaneous pneumothorax .
2 . history immune complex mediate glomerulonephritis .
3 . history peptic ulcer disease , status post surgery .
4 . Acute renal failure .
medication admission : Vicodin p.r.n .
allergie : patient state allergic Sulfa ,
Aspirin Naprosyn .
SOCIAL history : patient work sale . twenty
pack year history smoking . deny alcohol street
drug use .
FAMILY history : Noncontributory .
PHYSICAL EXAMINATION : admission , patient 's
temperature 97.0 , heart rate 107 , respiratory rate 15 ,
blood pressure 135/42 , oxygen saturation 98 % two liter .
general , patient alert , acute distress .
neck supple . Pulmonary examination indicate scant
crackle bilaterally . cardiovascular examination indicate
regular rhythm , normal S1 S2 , II / VI systolic
murmur . abdoman distend decrease bowel
sound mild diffuse tenderness percussion .
extremity examination , patient 2 + peripheral pulse
edema . stool guaiac negative .
LABORATORY DATA : initial laboratory study indicate
white count 28.6 , hematocrit 25.6 , platelet count 404,000 .
Chem7 indicate blood urea nitrogen 43 creatinine
3.4 . INR elevate 1.9 . liver function test
within normal limit .
Electrocardiogram indicate normal sinus rhythm , rate 99
beat per minute , normal axis , normal interval
ischemic change .
HOSPITAL COURSE : patient admit Intensive
Care Unit . nasogastric lavage perform indicate
presence coffee ground emesis . evaluate
gastroenterology service emergent endoscopy
perform indicate presence hiatal hernia
well compression second third part
duodenum . biopsy take compression site
indicate chronic inactive duodenitis focal Brunner gland
hyperplasia . also gastric mucocele metaplasia .
CT abdoman indicate 10 6.0 centimeter soft
tissue mass within mesentery pelvic rim
well 10 16 centimeter mesenteric retroperitoneal
hematoma display duodenum anteriorly compress
inferior vena cava . significant mesenteric
lymphadenopathy also note .
Renal surgery service consult .
recommendation surgery service , follow - abdominal
CT p.o . contrast complete indicate
persistent intra - abdominal hematoma intra - abdominal
mass . patient also note increase liver
function test ALT 622 , ast 649 , normal
total bilirubin alkaline phosphatase .
patient 's hematocrit continue drop , bleeding
scan conduct indicate active bleeding
abdomen clear source . patient therefore receive
angiogram indicate presence superior
mesenteric artery aneurysm well active bleeding
gastroduodenal artery embolize .
patient also develop shortness breath follow
administration total fourteen unit pack red
blood cell Intensive Care Unit . Chest x - ray
indicate presence congestive heart failure
possible left side infiltrate . patient start
Lasix well Levaquin Flagyl . hepatitis panel
send negative . ANCA send concern
possible polyarteritis nodosa , however , study
negative . patient also start total parenteral
nutrition secondary expected ileus follow
embolization .
Intensive Care Unit follow embolization ,
transaminase trend downward , creatinine improve ,
hematocrit remain stable . patient develop
transient episodic hypertension systolic pressure 200
require Labetalol drip , however , successfully
wean patient transition Labetalol tablet .
unit , also develop bipedal scrotal
edema , think secondary volume overload
setting multiple transfusion .
Echocardiogram conduct hospital day number four
indicate ejection fraction great 55 % 1 +
tricuspid regurgitation .
hospital day number six , patient transfer
floor additional workup questionable abdominal
mass . repeat [ * * Location ( un ) 1131 * * ] patient 's exist CAT scan ,
determine initially read mass
first CT likely extension hematoma .
follow - imaging four week recommend .
first day floor , patient spike
temperature 101.3 degree Fahrenheit . repeat chest x - ray
indicate worsen pulmonary infiltrate bilaterally .
point , patient switch Ceftazidime
Clindamycin treat possible nosocomial pneumonia . Sputum
blood culture send negative .
patient 's pulmonary status improve significantly
intravenous antibiotic . patient able tolerate
p.o . intake , total parenteral nutrition discontinue .
however , patient note pain eating
find small lesion site denture
insertion site . patient able tolerate food
pretreatment Viscous Lidocaine solution .
although patient 's initial abdominal pain subside ,
maintain Oxycontin control residual abdominal
pain floor . patient 's low extremity edema
decrease administration intravenous
subsequently p.o . Lasix .
hospital day number ten , patient note
increase jaundice alter mental status . liver
function test time indicate alkaline phosphatase
1091 total bilirubin 11.4 . transaminase
slightly elevated . right upper quadrant ultrasound
perform indicate dilatation common bile
duct well presence biliary sludge .
intrahepatic biliary duct dilatation gallstone .
Endoscopic retrograde cholangiopancreatography perform
consultation gastroenterology service .
study indicate fifteen millimeter common bile duct
stente well stenosis distal bulb .
patient 's liver function test , jaundice mental status
improve follow endoscopic retrograde
cholangiopancreatography . patient
follow - endoscopic retrograde cholangiopancreatography
three month stent removal .
although patient 's mental status improve follow
endoscopic retrograde cholangiopancreatography , residual
symptom agitation paranoia prompt psychiatry
consultation recommend low dose Haldol p.r.n .
worsening symptom . however , patient 's mental
status slowly return baseline .
patient evaluate physical therapy service
find would benefit acute rehabilitation .
time discharge summary , patient
screen placement acute rehabilitation facility .
discharge diagnosis :
1 . superior mesenteric artery aneurysm .
2 . Status post embolization gastroduodenal artery .
3 . Biliary sludge .
4 . Pneumonia .
5 . Glomerulonephritis .
6 . history peptic ulcer disease .
7 . history pneumothorax .
medication DISCHARGE :
1 . Lasix 80 mg p.o . q.d .
2 . Viscous Lidocaine 2 % solution 15 ccs swish spit
meal p.r.n .
3 . Senna two tablet p.o . q.h.s . p.r.n .
4 . Colace 100 mg p.o . b.i.d .
5 . Boost t.i.d . meal .
6 . Protonix 40 mg p.o . b.i.d .
7 . Labetalol 200 mg p.o . q12hour .
8 . Albuterol Atrovent MDI two puff q4hours p.r.n .
9 . lipitor 10 mg p.o . q.d .
10 . nephrocap 1 mg p.o . q.d .
DISPOSITION : time dictation , patient
screen placement acute rehabilitation
facility .
follow - endoscopic retrograde
cholangiopancreatography stent removal three month
follow discharge well follow - abdominal CT scan
three week follow discharge . follow -
[ * * Hospital * * ] Clinic .
discharge disposition : improve .
[ * * Doctor Last Name * * ] [ * * Name6 ( MD ) * * ] [ * * Name8 ( MD ) * * ] , M.D. [ * * MD Number(1 ) 5712 * * ]
dictate by:[**last Name ( NamePattern1 ) 194 * * ]
medquist36
: [ * * 2151 - 2 - 15 * * ] 19:22
: [ * * 2151 - 2 - 15 * * ] 19:42
JOB # : [ * * Job number 96120 * * ]
|
[
"5789",
"486",
"4280"
] |
Admission Date : [ * * 2135 - 12 - 26 * * ] Discharge Date : [ * * 2136 - 1 - 3 * * ]
Date Birth : [ * * 2080 - 2 - 9 * * ] sex :
Service :
history PRESENT ILLNESS : Patient 55 - year - old man
multiple medical problem include insulin dependent
diabete secondary severe pancreatitis [ * * 2123 * * ] , remote
history Hodgkin 's disease [ * * 2113 * * ] treat among
thing , radiation therapy leave patient
severe osteoporosis result compression fracture ,
history alcohol abuse , chronic opioid residual
pain secondary pancreatitis , present [ * * 12 - 26 * * ]
delta MS .
per patient 's lifetime partner , patient self
increase dose opiate use approximately four patch
Fentanyl increase Seroquel dose 150 300
mg . present ED [ * * 2135 - 12 - 26 * * ] increase
weakness , tremor , disorientation x2 month , bad
prior three day .
ED , patient 's temperature 98.4 , blood pressure
136 - 145/60 - 70 . heart rate 71 - 130 .
treat Ativan 7 mg think alcohol
withdrawal , increase patient 's sedation
subsequently systolic blood pressure decrease 88 - 97 .
Patient negative head CT . lumbar puncture
attempt , successful . Patient start
acyclovir , Vancomycin empiric meningitis coverage .
patient 's chem-7 time significant glucose
354 , anion gap 13 , 15 ketone urine .
result , ED start patient insulin drip .
blood gas initially 7.23/55/46 , decrease
7.16/56/260 . patient minimally alert time .
progressive somnolence . Patient start
BiPAP 10 5 , admit MICU .
PAST MEDICAL history :
1 . COPD .
2 . diabetes mellitus insulin dependent secondary chronic
pancreatitis .
3 . chronic alcohol induce pancreatitis status post
debridement .
4 . history alcohol abuse .
5 . osteoporosis .
6 . CHF ejection fraction 40 % .
7 . Hodgkin 's disease status post XRT , chemotherapy ,
splenectomy .
8 . Hypothyroidism .
9 . GERD .
10 . vocal cord paralysis .
11 . chronic pain multiple narcotic .
12 . anxiety depression .
allergy : know drug allergy .
SOCIAL history : Patient 40 pack year history
tobacco . recent ethanol use .
PHYSICAL EXAM : Temperature 98.5 , blood pressure 104/64 ,
heart rate 107 . Cardiovascular : Patient 3/6 systolic
murmur hear well left low sternal border
apex . Abdomen soft , nontender , nondistended , multiple
surgical scar . extremity : cyanosis , club ,
edema . pulse [ * * 12 - 30**]+ bilaterally . Neurologic :
patient respond command , move four extremity .
HOSPITAL COURSE : patient admit MICU
management . [ * * 2135 - 12 - 27 * * ] , intubate due
increase somnolence hypoxia .
[ * * 2135 - 12 - 28 * * ] , EEG perform , read
possibly consistent encephalitis . Patient see
Neuro team , recommend MRI LP .
[ * * 2135 - 12 - 28 * * ] , patient 's temperature spike 101.6 .
continue ampicillin , ceftriaxone , acyclovir
possible meningiti . also start bicarb drip
metabolic acidosis . patient initially treat
Ativan narcotic withdrawal , / C'd
later start low dose Fentanyl .
[ * * 2135 - 12 - 29 * * ] , patient transfer VICU .
analysis CSF fluid reveal 2 monocyte , 15
lymphocyte , 1 band . Gram stain negative PMNs ,
macrophage , bacteria . Culture negative . PCR
Listeria HSV negative .
result patient 's MRI [ * * 2135 - 12 - 28 * * ] reveal normal
brain parenchyma . blood breakdown edema present .
overall impression MRI grossly normal ,
however , study limit patient motion .
MICU , patient extubate . mental status
continue improve . continue antibiotic
treatment presume community acquire pneumonia .
note eosinophilia , improve course
hospitalization . transfuse 1 unit blood
transiently go pulmonary edema setting
transfusion . resolve Lasix nebulizer .
Acyclovir / C'd patient 's MRI lumbar puncture
negative .
patient transfer medical floor ,
alert oriented , able ambulate cane ,
tolerate good p.o . intake . see Physical
Therapy , feel would benefit rehabilitation
stay .
condition DISCHARGE : Stable .
DISCHARGE STATUS : [ * * hospital3 2558 * * ] [ * * Hospital * * ] Hospital .
discharge diagnosis :
1 . chronic obstructive pulmonary disease .
2 . insulin dependent diabete .
3 . history chronic alcoholic - induce pancreatitis .
4 . remote history alcohol abuse .
5 . severe osteoporosis .
6 . congestive heart failure ejection fraction 40 % .
7 . Hodgkin 's disease .
8 . Hypothyroidism .
9 . gastroesophageal reflux disease .
10 . vocal cord paralysis exacerbate recent intubation .
11 . chronic pain multiple narcotic .
12 . anxiety depression .
medication DISCHARGE :
1 . Lasix 20 mg p.o . q.d .
2 . Pantoprazole 40 mg p.o . q.d .
3 . lisinopril 5 mg p.o . q.d .
4 . morphine sulfate 15 mg p.o . q.6h . prn .
5 . Clindamycin 600 mg IV q.8h .
6 . Ceftriaxone 1 gram IV q.24h .
