SUBJECT_ID,AGGREGATED_TEXT,EXTRACTED_JSON
26979,admission date discharge date date of birth sex m service medicine allergies heparin agents attending chief complaint v fib arrest major surgical or invasive procedure spinal fixation history of present illness yo male w hx of a fib not on coumadin copd who was with his wife at an appt in the building who had a witnessed v fib arrest per pcp patient abruptly lost consciousness and stopped breathing and seized while sitting in a chair code was called and chest compressions performed until defibrillator available noted to be in vf and was shocked joules with rhythm return he was intubated in the clinic and transferred to the ed in the ed vitals were t hr bp rr sat soon began to move all extremities and required bolus sedation ekg was obtained with a fib and new rbbb cards was consulted and felt that his vf arrest was secondary to his underlying pulmonary issues and recommended cta to r o pe and echo in the am on arrival to the icu patient is intubated and sedated minimally responsive to commands past medical history severe copd on home o fev diastolic dysfunction with preserved left ventricular systolic function and normal ejection fraction chronic leg edema presumed to r heart failure on torsemide chronic atrial fibrillation not on anticoagulation by his choice hypertension lung cancer s p rul resection in prostate cancer tx w casodex and xrt at pack year history of cigarette smoking severe osteoarthritis involving both of his hips s p hip surgery social history patient lives with his wife a pack year smoking history no etoh or illicits per recent chf note patient severe sob with minimal exertion ie walking feet bathing and dressing in the morning he continues to sleep in a recliner chair family history nc physical exam on admission vitals t ax bp hr rr sat ac breathing tv peep