7 . Docusate 100 mg b.i.d .
8 . fentanyl patch 150 mcg / hour transdermal patch q.72h .
9 . Quetiapine fumarate 100 mg p.o . q.h.s .
10 . insulin - slide scale 7 unit glargine
bedtime .
11 . Lorazepam 1 - 2 mg IV q.3 - 4h . prn .
12 . Levothyroxine 125 mcg p.o . q.d .
13 . Folic acid 1 mg p.o . q.d .
14 . Multivitamin .
15 . pancrease four capsule p.o . t.i.d . meal .
16 . tylenol prn .
17 . Vitamin D.
18 . citalopram 40 mg p.o . q.d .
19 . calcium 500 mg p.o . t.i.d .
20 . antibiotic therapy complete [ * * 2136 - 1 - 10 * * ] .
[ * * First Name11 ( Name Pattern1 ) * * ] [ * * last Name ( namepattern4 ) 8184 * * ] , M.D. [ * * MD Number(1 ) 8185 * * ]
dictate by:[**last Name ( NamePattern1 ) 9725 * * ]
medquist36
: [ * * 2136 - 1 - 3 * * ] 10:42
: [ * * 2136 - 1 - 3 * * ] 11:00
JOB # : [ * * Job number 108105 * * ]
|
[
"486",
"496",
"4280",
"2762"
] |
Admission Date : [ * * 2165 - 4 - 29 * * ] Discharge Date : [ * * 2165 - 5 - 15 * * ]
service : MEDICINE
allergy :
Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin
Attending:[**Last Name ( NamePattern1 ) 1171 * * ]
Chief Complaint :
chest pain , total body pain
Major Surgical Invasive Procedure :
none
history Present Illness :
[ * * age 90 * * ] / F PMHx CAD , CHF EF 40 % , recent admission
respiratory failure require intubation present
total body pain chest pain . patient 's current symptom
begin Saturday nausea . follow day ( one day prior
admission ) , patient experience ache throughout
body , include back , chest , back head .
morning , patient awake sleep 6 due right index
finger pain , erythema , swell , calor spread
rest body ( back , chest , back head ) . Finger pain
describe stiff , sore , achy associated calor .
total body pain describe sharp body ache
generalize , last receive Morphine ED .
patient describe chest pain along total body
pain , receive SL Nitro x3 without relief . pain
similar feature prior anginal equivalent ,
experience chest pain , shortness breath , upper back
pain , current pain consist nausea without dyspnea
lightheadedness .
.
ER , vital T99.9 BP 156/61 P76 R18 PO2 100 % 2l.
Chest pain [ * * 7 - 18 * * ] arrival start nitro
gtt without significant relief symptom . however , symptom
resolve morphine , currently 0/10 . EKG reveal sinus
rhythm baseline LBBB acute ekg change .
receive Morphine 500cc bolus en route EMS ,
receive additional Morphine ED .
.
evaluation floor , pt asymptomatic complain
thirst . deny PND , report 2 pillow orthopnea
remain unchanged year .
.
.
REVIEW systems :
deny prior history stroke , TIA , deep venous
thrombosis , pulmonary embolism , bleed time surgery ,
myalgias , joint pain , cough , hemoptysis , black stool red
stool . deny recent fever , chill rigor . deny
exertional buttock calf pain . deny fever / chill ,
night - sweat , abdominal pain , diarrhea , dysuria , rash .
report ( + ) congestion / cough white sputum since
hospitalization , help albuterol . review
system negative .
.
Cardiac review system notable absence chest pain ,
dyspnea exertion , paroxysmal nocturnal dyspnea , ankle edema ,
palpitation , syncope presyncope .
Past Medical History :
# diabetes
# dyslipidemia
# hypertension
# Coronary Disease - / p NSTEMI [ * * 9 - 16 * * ] medically manage Cath
/ p stent [ * * 3 - 20 * * ] .
# Chronic systolic / diastolic congestive heart failure ,
recent EF>60 %
# chronic renal failure , stage III CKD - Dr [ * * last Name ( STitle ) * * ]
# hypertension
# Hyperlipidemia , intolerant statin
# type 2 diabetes , diet - control
# gerd
# Breast cancer - diagnose [ * * 2145 * * ] , / p lumpectomy [ * * State 108 * * ]
# / p total abdominal hysterectomy [ * * 2094 * * ] fibroid
# Cataracts
Social History :
live home alone , family area . social
history significant absence current tobacco use ,
remote social tobacco use college . history
alcohol abuse . home [ * * Year ( 4 digit ) 269 * * ] w tele report daily PT .
present rehab follow multiple admission .
Family history :
family history premature coronary artery disease
sudden death . father hypertension . sister
alive healthy 93 .
Physical Exam :
admission
VS : T=98.6 bp=146/70 hr=75 R=20 PO2 sat= 100 % 2L
GENERAL : WDWN NAD . orient x3 . mood , affect appropriate .
HEENT : NCAT . Sclera anicteric . PERRL , EOMI . Conjunctiva
pink , pallor cyanosis oral mucosa . xanthalesma .
neck : supple JVP < 9 cm .
CARDIAC : RRR , normal S1 , S2 . GII systolic murmer LSB ,
gallop , rub . S4 present LSB apex . thrill , lift .
lung : chest wall deformity , scoliosis kyphosis . Resp
unlabore , accessory muscle use . crackle basis b / l ;
egophany . wheeze rhonchus .
ABDOMEN : soft , NTND . HSM tenderness . abd aorta
enlarge palpation . abdominial bruit . NABS .
extremitie : c / c / e.
skin : stasis dermatitis , ulcer , scar , xanthomas .
pulse :
right : Carotid 2 + dp 2 + PT 2 +
leave : Carotid 2 + dp 2 + PT 2 +
discharge
VS : 97.3 , 120/47 , 52 , 18 , 100%RA
/ : 120/350 today , [ * * telephone / Fax ( 1 ) 93520 * * ] yesterday
GENERAL : AAOx3 , pleasant elderly female NAD . Fatigued ,
interactive .
HEENT : NCAT . Sclera anicteric .
neck : supple JVP < 9 cm sit 90 degree
CARDIAC : RRR , normal S1 , S2 . S4 present LSB apex .
lung : mild kyphosis . Resp unlabored , accessory muscle
use . soft crackle bibasilarly , breath sound basis decrease
ABDOMEN : soft , NTND . HSM tenderness . NABS .
extremitie : c / c / e.
pulse :
right : Carotid 2 + dp 2 + PT 2 +
leave : Carotid 2 + dp 2 + PT 2 +
pertinent result :
CXR ( [ * * 4 - 29 * * ] ): two view compare bedside examination
obtain 10 hour early , well previous examination
[ * * 4 - 16 * * ] [ * * 2165 - 4 - 19 * * ] . clear finding
CHF bilateral pleural effusion , residual rounded LV
enlargement atherosclerotic change involve thoracic
aorta . lung appear hyperinflated , suggestive underlying
obstructive disease ; however , focal airspace
opacity . diffuse osteopenia slight anterior
wedging several thoracic vertebrae resultant slight
kyphosis . acute abnormality thoracic
skeleton .
.
CXR ( [ * * 5 - 5 * * ] ):
1 . worsen pulmonary edema increase small pleural
effusion .
2 . bilateral low lobe airspace opacity , may due
dependent
area pulmonary edema superimpose secondary process
aspiration infectious pneumonia . followup radiograph
diuresis may helpful regard .
.
CXR ( [ * * 5 - 6 * * ] )
CHEST , AP : mild interstitial edema slightly worsen . mild
cardiomegaly small bilateral pleural effusion
unchanged . bibasilar consolidation stable . cardiac
silhouette normal . aorta calcified tortuous .
IMPRESSION : slightly increase vascular congestion .
.
SUPINE ABDOMEN ( [ * * 5 - 6 * * ] )
limited study partially image leave abdoman . Bowel gas
pattern present nonobstructive air see non - dilate
loop small large bowel . free intraperitoneal
air pneumatosis . cardiac silhouette moderately
enlarge . questionable deep sulcus sign right
hemithorax , right clinical setting , may represent
pneumothorax . small opacification left low
lung .
.
CBC
[ * * 2165 - 5 - 13 * * ] 05:15am blood WBC-8.3 RBC-3.41 * Hgb-10.1 * Hct-30.1 *
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt ct-402
[ * * 2165 - 5 - 12 * * ] 04:35am blood wbc-8.4 rbc-3.45 * Hgb-10.5 * Hct-30.3 *
MCV-88 MCH-30.5 mchc-34.7 RDW-14.9 Plt ct-355
[ * * 2165 - 5 - 11 * * ] 06:10AM blood WBC-7.8 RBC-3.28 * Hgb-9.7 * hct-28.7 *
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369
[ * * 2165 - 5 - 10 * * ] 05:20AM blood wbc-6.0 RBC-3.09 * Hgb-9.1 * hct-27.1 *
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt ct-389
[ * * 2165 - 5 - 9 * * ] 05:30AM blood wbc-5.6 RBC-3.16 * Hgb-9.1 * Hct-27.2 *
MCV-86 MCH-28.9 mchc-33.5 RDW-14.7 Plt ct-341
[ * * 2165 - 5 - 8 * * ] 05:15AM blood WBC-6.9 RBC-3.07 * Hgb-9.1 * Hct-26.5 *
MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286
[ * * 2165 - 5 - 7 * * ] 06:02AM BLOOD WBC-6.6 RBC-3.02 * hgb-9.0 * hct-26.2 *
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt ct-305
[ * * 2165 - 5 - 6 * * ] 12:48am blood wbc-7.4 # rbc-3.03 * Hgb-8.9 * Hct-25.7 *
MCV-85 MCH-29.4 mchc-34.7 RDW-14.8 Plt Ct-239
[ * * 2165 - 5 - 5 * * ] 04:10AM blood WBC-4.5 RBC-2.71 * Hgb-8.3 * hct-23.8 *
MCV-88 MCH-30.6 mchc-35.0 RDW-14.9 Plt Ct-248
[ * * 2165 - 5 - 4 * * ] 07:30AM blood WBC-4.9 RBC-3.01 * Hgb-9.1 * Hct-26.6 *
MCV-88 MCH-30.3 mchc-34.3 RDW-15.0 Plt Ct-239
[ * * 2165 - 5 - 3 * * ] 05:05AM blood WBC-5.7 RBC-3.06 * Hgb-9.4 * Hct-27.2 *
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242
[ * * 2165 - 5 - 2 * * ] 05:25am blood wbc-5.8 RBC-3.36 * Hgb-10.1 * Hct-29.2 *
MCV-87 MCH-30.0 mchc-34.6 RDW-15.0 Plt ct-225
[ * * 2165 - 5 - 1 * * ] 07:30AM blood WBC-8.6 RBC-3.31 * hgb-9.9 * Hct-29.5 *
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245
[ * * 2165 - 4 - 30 * * ] 10:50am blood WBC-7.8 RBC-3.29 * Hgb-9.8 * Hct-28.6 *
MCV-87 MCH-29.7 mchc-34.1 RDW-15.2 Plt ct-215
[ * * 2165 - 4 - 30 * * ] 07:25AM blood wbc-9.9 rbc-3.36 * Hgb-10.3 * Hct-29.9 *
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245
[ * * 2165 - 4 - 29 * * ] 07:55am blood wbc-16.0 * # rbc-3.75 * Hgb-11.3 * hct-32.3 *
MCV-86 MCH-30.0 mchc-34.9 RDW-15.6 * Plt ct-269
coag
[ * * 2165 - 5 - 11 * * ] 06:10am blood PT-12.7 PTT-30.2 INR(PT)-1.1
[ * * 2165 - 5 - 10 * * ] 05:20am blood PT-12.1 PTT-27.4 INR(PT)-1.0
[ * * 2165 - 5 - 9 * * ] 05:30AM blood PT-12.0 PTT-28.0 INR(PT)-1.0
[ * * 2165 - 5 - 8 * * ] 05:15am blood pt-12.8 PTT-28.9 INR(PT)-1.1
[ * * 2165 - 5 - 7 * * ] 06:02AM blood PT-12.6 PTT-31.4 INR(PT)-1.1
[ * * 2165 - 5 - 6 * * ] 01:01am blood pt-13.1 PTT-26.5 INR(PT)-1.1
[ * * 2165 - 4 - 30 * * ] 07:25AM blood pt-13.2 PTT-28.4 INR(PT)-1.1
Chemistry
[ * * 2165 - 5 - 13 * * ] 05:15am blood glucose-117 * urean-116 * Creat-3.7 *
Na-131 * k-3.5 cl-78 * HCO3 - 40 * AnGap-17
[ * * 2165 - 5 - 12 * * ] 04:35am blood glucose-121 * urean-117 * Creat-3.5 *
Na-131 * K-3.7 cl-78 * HCO3 - 39 * angap-18
[ * * 2165 - 5 - 11 * * ] 06:10AM blood glucose-131 * urean-117 * Creat-3.7 *
na-130 * K-3.8 Cl-79 * HCO3 - 38 * AnGap-17
[ * * 2165 - 5 - 10 * * ] 05:20AM blood Glucose-118 * UreaN-119 * Creat-3.7 *
na-130 * K-4.0 Cl-79 * HCO3 - 37 * angap-18
[ * * 2165 - 5 - 9 * * ] 05:30AM blood glucose-109 * UreaN-119 * Creat-3.7 *
Na-129 * K-3.2 * Cl-79 * HCO3 - 35 * angap-18
[ * * 2165 - 5 - 8 * * ] 05:15am blood Glucose-111 * UreaN-118 * Creat-3.9 *
na-128 * K-3.4 Cl-77 * HCO3 - 34 * AnGap-20
[ * * 2165 - 5 - 7 * * ] 06:02AM blood Glucose-115 * urean-116 * Creat-4.1 *
na-125 * K-3.3 cl-76 * HCO3 - 34 * angap-18
[ * * 2165 - 5 - 6 * * ] 04:08PM blood UreaN-112 * Creat-4.2 * Na-129 * K-3.7
Cl-81 * HCO3 - 32 AnGap-20
[ * * 2165 - 5 - 6 * * ] 12:48am blood Glucose-137 * UreaN-108 * Creat-4.4 *
Na-123 * K-3.8 cl-75 * HCO3 - 29 angap-23 *
[ * * 2165 - 5 - 5 * * ] 04:10am blood Glucose-107 * UreaN-105 * Creat-4.3 *
Na-125 * K-3.9 Cl-80 * HCO3 - 30 AnGap-19
[ * * 2165 - 5 - 4 * * ] 07:30AM blood Glucose-127 * UreaN-95 * Creat-3.9 * Na-126 *
k-3.9 Cl-80 * HCO3 - 29 AnGap-21 *
[ * * 2165 - 5 - 3 * * ] 05:10PM blood Glucose-202 * UreaN-93 * Creat-3.8 * Na-125 *
K-4.2 Cl-81 * HCO3 - 28 AnGap-20
[ * * 2165 - 5 - 5 * * ] 04:10am blood Glucose-107 * UreaN-105 * Creat-4.3 *
Na-125 * K-3.9 Cl-80 * HCO3 - 30 AnGap-19
[ * * 2165 - 5 - 4 * * ] 07:30AM blood Glucose-127 * UreaN-95 * Creat-3.9 * Na-126 *
k-3.9 Cl-80 * HCO3 - 29 AnGap-21 *
[ * * 2165 - 5 - 3 * * ] 05:10PM blood Glucose-202 * UreaN-93 * Creat-3.8 * Na-125 *
K-4.2 Cl-81 * HCO3 - 28 AnGap-20
[ * * 2165 - 5 - 3 * * ] 05:05AM blood glucose-136 * UreaN-91 * Creat-3.6 * Na-127 *
K-4.1 cl-85 * HCO3 - 29 AnGap-17
[ * * 2165 - 5 - 2 * * ] 05:25am blood Glucose-135 * UreaN-84 * Creat-3.1 * Na-135
K-4.0 cl-92 * HCO3 - 28 AnGap-19
[ * * 2165 - 5 - 1 * * ] 07:30AM blood Glucose-110 * UreaN-82 * Creat-3.0 * na-136
K-4.3 Cl-94 * HCO3 - 32 angap-14
[ * * 2165 - 4 - 30 * * ] 10:50am blood glucose-186 * UreaN-81 * Creat-2.9 * Na-135
K-3.4 cl-92 * HCO3 - 32 angap-14
[ * * 2165 - 4 - 30 * * ] 07:25AM blood glucose-109 * UreaN-81 * Creat-2.9 * Na-136
K-3.4 cl-92 * HCO3 - 32 angap-15
[ * * 2165 - 4 - 29 * * ] 07:55am blood glucose-163 * UreaN-84 * Creat-2.9 * Na-138
K-3.5 cl-94 * HCO3 - 30 angap-18
[ * * 2165 - 5 - 13 * * ] 05:15am blood calcium-9.0 Phos-5.1 * Mg-3.8 *
[ * * 2165 - 5 - 12 * * ] 04:35am blood calcium-9.0 phos-4.7 * Mg-4.0 *
[ * * 2165 - 5 - 11 * * ] 06:10AM blood calcium-8.7 phos-4.2 Mg-4.0 *
[ * * 2165 - 5 - 10 * * ] 05:20AM blood Calcium-8.5 phos-4.1 Mg-4.0 *
[ * * 2165 - 5 - 9 * * ] 05:30AM blood calcium-8.8 Phos-5.3 * Mg-3.8 *
[ * * 2165 - 5 - 8 * * ] 05:15am blood calcium-8.6 Phos-5.4 * Mg-4.0 *
[ * * 2165 - 5 - 7 * * ] 06:02AM blood Calcium-9.2 Phos-6.5 * Mg-4.1 *
[ * * 2165 - 5 - 6 * * ] 12:48am blood Albumin-3.6 Calcium-9.2 Phos-5.8 * Mg-3.6 *
[ * * 2165 - 5 - 5 * * ] 04:10am blood Calcium-8.9 Phos-6.1 * Mg-3.3 *
[ * * 2165 - 5 - 4 * * ] 07:30AM blood calcium-9.1 Phos-5.1 * Mg-3.0 *
[ * * 2165 - 5 - 3 * * ] 05:05AM blood calcium-9.1 Phos-4.2 Mg-3.0 *
[ * * 2165 - 5 - 2 * * ] 05:25am blood calcium-9.6 phos-4.8 * mg-2.7 *
[ * * 2165 - 5 - 1 * * ] 07:30AM blood Calcium-9.4 phos-3.9 Mg-2.9 *
[ * * 2165 - 4 - 30 * * ] 10:50am blood Calcium-9.2 Phos-4.1 Mg-2.6
[ * * 2165 - 4 - 30 * * ] 07:25AM blood Calcium-9.5 phos-4.8 * Mg-2.5
[ * * 2165 - 4 - 29 * * ] 07:55am blood Calcium-9.9 Phos-4.2 mg-2.5
Cardiac Enzymes
[ * * 2165 - 5 - 6 * * ] 12:48am blood CK(CPK)-17 *
[ * * 2165 - 5 - 5 * * ] 04:10AM blood ck(cpk)-11 *
[ * * 2165 - 5 - 2 * * ] 05:25am blood ck(cpk)-16 *
[ * * 2165 - 5 - 1 * * ] 09:14PM blood ck(cpk)-20 *
[ * * 2165 - 4 - 30 * * ] 07:25AM blood CK(CPK)-17 *
[ * * 2165 - 4 - 30 * * ] 03:40AM blood ck(cpk)-15 *
[ * * 2165 - 4 - 29 * * ] 03:05PM blood ck(cpk)-19 *
[ * * 2165 - 4 - 29 * * ] 07:55am blood ck(cpk)-20 *
[ * * 2165 - 5 - 6 * * ] 12:48am blood CK - MB - NotDone cTropnT-0.20 *
[ * * 2165 - 5 - 5 * * ] 04:10am blood CK - MB-1 cTropnT-0.19 *
[ * * 2165 - 5 - 2 * * ] 05:25am blood CK - MB - NotDone cTropnT-0.09 *
[ * * 2165 - 5 - 1 * * ] 09:14PM blood CK - MB - notdone cTropnT-0.07 *
[ * * 2165 - 4 - 30 * * ] 07:25AM blood CK - MB - notdone cTropnT-0.07 *
[ * * 2165 - 4 - 30 * * ] 03:40AM blood CK - MB - NotDone cTropnT-0.06 *
[ * * 2165 - 4 - 29 * * ] 03:05pm blood CK - MB - notdone ctropnt-0.03 * probnp-[**numeric Identifier 93521 * * ] *
[ * * 2165 - 4 - 29 * * ] 07:55am blood cTropnT-0.03 *
Brief Hospital course :
[ * * age 90 * * ] yof CAD / p stent mid-[**name ( NI ) * * ] , PTCA jailed OM1 , ivu
LMCA MLA present body pain chest pain .
.
# coronarie : Patient h / prior stent [ * * Name ( NI ) * * ] PTCA
jail om1 present atypical chest pain concern
ACS . significant ekg change light LBBB
( Sgarbossa criterion ) , CE 's negative . patient
continue Aspirin 162 mg daily Clopidogrel 75 mg daily
per outpatient regiman .
.
# PUMP / CHF : Patient history chronic systolic
diastolic heart failure EF 40 % [ * * 3-/2165 * * ] , moderate ( 2 + ) MR ,
small secundum ASD left - - right shunt across
interatrial septum rest . appear clinically fluid
overload without hypoxia , BNP > 45,000 . Pt complex
course medicine floor multiple episode worsening
resp status think due flash pulm edema . initially ,
symptom respond lasix additional BP control . however ,
renal function slowly worsen decrease
response diuresis . Pt become progressively uremic
confuse [ * * 5 - 5 * * ] mild respiratory distress .
transfer CCU [ * * 5 - 6 * * ] receive 240 mg Lasix IV bolus
follow gtt . aggressively diurese , per renal recs ,
start Lasix 80 mg PO BID . good volume output
lasix . Patient good volume status since ,
episode flash pulmonary edema .
fluctuate O2 requirement , time saturate well
room air time require 2L O2 .
.
# chronic renal failure : Stage III CKD , follow Dr [ * * last Name ( STitle ) * * ] .
Patient baseline Cr 1.5 [ * * Month ( ) 956 * * ] baseline
increase 2.4 . admission patient worsen renal
function creatinine rise 2.9 4.3 . unclear
whether patient 's increase creatinine due
dehydration vs volume overload - particularly give
recurrent episode flash pulmonary edema CXR show
evidence fluid overload . aggressively diurese
CCU volume status stable 80 mg po
lasix [ * * hospital1 * * ] . Patient family decide decline
hemodialysis focus comfort measure .
# Renal Artery Stenosis : Patient atrophic right kidney ,
leave renal artery stenosis . likely reason
difficult diurese reason
flash easily . originally plan renal artery
stenting , procedure hold
unstable , require CCU transfer . goal care discuss
patient renal stenting table patient decide
aggressive management focus comfort .
.
# Body Pain : Patient describe body pain since wake
morning admission . Unclear etiology , likely
viral symptom vs non - specific finding [ * * 3 - 12 * * ] chf exacerbation .
infectious workup negative . Leukocytosis resolve
discharge . Patient 2 transient episode chest pain
admission reproducible palpation
bad movement , likely musculoskeletal etiology ,
relieve 0.5 mg po morphine .
.
# right Finger Pain : Pt initially present right index
finger erythema , swell , calor consistent gout ;
septic arthritis osteomyelitis less likely give
fever , effusion , nidus infection . resolve without
intervention .
.
# Hypertension : Patient 's home antihypertensive initially
continue , follow CCU transfer recurrent flash
pulmonary edema , change amlodipine , carvedilol ,
furosemide , imdur . follow CCU admission
stable SBP range 110s-130s .
.
# hyperlipidemia : Pt intolerant statin ,
give statin discussion PCP [ * * last Name ( namepattern4 ) * * ] : goal
patient 's care .
.
# type 2 diabetes : diet - control . cover SSI - house .
.
# GERD : continue Famotidine 20 mg Tablet per outpatient
regimen
.
# goal care : patient make DNR / DNI CCU .
Patient family decide start hemodialysis ,
preference comfort direct care . prior
discharge hospital , patient ask sign DNR / DNI
form would continue DNR / DNI status transport
nursing facility , refuse sign . Patient
repeatedly state want resuscitate ,
however refuse sign form . amenable
daughter ( HCP ) sign DNR / DNI form , however
daughter available prior discharge sign
paper . daughter understand would able sign
DNR / DNI paper nursing facility . nursing
facility , patient 's care focus comfort care .
medication admission :
1 . senna 8.6 mg [ * * hospital1 * * ]
2 . famotidine 20 mg Tablet
3 . Calcitriol 0.25 mcg Capsule po QMOWEFR
4 . aspirin 162 mg daily
5 . clopidogrel 75 mg daily
6 . cyanocobalamin 500 mcg daily
* * 7 . Hydralazine 10 mg q6hr
* * 8 . Isosorbide Mononitrate 20 mg [ * * hospital1 * * ]
9 . Docusate Sodium 100 mg [ * * hospital1 * * ]
10 . felodipine 10 mg daily
11 . Carvedilol 12.5 mg [ * * hospital1 * * ]
* * 12 . furosemide 40 mg Tablet [ * * hospital1 * * ]
13 . iron ( Ferrous Sulfate ) 325 mg daily
14 . Nitrostat 0.4 mg Tablet , Sublingual prn
Discharge medication :
1 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
2 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
3 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
4 . Nitroglycerin 0.3 mg Tablet , Sublingual Sig : one ( 1 ) Tablet ,
Sublingual Sublingual PRN ( need ) need chest pain :
3 tablet need chest pain 5 minute apart .
5 . famotidine 20 mg Tablet Sig : one ( 1 ) Tablet PO Q24H ( every 24
hour ) .
6 . Carvedilol 12.5 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
7 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
8 . albuterol Sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) nebulizer Inhalation Q6H ( every 6
hour ) need shortness breath , wheezing .
9 . Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig : three ( 3 ) Tablet Sustained Release 24 hr po DAILY ( Daily ) .
10 . lanthanum 500 mg Tablet , Chewable Sig : one ( 1 ) Tablet ,
Chewable PO TID W / MEALS ( 3 time DAY MEALS ) .
11 . lidocaine 5 % ( 700 mg / patch ) Adhesive Patch , Medicated Sig :
two ( 2 ) Adhesive Patch , Medicated Topical 12 HOURS , 12 hour
( ) .
12 . Ipratropium Bromide 0.02 % solution Sig : one ( 1 ) nebulizer
Inhalation Q6H ( every 6 hour ) .
13 . furosemide 80 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
14 . amlodipine 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
15 . Dulcolax 5 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) po day need
constipation .
16 . Miralax 17 gram Powder Packet Sig : Seventeen ( 17 ) gram
po day need constipation .
17 . Heparin ( Porcine ) 5,000 unit / mL Solution Sig : 5000 ( 5000 )
unit Injection TID ( 3 time day ) .
18 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need
constipation .
19 . Lactulose 10 gram/15 ml Syrup Sig : thirty ( 30 ) ML PO Q8H
( every 8 hour ) need constipation .
20 . Morphine Concentrate 20 mg / mL Solution Sig : 0.5 mg po every
six ( 6 ) hour need pain .
discharge Disposition :
Extended Care
Facility :
[ * * hospital3 2732 * * ] & Retirement Home - [ * * Location ( un ) 55 * * ]
discharge Diagnosis :
Primary Diagnosis :
Acute Chronic Systolic Diastolic Heart Failure
Pulmonary Edema
leave Renal Artery Stenosis
secondary Diagnosis :
Hypertension
Diabetes
Coronary Artery Disease
Discharge condition :
Mental Status : confused - sometimes
level Consciousness : lethargic arousable
Activity Status : ambulatory - require assistance aid ( walker
cane )
Discharge instruction :
present hospital body pain chest pain .
ekg blood test show evidence heart
attack , find heart failure .
hospital , frequent episode shortness breath
improve start Lasix help remove fluid .
admission , many discussion whether
start dialysis . final decision dialysis
start , instead pursue hospice care instead .
discharge nursing facility help
treat symptom make comfortable .
.
medication change , please take medication
list :
1 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
2 . clopidogrel 75 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
3 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
4 . Nitroglycerin 0.3 mg Tablet , Sublingual Sig : one ( 1 ) Tablet ,
Sublingual Sublingual PRN ( need ) need chest pain :
3 tablet need chest pain 5 minute apart .
5 . famotidine 20 mg Tablet Sig : one ( 1 ) Tablet PO Q24H ( every 24
hour ) .
6 . Carvedilol 12.5 mg Tablet Sig : two ( 2 ) Tablet po BID ( 2 time
day ) .
7 . aspirin 325 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
8 . albuterol Sulfate 2.5 mg /3 mL ( 0.083 % ) solution
Nebulization Sig : one ( 1 ) nebulizer Inhalation Q6H ( every 6
hour ) need shortness breath , wheezing .
9 . Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig : three ( 3 ) Tablet Sustained Release 24 hr po DAILY ( Daily ) .
10 . lanthanum 500 mg Tablet , Chewable Sig : one ( 1 ) Tablet ,
Chewable PO TID W / MEALS ( 3 time DAY MEALS ) .
11 . lidocaine 5 % ( 700 mg / patch ) Adhesive Patch , Medicated Sig :
two ( 2 ) Adhesive Patch , Medicated Topical 12 HOURS , 12 hour
( ) .
12 . Ipratropium Bromide 0.02 % solution Sig : one ( 1 ) nebulizer
Inhalation Q6H ( every 6 hour ) .
13 . furosemide 80 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
14 . amlodipine 5 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
15 . Dulcolax 5 mg Tablet , Delayed Release ( E.C. ) Sig : one ( 1 )
Tablet , Delayed Release ( E.C. ) po day need
constipation .
16 . Miralax 17 gram Powder Packet Sig : Seventeen ( 17 ) gram
po day need constipation .
17 . Heparin ( Porcine ) 5,000 unit / mL Solution Sig : 5000 ( 5000 )
unit Injection TID ( 3 time day ) .
18 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need
constipation .
19 . Lactulose 10 gram/15 ml Syrup Sig : thirty ( 30 ) ML PO Q8H
( every 8 hour ) need constipation .
20 . Morphine Concentrate 20 mg / mL Solution Sig : 0.5 mg po every
six ( 6 ) hour need pain .
weigh every morning , [ * * Name8 ( MD ) 138 * * ] MD weight go
3 lbs .
Followup Instructions :
please call schedule appointment see primary care
physician , [ * * last Name ( namepattern4 ) * * ] . [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) 3029 * * ] ( [ * * telephone / Fax ( 1 ) 250 * * ] ) , need .
|
[
"5849",
"2761",
"4280",
"496",
"412",
"2749",
"4240"
] |
Admission Date : [ * * 2191 - 11 - 28 * * ] Discharge Date : [ * * 2191 - 12 - 21 * * ]
Date Birth : [ * * 2114 - 4 - 22 * * ] sex : F
Service : CARDIOTHORACIC
allergy :
Morphine / Heparin Agents
attending:[**first Name3 ( LF ) 1283 * * ]
Chief Complaint :
Mrs. [ * * know lastname * * ] / p CABG [ * * 2187 * * ] , increase
SOB / DOE . undergo cardiac catheterization [ * * 11 - 24 * * ]
show patent LIMA - LAD , totally occlude SVG - OM ectatic
SVG - PDA , aortic valve area 0.59cm2 . admit
[ * * hospital 24356 * * ] hospital diuresis due elevated wedge
pressure transfer [ * * Hospital1 18 * * ] surgery
Major Surgical Invasive Procedure :
/ p redo sternotomy / CABGx1 SVG - PDA / AVR 21 mm pericardial [ * * 12 - 7 * * ]
history Present Illness :
Mrs. [ * * know lastname * * ] / p CABG [ * * 2187 * * ] , increase
SOB / DOE . undergo cardiac catheterization [ * * 11 - 24 * * ]
show patent LIMA - LAD , totally occlude SVG - OM ectatic
SVG - PDA , aortic valve area 0.59cm2 . admit
[ * * hospital 24356 * * ] hospital diuresis due elevated wedge
pressure transfer [ * * Hospital1 18 * * ] surgery .
Past Medical History :
CAD
/ p CABG [ * * 2187 * * ]
aortic stenosis
h / breast CA / p lumpectomy radiation therapy r breast
carotid stenosis - bilateral 50 - 70 % lesion
DM - type 2
elevate cholesterol
venous stasis
Physical Exam :
discharge physical exam :
t:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA : spo2 95 % RA
weight:[**12 - 21 * * ] 91.4 kg
neurological exam : awake , alert , orient x3 , non - focal .
cardiovascular exam : regular rate rhythm without rub
murmur
Respiratory : breath sound clear without wheeze rale
GI : positive bowel sound , soft , obese , non - tender ,
non - distended , nausea
extremity : warm well perfuse , bilateral low extremetie
mild erythema , chronic venous stasis change plaque .
warmth tenderness .
sternal incision clean dry , area
proximal portion incision 2 area scabbe
skin tear . erythema drainage .
veing harvest site knee clean , dry intact
pertinent result :
[ * * 2191 - 12 - 21 * * ] 05:58AM blood wbc-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89
MCH-30.3 mchc-34.1 RDW-15.7 * Plt ct-277
[ * * 2191 - 12 - 21 * * ] 05:58AM blood Plt ct-277
[ * * 2191 - 12 - 21 * * ] 05:58AM blood pt-20.3 * PTT-32.6 INR(PT)-2.6
[ * * 2191 - 12 - 21 * * ] 05:58AM blood Glucose-66 * UreaN-16 Creat-1.0 Na-138
K-4.2 cl-95 * HCO3 - 34 * AnGap-13
Brief Hospital course :
Mrs. [ * * know lastname * * ] admit [ * * Hospital1 18 * * ] [ * * 11 - 28 * * ]
pre - operative evaluation . start IV heparin
coronary disease . take operating room [ * * 12 - 2 * * ]
induce general anesthesia . note
purulent drainage low extremetie area
venous stasis . surgery cancel
transfer ICU allow awaken start
antibiotic . vascular surgery infectious disease consult
obtain patient underwent ultrasound study LE
show significant reflux arterial
occlusion . antibiotic , erythema drainage
improve continued Lasix edema improve patient
take operating room [ * * 12 - 7 * * ] redo sternotomy ,
CABGx1 - SVG - PDA , AVR 21 mm pericardial valve .
patient transfer ICU stable condition .
wean extubate mechanical ventilation [ * * 12 - 7 * * ]
without difficulty . episode nausea start
Reglan antiemetic relief . chest tube
pace wire remove without incident . start
lo dose Lopressor tolerate well ,
escalate dose Lasix achieve adequate diuresis .
transfer ICU regular floor POD#5 .
early morning POD 6 , develop atrial fibrillation
rate control . thrombocytopenia
postoperatively heparin antibody test find
positive . hematology consult obtain
recommend start argatroban
anticoagulation . start well Coumadin
argatroban turn INR become therapeutic .
undergo ultrasound r arm due swelling
show venous clot obstruction .
postoperative course , continue nauseaus , KUB show
lot stool aggressive bowel regime .
time , po intake poor . GI consult obtain
recommend continue current therapy
pod#13 nausea improve . pod#12 note
period bradycardia atrial
fibrillation decide discontinue Lopressor ,
pause .
medication admission :
aspirin 325 mg qd
lisinopril 5 mg qd
insulin 70/30 18 unit qam , 15units qpm
lopressor 50 mg qam 25 mg qpm
nitropaste
lasix 80 mg iv qd
Discharge medication :
1 . Potassium Chloride 10 meq Capsule , Sustained Release Sig : two
( 2 ) Capsule , Sustained Release po Q12H ( every 12 hour ) .
2 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule 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 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet po Q4H ( every
4 hour ) need .
5 . Magnesium Hydroxide 400 mg/5 ml Suspension Sig : thirty ( 30 )
ML po HS ( bedtime ) need constipation .
6 . Bisacodyl 10 mg Suppository Sig : one ( 1 ) Suppository Rectal
DAILY ( Daily ) need constipation .
7 . Rosuvastatin Calcium 10 mg Tablet Sig : one ( 1 ) Tablet PO
DAILY ( Daily ) .
8 . Miconazole Nitrate 2 % Powder Sig : one ( 1 ) Appl Topical TID
( 3 time day ) .
9 . Senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) need .
10 . lactulose 10 g/15 mL Syrup Sig : thirty ( 30 ) ML po Q8H ( every
8 hour ) need .
11 . Hydrocodone - Acetaminophen 5 - 500 mg Tablet Sig : 1 - 2 tablet
PO q4 - 6h ( every 4 6 hour ) need pain .
12 . Pantoprazole Sodium 40 mg Tablet , Delayed Release ( E.C. )
Sig : one ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24
hour ) .
13 . furosemide 40 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
14 . Warfarin Sodium 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ) .
15 . Reglan 10 mg Tablet Sig : one ( 1 ) Tablet PO four time day
need nausea .
16 . Insulin 70/30 70 - 30 unit / mL Suspension Sig : five ( 5 ) unit
Subcutaneous twice day .
17 . Insulin Regular Human 300 unit/3 mL Syringe Sig : direct
Subcutaneous four time day : BS 121 - 140 2units SC
BS 141 - 160 3units SC
BS 161 - 180 4units SC
BS 181 - 200 5units SC
BS 201 - 220 6units SC
BS 221 - 240 7unit SV
.
discharge Disposition :
Extended Care
Facility :
[ * * Location ( un ) * * ] [ * * Location ( un ) 701 * * ]
discharge Diagnosis :
/ CAD
h / CHF
DM
PVD
/ p breast lumpectomy / CA
/ p radiation r breast
carotid stenosis 50 - 70 % bilaterally
/ p CABG [ * * 2187 * * ]
/ p redo sternotomy / AVR / redo CABG
bilateral LE venous stasis
bilateral LE cellulitis
post op atrial fibrillation
post op urinary retention
post op gastroparesis / ileus / constipation
+ heparin antibodie
discharge condition :
good
Discharge instruction :
may take shower wash incision mild soap
water
swim take bath 1 month
drive 1 month
lift anything heavy 10 pound 1 month
apply lotion , cream , ointment powder
incision
Followup Instructions :
follow Dr. [ * * last Name ( STitle ) * * ] 2 week
follow [ * * Doctor Last Name * * ] 2 week
follow Dr. [ * * last Name ( STitle ) * * ] [ * * 3 - 31 * * ] week
complete by:[**2191 - 12 - 21 * * ]
|
[
"4241",
"9971",
"4280",
"5180",
"2720",
"412"
] |
Admission Date : [ * * 2162 - 10 - 10 * * ] Discharge Date : [ * * 2162 - 10 - 14 * * ]
service : MEDICINE
allergy :
Penicillins / Bactrim
attending:[**first Name3 ( LF ) 2736 * * ]
Chief Complaint :
fall
Major Surgical Invasive Procedure :
single lead [ * * first Name8 ( NamePattern2 ) * * ] [ * * Hospital 923 * * ] Medical Identity ADx SR 5180
history Present Illness :
Ms. [ * * know lastname * * ] [ * * age 90 * * ] yo female h / dementia , hypertension ,
osteoporosis present [ * * hospital1 43650 * * ] / p fall [ * * hospital3 * * ] .
find bathroom wet floor recall
happen . initially complain left knee pain
find leave eye hematoma . deny head injury / LOC
normal head image ED . additionally
unremarkable C / / L spine , bilaterall knee xray , CXR ED .
patient initially place observation plan
PT case managment see send back
assisste living .
however , ED around 8 become bradycarduc 30 ,
asystolic , pulseless . compression deliver
patient ROSC , shock deliver . 7 second
pause go back sinus rhythm . patient unable
describe feel , however back baseline
mental status within 1 - 2 minute . complaint
recollection event . respond question say
feel " lousy " , could provide detail .
note patient visit [ * * Hospital1 18 * * ] ed mechanical fall [ * * 8 - 14 * * ]
also admit mechanical fall [ * * 2161 - 8 - 20 * * ] .
recent previous admission [ * * 2162 - 6 - 20 * * ] E. Coli Septicemia
likely secondary Cholangitis c / b pancreatitis resolve
antibiotic conservative management .
ED patient receive ASA 300 mg pr oxycodone . prior
transfer CCU patient hemodynamically stable
VS 97.7 , hr 68 , BP 128/51 , RR 20 , 99 % RA .
arrival floor , patient report bladder hurt
since foley place . deny pain . deny CP , SOB ,
palpitation , dizziness / lightheadedness . report
hosptial fall , provide
detail .
REVIEW systems :
Postive achy joint frequency urination . negative
dysuria .
review system , deny prior history stroke ,
tia , deep venous thrombosis , pulmonary embolism , bleed
time surgery , myalgias , joint pain , cough , hemoptysis , black
stool red stool . deny recent fever , chill
rigor . deny exertional buttock calf pain .
review system negative .
Cardiac review system notable absence chest pain ,
dyspnea exertion , paroxysmal nocturnal dyspnea , orthopnea ,
ankle edema , palpitation , syncope presyncope .
Past Medical History :
- Dementia
- Hypertension
- Arthritis
- Sjogrens
- Cataracts
- h / bleed ulcer
- narrow complex tachycardia : [ * * 1 - 29 * * ] , revert sinus ,
toprol .
- L2 - L3 compression fracture
- Anterior abdominal wall fat - contain hernia right
inguinal hernia
- Osteoporosis
- Spinal Stenosis
Social History :
live [ * * hospital3 * * ] [ * * first Name4 ( NamePattern1 ) * * ] [ * * last Name ( NamePattern1 ) * * ] facility ambulate
walker . cooking cleaning do .
help shower three time per week . previously interior
decorator , 3 child , widow , family involve .
Patient state daughter [ * * Name ( NI ) * * ] daughter
[ * * Name ( NI ) 6607 * * ] . report grand - daughter visit frequently .
-Tobacco history : deny
-etoh : deny
-illicit drug : deny
family history :
Mother / Father CAD .
Physical Exam :
Admission exam :
vs : T=98.1 BP=161/74 hr= 60 rr=18 O2 sat= 93 - 97 % RA
GENERAL : WDWN [ * * age 90 * * ] / female NAD . orient person , place ,
time ( know month , year ) . hard hearing .
Mood , affect appropriate . pleasantly confused .
HEENT : NC . leave eye hematoma bruise present . Sclera
anicteric . PERRL , EOMI . sl dry mucous membrane .
neck : Supple flat neck vein .
CARDIAC : RRR , normal S1 , S2 . 3/6 systolic murmur hear well
right upper sternal border radiate clavicle .
thrill , lift . S3 S4 .
lung : Resp unlabored , accessory muscle use . CTAB ,
crackle , wheeze rhonchus .
ABDOMEN : soft , NTND . HSM tenderness . + bs
extremity : c / c / e.
SKIN : scatter bruise UE bilaterally . 5 - 8 mm slightly
raise round lesion scatter upper LE bilaterally
( posterior > anterior L > R ) .
pulse : dp pulse 2 + bilaterally
Discharge Exam :
97.8 , p 80 , BP : 94 - 159/50 - 80 , RR : 18 , 94 % RA
GENERAL : WDWN [ * * age 90 * * ] / female NAD . hard hearing . mood ,
affect appropriate . heent : NC . leave eye hematoma
bruise present . Sclera anicteric . PERRL , EOMI . sl dry mucous
membrane .
neck : Supple flat neck vein .
CARDIAC : RRR , normal S1 , S2 . 3/6 systolic murmur hear well
right upper sternal border radiate clavicle .
thrill , lift . S3 S4 .
lung : Resp unlabored , accessory muscle use . CTAB ,
crackle , wheeze rhonchus .
ABDOMEN : soft , NTND . HSM tenderness . + bs
extremity : c / c / e.
SKIN : scatter bruise UE bilaterally . 5 - 8 mm slightly
raise round lesion scatter upper LE bilaterally
( posterior > anterior L > R ) . bruise left knee .
pulse : dp pulse 2 + bilaterally
pertinent result :
Admission Labs :
[ * * 2162 - 10 - 10 * * ] 02:30AM blood WBC-9.7 RBC-5.00 Hgb-13.7 Hct-41.6 MCV-83
MCH-27.3 MCHC-32.8 RDW-16.6 * Plt Ct-517 *
[ * * 2162 - 10 - 10 * * ] 02:30AM blood Neuts-66.0 lymphs-21.4 Monos-10.5 Eos-1.3
Baso-0.7
[ * * 2162 - 10 - 10 * * ] 02:30AM blood pt-9.4 PTT-20.4 * INR(PT)-0.9
[ * * 2162 - 10 - 10 * * ] 02:30AM blood glucose-107 * UreaN-12 creat-0.5 na-127 *
K-7.8 * Cl-94 * HCO3 - 26 angap-15 ( hemolyze speciman )
[ * * 2162 - 10 - 10 * * ] 04:41pm blood ck(cpk)-209 *
[ * * 2162 - 10 - 10 * * ] 04:41pm blood ck(cpk)-209 *
[ * * 2162 - 10 - 10 * * ] 08:55am blood ctropnt-<0.01
[ * * 2162 - 10 - 10 * * ] 04:41PM blood CK - MB-7 cTropnT-<0.01
[ * * 2162 - 10 - 10 * * ] 01:00PM blood Calcium-9.2 Phos-4.3 Mg-2.2
[ * * 2162 - 10 - 10 * * ] 04:21am blood Na-132 * K-4.2
Discharge lab
[ * * 2162 - 10 - 14 * * ] 05:47am blood wbc-9.6 RBC-4.45 Hgb-12.4 Hct-37.4 MCV-84
MCH-27.9 MCHC-33.2 RDW-17.0 * Plt Ct-518 *
[ * * 2162 - 10 - 14 * * ] 05:47AM blood urean-14 Creat-0.7 Na-131 * K-4.4 Cl-94 *
HCO3 - 25 AnGap-16
[ * * 2162 - 10 - 12 * * ] 08:30AM blood Calcium-9.4 phos-3.9 mg-2.1
image :
CT Head [ * * 10 - 10 * * ] : 1 . acute intracranial hemorrhage
fracture .
2 . new opacification left mastoid air cell middle
ear cavity , please correlate sign infection .
CT C - Spine [ * * 10 - 10 * * ] : acute cervical spine fracture . Multilevel
moderate - - severe degenerative change cervical spine ,
bad C4 - C5 level .
CT L - Spine [ * * 10 - 10 * * ] : 1 . new lumbar spine fracture . stable
compression l2 L3 vertebral body .
2 . Multilevel severe degenerative change lumbar spine ,
bad L3 - L4 level moderate spinal canal stenosis .
CT - Spine [ * * 10 - 10 * * ] : acute thoracic spine fracture . mild
compression superior endplate t3 vertebral body ,
likely chronic .
bilateral Knee Xray [ * * 10 - 10 * * ] : 1 . acute fracture .
2 . bilateral tricompartmental osteoarthritis , severe
left mild right .
CXR [ * * 10 - 10 * * ] : cardiomediastinal hilar contour normal .
lung volume low , crowding bronchovascular
marking lung basis . patchy right basilar opacity may
reflect
atelectasis , aspiration focal / early pneumonia .
CXR [ * * 10 - 10 * * ] ( post chest compression ): cardiomediastinal contour
normal appearance . lung clear except tiny
calcify granuloma periphery right low lobe .
rib fracture identify , portable chest radiograph
relatively insensitive detect rib fracture ,
especially involve anterior rib .
visible pneumothorax pleural effusion .
Echo : [ * * 2162 - 10 - 11 * * ]
left atrium normal size . atrial septal defect
see 2D color Doppler . mild symmetric left
ventricular hypertrophy . left ventricular cavity
unusually small . regional left ventricular wall motion
normal . left ventricular systolic function hyperdynamic
( EF>75 % ) . Doppler parameter consistent Grade
( mild ) leave ventricular diastolic dysfunction . mild
resting leave ventricular outflow tract obstruction . normal
free wall contractility . aortic valve leaflet ( 3 )
mildly thicken aortic stenosis present .
valvular aortic stenosis . increase transaortic velocity
likely relate high cardiac output . mild moderate ( [ * * 12 - 21**]+ )
aortic regurgitation see . mitral valve leaflet
moderately thicken . trivial mitral regurgitation see .
leave ventricular inflow pattern suggest impaired relaxation .
tricuspid valve leaflet mildly thicken . estimate
pulmonary artery systolic pressure normal .
pericardial effusion .
IMPRESSION : mild symmetric LVH small LV cavity size
hyperdynamic LV systolic function . consequently mild
leave ventricular outflow tract gradient systole .
aortic valve thicken open reasonably well - high
velocity due LVOT gradient . mild moderate aortic
regurgitation . probable diastolic dysfunction .
CXR [ * * 10 - 13 * * ]
single - lead pacemaker standard position , terminate
right ventricle . acute cardiopulmonary disease .
Brief Hospital course :
Ms. [ * * know lastname * * ] [ * * age 90 * * ] / female history dementia ,
hypertension , previous h / narrow complex tachycardia
know cardiac history present [ * * 1 - 21 * * ] fall
find symptomatic 7 second asystolic pause ED
ROSC chest compression , shock deliver .
active issue :
# RHYTHM : patient previous history narrow complex
tachycardia metoprolol . 7 second asystolic pause
ED . patient mulitple fall recently , unclear whether
mechanical secondary bradycardia conduction
abnormality . Differential include high vagal tone , sick sinus
syndrome , junctional abnormality . Tropnoin negative x 2 . normal
K+ mg2 + . Metoprolol hold . Patient monitor telemetry
XX . EP consult follow patient . pacemaker
implant [ * * 10 - 12 * * ] concern arrhythmia cause
recurrent fall . patient follow EP
pacemaker interrogation discharge . start
diltiazem 45 mg po QID control rate rhythm give
family report " fuzziness " fatigue attribute
beta - blocker . one day levofloxacin
discharge prophylaxis infection .
# / p fall : patient present ED secondary fall . patient
multiple fall recently . cause unclear , likely
multifactorial give dementia , patient use walker ,
find symptomatic 7 second asystolic pause . patient
negative head CT , C / / L spine CT , bilateral knee xray ED .
Falls sound mostly mechanical talk family . PT
consult recommend rehab .
# ? bladder pain increase frequency urination : UA
neg nitrite , neg leuk . patient mild leukocytosis , however
CPR preform likely stress reaction . last
admission patient asymptomatic bacturia . Urine culture send
ED , grow proteus mirabilis sensitive ciprofloxacin
levofloxacin . receive dose ciprofloxacin
continue levofloxacin prophylaxis pacemaker
insertion . complete three day course UTI [ * * 10 - 14 * * ] .
# Hypertension : patient reported hypertension , labile
last admission . home metoprolol hold bradycardia
asystole . BP monitor throughout stay stable 45 mg
diltiazem QID .
Chronic issue :
# Dementia : patient currently AAO x 3 , however confused . home
donezepil continue .
# Sjogren 's : continue saline eye drop
# Osteoporosis , compression fracture : continued calcium ,
vitamin , weekly alendronate . home oxycodone continue prn
pain .
transitional :
-will need pacemaker interrogate [ * * 12 - 21 * * ] week
-titrate diltiazem dose target BP hr , change
long - act formulation stable dose
medication admission :
Preadmission Medication list accurate complete .
1 . Donepezil 10 mg PO HS
2 . omeprazole 20 mg PO DAILY
3 . vitamin 1000 UNIT PO DAILY
4 . Metoprolol Succinate XL 25 mg PO DAILY
5 . Artificial Tears Preserv . free 1 - 2 drop eyes HS : PRN dry
eye
6 . Alendronate Sodium 70 mg po QMON
7 . calcium Carbonate 600 mg PO DAILY
8 . oxycodone ( Immediate Release ) 10 mg po BID : PRN pain
9 . Polyethylene Glycol 17 g PO TID
10 . cranberry * NF * unknown oral daily
11 . Glucosamine Sulf - Chondroitin * NF * ( glucosamine [ * * Doctor First Name * * ]
2KCl - chondroit ) 500 - 400 mg oral daily
2 tab daily
Discharge medication :
1 . Alendronate Sodium 70 mg po QMON
2 . Artificial Tears Preserv . free 1 - 2 drop eyes HS : PRN dry
eye
3 . calcium Carbonate 600 mg PO DAILY
4 . Donepezil 10 mg PO HS
5 . omeprazole 20 mg PO DAILY
6 . oxycodone ( Immediate Release ) 10 mg po BID : PRN pain
7 . vitamin 1000 UNIT PO DAILY
8 . Glucosamine Sulf - Chondroitin * NF * ( glucosamine [ * * Doctor First Name * * ]
2KCl - chondroit ) 500 - 400 mg oral daily
2 tab daily
9 . cranberry * NF * 0 unknown ORAL DAILY
10 . Levofloxacin 500 mg PO Q24H Duration : 1 day
last day [ * * 10 - 15 * * ]
11 . diltiazem 45 mg PO QID
12 . polyethylene Glycol 17 g PO DAILY
Discharge Disposition :
Extended Care
Facility :
[ * * first Name4 ( NamePattern1 ) 1188 * * ] [ * * last Name ( NamePattern1 ) * * ] - [ * * Location ( un ) 538 * * ]
discharge diagnosis :
sinus arrest
Urinary Tract infection
Discharge condition :
Mental Status : confused - always .
level consciousness : alert interactive .
Activity Status : Bed assistance chair
wheelchair .
Discharge instruction :
pleasure take care [ * * Hospital1 18 * * ] .
fall home bring hospital .
test look serious injury negative . slow
heart rate need pacemaker . pacemaker place
[ * * 10 - 12 * * ] complication . urine sample show
urinary tract infection
antibiotic one week .
lifting 5 pound left hand lift
left arm head 6 week .
Followup Instructions :
Department : CARDIAC SERVICES
: MONDAY [ * * 2162 - 10 - 18 * * ] 11:00
: [ * * First Name11 ( Name Pattern1 ) 539 * * ] [ * * last Name ( namepattern4 ) 13861 * * ] , NP [ * * telephone / Fax ( 1 ) 62 * * ]
building : SC [ * * Hospital Ward Name 23 * * ] Clinical Ctr [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] Garage
Department : [ * * hospital3 1935 * * ] CENTER
: FRIDAY [ * * 2163 - 4 - 22 * * ] 1 pm
: [ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) 14290 * * ] , OD [ * * telephone / Fax ( 1 ) 253 * * ]
building : [ * * hospital6 29 * * ] [ * * Location ( un ) * * ]
campus : EAST good parking : [ * * Hospital Ward Name 23 * * ] garage
|
[
"4275",
"5990",
"2761",
"4019"
] |
Admission Date : [ * * 2107 - 1 - 17 * * ] Discharge Date : [ * * 2107 - 2 - 12 * * ]
Date Birth : [ * * 2042 - 4 - 4 * * ] sex : F
Service : MEDICINE
allergy :
Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor
attending:[**first Name3 ( LF ) 2932 * * ]
Chief Complaint :
SOB
Major Surgical Invasive Procedure :
none .
history Present Illness :
64 yo woman w/ h / recurrent pes s/[**Initials ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 260 * * ] filter , GIB
anticoagulate , COPD , discharge [ * * 2107 - 1 - 12 * * ]
treat new PE present ED SOB
productive cough . readmitte [ * * 2107 - 1 - 17 * * ]
find multifocal pneumonia treat
Levo / Flagyl Vanco . culture positive MRSA . Levo
Flagyl continue suspect aspiration PNA . pt
recover quickly since admission back
home O2 requirement . getting bridge
anticoagulation Lovenox start [ * * 1 - 18 * * ] preparation
discharge . however , develop severe abdominal pain
palpable mass L abdomen . CT show new large
hematoma muscle left anterior lateral low
abdominal pelvic wall , without intraperitoneal
retroperitoneal extent , associate mass effect
low abdominal pelvic bowel loop . Surgery [ * * Month / Year ( 2 ) 4221 * * ]
suggest intervention , monitor . HCT
drop 6 point setting , remain
hemodynamically stable tachycardia present
throughout hospital stay ( 95 - 115 ) .
require total 5 unit PRBC 4 unit ffp
transfusion transfer MICU
monitoring . hematocrit since stable serial
check .
.
ROS : baseline leave mid chest pain exertion
currently bother . deny current chest pain ,
SOB , dysuria , increase urinary frequency . stable r knee
pain .
Past Medical History :
1 . h / Rheumatic Fever - age 8 -dx'ed last year rheumatic
heart disease per pt ( state ED diagnose )
syndenham chorea
2 . ? CHF per pt . although [ * * 12 - 13 * * ] Echo reveal low normal LVEF ,
mildly thicken aortic mitral valve mild MR [ * * First Name ( Titles ) * * ] [ * * last Name ( Titles ) * * ] .
3 . orthostatic hypotension
4 . chest pain - nearly monthly visit ED negative
ischemic w / u past
5 . duodenal / gastric ulcer
6 . seven miscarriage
7 . ulcerative colitis
8 . diverticulosis - / p colostomy reversal colostomy -
Colonoscopy [ * * 1 - 12 * * ] show diverticuli without e / active
bleed
8 . panic attack x 15 yrs
9 . depression - several SA past
10 . schizoaffective disorder
11 . h / polysubstance abuse
12 . iron deficiency anemia ( baseline unclear - high 20 's 30 's )
13 . COPD
14 . PE [ * * 7 - 13 * * ] , c / b GIB anticoagulation , s/[**Initials ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 260 * * ]
filter . new PE [ * * 2107 - 1 - 2 * * ] , anticoagulation
Social History :
live lodge house . homemaker help
cleaning . get meal wheel . limited fund .
smoke 2 PPD X 40 yrs , quit smoking 4 month ago . former
drinker , report drink two 6 pack per day 2 yrs ; quit 27
yrs ago . Denies h / illicit IVDA . H / domestic violence .
Family history :
daughter -40 - colitis . 6 sibling . one sister die , 35 ,
ovarian CA . Brother , die 48 , stroke . sister , die 64
infection . Father die 65 mi . mom " psychotic " , die
stroke 93
Physical Exam :
VS : 97.6 hr 114 , Bp 118/74 RR 20 - 30 sat 98 % 2l.
Gen : NAD , pleasant
HEENT : PEERLA , MMM .
Neck : supple , LAD
lung : moderate air movement , decrease breath sound basis
CV : RRR , S1S2 present , distant heart sound , murmurs
Abd : + BS , / ND , + umbilical hernia , ulcer mid abdoman - reportedly
chronic , unchanged , mildy errythematous base . secretion .
Tenderness L abdoman , palpable mass unclear extension ,
guarding , rebound
back : CVA tenderness .
Ext : 2 + RLE , 1 + edema LLE/ c / c/ 1 + dp
Neuro : a&ox3 , CN II - XII intact . move extremity .
pertinent result :
ADMISSION labs :
[ * * 2107 - 1 - 16 * * ] 08:40PM pt-87.9 * PTT-41.3 * inr(pt)-11.8 *
[ * * 2107 - 1 - 16 * * ] 08:40PM WBC-16.2 * # RBC-3.63 * HGB-11.6 * HCT-33.5 *
MCV-93 MCH-32.1 * mchc-34.7 RDW-14.0
[ * * 2107 - 1 - 16 * * ] 08:40PM NEUTS-90.5 * BANDS-0 LYMPHS-4.7 * MONOS-2.4
EOS-2.0 BASOS-0.5
[ * * 2107 - 1 - 16 * * ] 08:40PM glucose-127 * UREA n-16 CREAT-1.0 sodium-136
POTASSIUM-3.9 chloride-98 total CO2 - 29 anion GAP-13
[ * * 2107 - 1 - 16 * * ] 11:00PM URINE blood - NEG NITRITE - NEG protein - NEG
GLUCOSE - NEG KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH-5.0
LEUK - NEG
[ * * 2107 - 1 - 17 * * ] 12:47AM lactate-1.3
[ * * 2107 - 1 - 22 * * ] 03:07am blood wbc-7.5 rbc-2.85 * # hgb-8.6 * # hct-25.6 *
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243
[ * * 2107 - 1 - 22 * * ] 03:07am blood PT-22.4 * PTT-31.1 INR(PT)-2.2 *
[ * * 2107 - 1 - 22 * * ] 03:07am blood Glucose-105 UreaN-11 Creat-0.6 na-141
K-4.0 Cl-102 HCO3 - 35 * AnGap-8
[ * * 2107 - 1 - 22 * * ] 03:07am blood calcium-9.0 phos-4.1 mg-2.1
[ * * 2107 - 1 - 23 * * ] 04:34PM blood PEP - HYPOGAMMAG IgG-535 * IgA-254 IgM-109
.
CTA chest :
1 . interval development patchy area consolidation
mucous plugging , particularly right low lobe , right
upper mid lobe suggest new infectious process
aspiration .
2 . resolution previously identify pulmonary embolism .
3 . extensive centrilobular paraseptal emphysematous change .
4 . fluid - attenuate structure adjacent right T11 - 12
neural foraman also unchanged could perineural cyst .
.
CT abdomen / pelvis :
1 . new large hematoma muscle left anterior
lateral low abdominal pelvic wall , without
intraperitoneal retroperitoneal extent , associate
mass effect low abdominal pelvic bowel loop .
2 . unchanged infectious inflammatory opacity right
middle low lobe .
.
[ * * 2107 - 2 - 1 * * ] IR Embolization : 1 . right inferior epigastric
arteriogram demonstrate extravasation contrast
successful embolization Gelfoam stagnation flow .
2 . right internal mammary artery demonstrate area
active extravasation contrast .
.
[ * * 2107 - 2 - 3 * * ] CXR : irregular opacity right low
lobe
concern pneumonia . pleural effusion .
pneumothorax . left subclavian catheter tip overlie mid
SVC . Heart size normal . mediastinal hilar contour
normal . impression : opacity right low lobe concern
pneumonia .
.
[ * * 2107 - 2 - 8 * * ] LENIS : extensive occlusive thrombus demonstrate
common femoral vein takeoff greater saphenous
vein extend distally popliteal vein bilaterally .
color flow , compressibility , waveform demonstrate
within area thrombus . impression : extensive ,
completely occlusive , bilateral deep venous thrombi extend
common femoral vein popliteal vein .
.
[ * * 2107 - 2 - 9 * * ] ECG : sinus tachycardia , Normal ECG except rate
Brief Hospital Course :
64f w/ h / recurrent PE s/[**Initials ( namepattern4 ) * * ] [ * * last Name ( namepattern4 ) 260 * * ] filter , gib
anticoagulation , COPD , recently admit new PE , readmitte
multifocal PNA , develop large abdominal wall
hematoma context enoxaparin injection .
# Multifocal Pneumonia : admit multifocal
pneumonia . start levofloxacin vancomycin .
complete 7 day course levofloxacin . MRSA find
grow sputum continue 14 day course
vancomycin . originally present elevated WBC count
leave shift quickly resolve initiation
antibiotic . productive cough improve well
remain baseline home O2 2l. approximately 4 day
completion 14 day course Vancomycin , patient
develop worsen cough , SOB , upper respiratory symptom .
repeat CXR show evidence new consolidation RLL .
patient start back Levofloxacin / Flagyl . Vancomycin
add regiman blood culture show 2/4 bottle
GPC cluster chain . additionally , sputum
culture grow gnr . Levofloxacin discontinue
Meropenem start concern Pseudomonas give
patient 's long hospital course . O2 sit remain stable
93 - 100 % 2L nasal cannula ( baseline ) .
give mucomyst inhale nebulizer assist break thick
sputum . gnr sputum grow E. coli .
sensitivity profile E. coli patient 's allergy
penicillin cephalosporin , patient continue
Meropenem . gpc find grow Coag negative Staph .
Surveillance culture growth coag
negative staph think likely contaminant .
Vancomycin discontinue . continue 14 day course
Meropenem discharge PICC complete
course .
.
# Pulmonary embolism / dvt : multiple pes
one even since placement TrapEase IVC filter . CT
recent previous hospitalization reveal appropriate location
filter CTA admission show improvement clot .
Admission labwork reveal INR 7.9 . Coumadin thus
hold reverse FFP vitamin k give history
GIB anticoagulation . interim , therapeutic lovenox
injection initiate , within day start ,
develop large abdominal wall hematoma near lovenox
injection site . hematocrit stabilize , start
heparin gtt coumadin overlap . [ * * last Name ( namepattern4 ) 9533 * * ]
Coumadin INR 1.2 , find large Hct drop
CT scan abdoman show new rectus hematoma .
subsequently transfer MICU close monitoring .
decide second hematoma
anticoagulation , risk anticoagulation outweigh
benefit time anticoagulate . term
hypercoagulable workup , negative thus far
hyperhomocysteinemia , Factor V Leiden antiphospholipid
antibody . malignancy workup include colonoscopy egd
well CEA , within normal limit . SPEP
reveal hypogammaglobulinemia , otherwise unremarkable .
hospital course , also begin complain
worsen low extremity pain . leni obtain
show evidence extensive , completely occlusive , bilateral
deep venous thrombi extend common femoral vein
popliteal vein . Radiology feel clot
likely acute subacute nature . setting ,
hematology / oncology see patient consider risk
vs benefit anticoagulation . Antithrombin III , prothrombin
mutation , Lupus anticoagulation [ * * Location ( un ) 1169 * * ] Venom Viper
send reevaluate reason hypercoagulability .
hematology / oncology team still feel risk
coagulation outweigh potential benefit give
patient multiple bleeding episode setting
anticoagulation .
# abdominal wall hematoma : mention , develop
large left - sided abdominal wall hematoma Lovenox
injection site cause significant hct drop ( originally
28.1 - ->19.4 ) . despite drop , remain hemodynamically
stable ( sinus tachycardia baseline prior bleed ) .
receive 3 unit prbc , 4 unit FFP . hematocrit
stabilize stable , restart heparin gtt .
Coumadin - initiate heparin gtt continue
await INR become therapeutic . [ * * Location ( un ) 9533 * * ]
Coumadin INR 1.2 , find another Hct drop
( 25.9- > 22.2 ) CT scan abdoman show new
right - sided rectus hematoma . subsequently transfer
MICU close monitoring . give 1 unit FFP
9 unit prbc [ * * Date range ( 1 ) 39125 * * ] hematocrit become
stable bump appropriately transfusion .
decide second hematoma anticoagulation ,
risk anticoagulation outweigh benefit time
anticoagulate . complain [ * * 6 - 16 * * ]
abdominal pain movement maintain stable
hematocrit . pain likely [ * * 3 - 11 * * ] large rectus
hematoma resolve time . Hct remain stable
anticoagulation discontinue .
# Thoracic mass : CT chest abdomen reveal stable
thoracic mass ( stable x 3years ) think potentially
consistent neural cyst . evaluate
MRI give long term stability also metal
hardware place / p elbow surgery facial plate .
follow imaging ensure remain
unchanged future .
# ? Zoster : Patient report history " herpe "
right buttock . stay , develop tingling ,
itchiness multiple small erythematous skin lesion
right buttock S2 , S3 dermatomal distribution .
vesicle appreciate . treat acyclovir .
# candidal vaginitis : treat fluconazole x 2
resolution symptom .
# H / GI bleeding recent admission : recent colonoscopy
show diverticulosis active sign bleeding .
blood stool admission even
anticoagulate . stool guiac - ed multiple time
find guiac negative .
# constipation : constipate baseline require
daily schedule bowel regiman maintian regularity .
# hyperlipidemia : continue lipitor .
# Depression / SAD : continue Prozac , risperdone , wellbutrin ,
klonopin .
# Ulcerative Colitis : remain remission . continue
mesalamine .
# orthostatic hypotension : remain asymptomatic even
ambulate physical therapy . continue
midodrine .
medication admission :
1 . fluoxetine 30 mg daily
2 . risperidone 3 mg PO HS
3 . Bupropion SR 150 mg [ * * hospital1 * * ]
5 . nicotine 7 mg/24 hr Patch
6 . Hexavitamin daily
7 . ascorbic acid 500 tab 1 [ * * hospital1 * * ]
8 . calcium Carbonate 500 tab [ * * hospital1 * * ]
9 . ferrous gluconate 325 PO daily
10 . Atorvastatin 20 mg daily
11 . Fluticasone Salmeterol 250/50 [ * * hospital1 * * ]
12 . midodrine 5 mg tab 1 TID
13 . tiotropium bromide capsule one cap /day
14 . Mesalamine 1200 TID
15 . pantoprazole 40/ day
16 . Albuterol nebs prn ( tid generally )
17 . docusate sodium
18 . warfarin 5 mg / day
19 . ipratropium nebs prn ( tid generally )
20 . clonazepam 1 mg po tid
discharge medication :
1 . fluoxetine 10 mg Capsule Sig : three ( 3 ) Capsule po DAILY
( Daily ) .
2 . risperidone 1 mg Tablet Sig : three ( 3 ) Tablet PO HS (
bedtime ) .
3 . bupropion 150 mg Tablet Sustained Release Sig : one ( 1 ) Tablet
Sustained Release po BID ( 2 time day ) .
4 . Hexavitamin Tablet Sig : one ( 1 ) Cap po DAILY ( Daily ) .
5 . calcium Carbonate 500 mg Tablet , Chewable Sig : one ( 1 )
Tablet , Chewable po BID ( 2 time day ) .
6 . Fluticasone - Salmeterol 250 - 50 mcg / Dose Disk Device Sig :
one ( 1 ) disk Device Inhalation [ * * hospital1 * * ] ( 2 time day ) .
7 . midodrine 5 mg Tablet Sig : one ( 1 ) Tablet PO TID ( 3 time
day ) .
8 . mesalamine 400 mg Tablet , Delayed Release ( E.C. ) Sig : three
( 3 ) Tablet , Delayed Release ( E.C. ) PO TID ( 3 time day ) .
9 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
10 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID
( 2 time day ) .
11 . nicotine 7 mg/24 hr Patch 24hr Sig : one ( 1 ) patch 24hr
Transdermal DAILY ( Daily ) .
12 . ferrous Gluconate 300 mg Tablet Sig : one ( 1 ) Tablet PO DAILY
( Daily ): please take levofloxacin .
13 . cepacol 2 mg Lozenge Sig : one ( 1 ) lozenge mucous membrane
Q4H ( every 4 hour ) need .
Disp:*100 Lozenge(s ) * Refills:*0 *
14 . Tiotropium Bromide 18 mcg Capsule , w / Inhalation Device Sig :
one ( 1 ) Cap Inhalation DAILY ( Daily ) .
15 . Sodium Chloride 0.65 % Aerosol , Spray Sig : [ * * 2 - 8 * * ] Sprays Nasal
QID ( 4 time day ) .
disp:*q bottle * Refills:*2 *
16 . senna 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
Disp:*60 Tablet(s ) * Refills:*2 *
17 . Clonazepam 1 mg Tablet Sig : one ( 1 ) Tablet PO TID ( 3 time
day ) need anxiety .
Disp:*20 Tablet(s ) * Refills:*0 *
18 . saline flush 0.9 % Syringe Sig : three ( 3 ) ml Injection twice
day 20 dose : prior vanco dose .
Disp:*20 syringe * Refills:*0 *
19 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po twice
day .
20 . simethicone 80 mg Tablet , Chewable Sig : one ( 1 ) Tablet ,
Chewable PO QID ( 4 time day ) need .
21 . Aluminum - Magnesium Hydroxide 225 - 200 mg/5 ml Suspension Sig :
15 - 30 ml PO QID ( 4 time day ) need .
22 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) need
constipation .
23 . oxycodone 5 mg Tablet Sig : 1 - 2 tablet PO q4 - 6h ( every 4
6 hour ) need pain .
24 . lidocaine 5 % ( 700 mg / patch ) Adhesive Patch , Medicated Sig :
one ( 1 ) Adhesive Patch , Medicated Topical QD ( ) .
25 . Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : one
( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hour ) .
26 . Nystatin 100,000 unit / g Cream Sig : one ( 1 ) Appl Topical [ * * hospital1 * * ]
( 2 time day ) .
27 . Albuterol Sulfate 0.083 % solution Sig : one ( 1 ) Inhalation
Q6H ( every 6 hour ) need wheezing .
28 . Ezetimibe 10 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
29 . Acetaminophen 325 mg Tablet Sig : two ( 2 ) Tablet PO Q6H
( every 6 hour ) need pain .
30 . Heparin Lock Flush ( Porcine ) 100 unit / mL Syringe Sig : one
( 1 ) ML Intravenous DAILY ( Daily ) need : PICC line .
31 . Meropenem 500 mg Recon Soln Sig : one ( 1 ) Recon Soln
Intravenous Q6H ( every 6 hour ) 7 day .
discharge Disposition :
Extended Care
Facility :
[ * * Hospital3 7 * * ] & Rehab Center - [ * * hospital1 8 * * ]
discharge diagnosis :
Primary :
1 ) Pulmonary Embolism history DVT IVC filter
placement [ * * 2106 - 7 - 8 * * ]
2 ) Community Acquired Pneumonia
3 ) history GI Bleed ( extensive ) [ * * 2106 - 7 - 8 * * ]
anticoagulate
4 ) abdominal wall hematoma , acute blood loss anemia
require 10 unit prbc anticoagulate current
pulmonary embolism
5 ) Noscomial Pneumonia GNR sputum ,
6 ) Coagulopathy
7 ) noscomial UTI E. coli - quinolone resistant
8) Vagnitis , attribute broad spectrum antibiotic usage
9 ) otitis externa
10 ) tachycardia
11 ) diarrhea
12 ) incidentally note leave renal cyst / mass NOS
13 ) Coagulase negative staphylococcal bacteremia
14 ) Rectus sheath hematoma setting anticoagulation
.
secondary :
1 ) chronic orthostatic hypotension
2 ) recurrent otitis externa
3 ) ulcerative colitis remission
4 ) chronic obstructive pulmonary disease
5 ) depression
6 ) h / schizoaffective disorder
Discharge condition :
Stable .
Discharge instruction :
please take medication prescribe , please keep
follow - appointment . please call primary care doctor ,
Dr. [ * * First Name8 ( NamePattern2 ) 1158 * * ] [ * * last Name ( NamePattern1 ) * * ] , return Emergency Department
experience fever , chill , worsen shortness breath ,
dizziness , lightheadedness , worsen chest pain , nausea ,
vomiting , diarrhea , blood stool symptom
concern .
.
please take medication prescribe follow
primary care doctor [ * * First Name ( Titles ) 3 * * ] [ * * last Name ( Titles ) 4030 * * ] .
Followup Instructions :
need set followup appointment see Dr. [ * * First Name8 ( NamePattern2 ) 1158 * * ] [ * * last Name ( NamePattern1 ) * * ]
[ * * 2 - 8 * * ] week . please call ( [ * * telephone / Fax ( 1 ) 39126 * * ] set
appointment .
.
follow appointment schedule prior
hospitalization :
Provider : [ * * Name10 ( NameIs ) * * ] SURGERY CLINIC phone:[**telephone / fax ( 1 ) 4652 * * ]
Date / Time:[**2107 - 1 - 28 * * ] 1:00
* * * follow CT scan ultrasound left kidney recommend
well urologic follow due incidentally note leave
renal cyst / mass may malignant . * * * * * * *
[ * * first Name8 ( NamePattern2 ) * * ] [ * * last Name ( NamePattern1 ) * * ] MD [ * * MD Number(2 ) 2937 * * ]
complete by:[**2107 - 2 - 12 * * ]
|
[
"496",
"2851",
"2724"
] |
Admission Date : [ * * 2193 - 4 - 11 * * ] Discharge Date : [ * * 2193 - 4 - 16 * * ]
Date Birth : [ * * 2121 - 3 - 15 * * ] sex :
Service : NEUROSURGERY
allergy :
Patient record known allergy drug
attending:[**first Name3 ( LF ) 1854 * * ]
Chief Complaint :
Elective Admission Mass resection
Major Surgical Invasive Procedure :
[ * * 4 - 11 * * ] : right craniotomy mass resection
history Present Illness :
Patient 72 know neurosurgery service prior
hospitalization AVM hemorrhage . time , incidental
mass identify , present electively
resection say mass .
Past Medical history :
IVH / AVM bleed [ * * 10 - 3 * * ] h / Lt temporal AVM , HTN , depression ,
BPH , UTI , seizure , bladder stone
/ p VP shunt , cyberknife ( AVM [ * * 11 - 3 * * ] ) , cyst removal skin ,
lithotripsy , extra - ventricular drain [ * * 10 - 3 * * ]
Social History :
reside home wife
Family history :
Non - contributory
Physical Exam :
discharge :
patient orient x 3 . pupil 2 mm bilaterally .
eom intact . face symmetric . Tongue midline . leave pronator
drift . LUE weak well IP LLE . right side
full strength . dressing remove staple
clean , dry , intact .
pertinent result :
Labs Admission :
[ * * 2193 - 4 - 11 * * ] 02:46pm blood WBC-18.4 * # RBC-3.81 * Hgb-11.0 * Hct-32.7 *
MCV-86 MCH-28.8 mchc-33.5 RDW-15.5 Plt Ct-517 *
[ * * 2193 - 4 - 12 * * ] 03:11am blood pt-12.8 PTT-24.1 INR(PT)-1.1
[ * * 2193 - 4 - 11 * * ] 02:46PM blood glucose-179 * UreaN-11 Creat-0.7 na-139
K-4.2 Cl-107 HCO3 - 24 AnGap-12
[ * * 2193 - 4 - 11 * * ] 02:46PM blood Calcium-8.3 * Phos-4.2 Mg-1.7
Imaging :
MRI / Head Neck [ * * 4 - 13 * * ] :
TECHNIQUE : T1 sagittal axial FLAIR T2 susceptibility
diffusion
axial image brain acquire gadolinium . T1
axial MP-
rage sagittal image obtain follow gadolinium . 3d
time - - flight
MRA circle [ * * Location ( un ) 431 * * ] obtain . gadolinium - enhance MRA
neck fat - suppress axial image neck
acquire .
finding : BRAIN MRI :
Comparison make previous MRI [ * * 2193 - 4 - 11 * * ] . since
previous study , patient undergo resection large
meningioma right frontal region . extensive right - side
brain edema identify . blood product
surgical site . although
residual nodular enhancement see , enhancement see
along
sulci meningeal enhancement identify region .
finding
indicate pachy leptomeningeal enhancement . mild slow
diffusion
surround area diffusion image indicative
postoperative
change . blood left lateral ventricle .
persistent
mass effect right lateral ventricle . change small
vessel disease
see . left frontal drainage catheter identify . note
make new area slow diffusion right medial
thalamus . finding indicative acute infarct
new since previous study .
note enhance meningioma tuberculum sella
region .
additionally , enhancement flow void left medial
temporal lobe
region indicative aneurysm site previously note
arteriovenous malformation . post - craniectomy change see
right frontal region . Pneumocephalus identify .
IMPRESSION : previous MRI examination , patient undergo
resection large frontal meningioma blood product
surgical site without residual nodular enhancement .
Leptomeningeal pachymeningeal enhancement see
appear postoperative . Acute right - side thalamic infarct
see new since previous study . finding
stable describe .
MRA neck :
neck MRA demonstrate normal flow carotid
vertebral artery . fat - suppress image demonstrate subtle
increase soft tissue adjacent proximal right common
carotid artery see CTA . could relate
small amount blood surround soft tissue
recent attempt central venous line placement .
definite dissection see .
IMPRESSION : normal MRA neck .
MRA head :
head MRA demonstrate evidence vascular occlusion
stenosis . previously see aneurysm relation left
posterior cerebral artery apparent MRA . left
medial temporal lobe arteriovenous malformation also
clearly visualize .
IMPRESSION : vascular occlusion stenosis see MRA
head .
postoperative change note follow removal frontal
lobe tumor .
Acute right thalamic infarct identify . MRA neck
normal
without dissection . MRA head demonstrate stenosis
occlusion .
Brief Hospital course :
Patient electively admit [ * * 4 - 11 * * ] undergo resection
brain mass . Post - operatively , transfer ICU
continuous monitoring . perioperative course ,
central line placement complicate access carotid
artery . Post - op , vascular surgery consult , duplex study
perform , determine without injury carotid
artery . MRI / also do confirm well
evaluate surgical resection . vascular surgery team agree
carotid artery dissection intervention
need part .
patient extubate ICU transfer
floor . well weekend . patient able
eat without difficulty . PT OT evaluate recommend
rehab placement . [ * * 4 - 16 * * ] patient note bloody
urine foley . urinalysis reveal UTI . start
14 - day course cipro . patient send rehab
[ * * 4 - 16 * * ] .
medication admission :
APAP , Celexa 20 mg ' , Compazine 20 mg prn , Flomax 0.4 mg ' , Folic
Acid 1 mg ' , Keppra 500 mg " , lactulose prn , Ativan 1 mg prn ,
Metoprolol 50 mg " ' , [ * * Name ( NI ) 10687 * * ] , MOM , Ritalin 20 mg ' , Seroquel 25 mg " ' ,
Trazadone 50 mg hs
discharge medication :
1 . Acetaminophen 325 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every
6 hour ) need .
2 . [ * * Name ( NI ) 10687 * * ] 8.6 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
3 . Docusate Sodium 100 mg Capsule Sig : one ( 1 ) Capsule po BID ( 2
time day ) .
4 . Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : two ( 2 )
Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) .
5 . Metoprolol Tartrate 25 mg Tablet Sig : three ( 3 ) Tablet PO TID
( 3 time day ) .
6 . tamsulosin 0.4 mg Capsule , Sust . release 24 hr Sig : one ( 1 )
Capsule , Sust . release 24 hr po HS ( bedtime ) .
7 . citalopram 20 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
8 . Folic Acid 1 mg Tablet Sig : one ( 1 ) Tablet PO DAILY ( Daily ) .
9 . Lorazepam 0.5 mg Tablet Sig : one ( 1 ) Tablet PO Q6H ( every 6
hour ) need .
10 . methylphenidate 10 mg Tablet Sig : two ( 2 ) Tablet PO DAILY
( Daily ) .
11 . Quetiapine 25 mg Tablet Sig : one ( 1 ) Tablet PO TID ( 3 time
day ) .
12 . Lactulose 10 gram/15 ml Syrup Sig : thirty ( 30 ) ML PO Q8H
( every 8 hour ) need .
13 . Ciprofloxacin 500 mg Tablet Sig : one ( 1 ) Tablet po Q12H
( every 12 hour ) 14 day .
14 . famotidine 20 mg Tablet Sig : one ( 1 ) Tablet po BID ( 2 time
day ) .
15 . Levetiracetam 500 mg Tablet Sig : three ( 3 ) Tablet po BID ( 2
time day ) .
discharge Disposition :
Extended Care
Facility :
[ * * hospital6 85 * * ] - [ * * Location ( un ) 86 * * ]
discharge Diagnosis :
right Frontal Meningioma
Discharge condition :
neurologically stable
Discharge instruction :
General Instructions / Information
? ? ? ? ? ? friend / family member check incision daily
sign infection .
? ? ? ? ? ? take pain medicine prescribe .
? ? ? ? ? ? Exercise limit walk ; lifting , strain ,
excessive bending .
? ? ? ? ? ? may wash hair staple remove .
? ? ? ? ? ? may shower time use show cap cover
head .
? ? ? ? ? ? increase intake fluid fiber , narcotic pain
medicine cause constipation . generally recommend take
counter stool softener , Docusate ( Colace )
take narcotic pain medication .
? ? ? ? ? ? unless direct doctor , take
anti - inflammatory medicine Motrin , Aspirin , Advil ,
Ibuprofen etc .
? ? ? ? ? ? discharge Keppra ( Levetiracetam ) ,
require blood work monitoring .
? ? ? ? ? ? clearance drive return work address
post - operative office visit .
? ? ? ? ? ? make sure continue use incentive spirometer
home .
call SURGEON IMMEDIATELY experience
following
? ? ? ? ? ? new onset tremor seizure .
? ? ? ? ? ? confusion change mental status .
? ? ? ? ? ? numbness , tingling , weakness extremity .
? ? ? ? ? ? pain headache continually increase ,
relieve pain medication .
? ? ? ? ? ? sign infection wound site : increase redness ,
increase swell , increase tenderness , drainage .
? ? ? ? ? ? fever great equal 101 ? ? ? ? ? ? F.
Followup Instructions :
follow - Appointment instruction
? ? ? ? ? ? please return office [ * * 4 - 26 * * ] 10:00 removal
staple wound check [ * * telephone / Fax ( 1 ) 1669 * * ] .
? ? ? ? ? ? need appointment Brain [ * * Hospital 341 * * ] Clinic .
call appointment . Brain [ * * Hospital 341 * * ] Clinic
locate [ * * Hospital Ward Name 516 * * ] [ * * Hospital1 18 * * ] , [ * * Hospital Ward Name 23 * * ] building .
phone number [ * * telephone / Fax ( 1 ) 1844 * * ] . please call need
change appointment , require additional direction .
? ? ? ? ? ? need MRI brain do
acute hospitalization .
complete by:[**2193 - 4 - 16 * * ]
|
[
"5990",
"4019"
] |
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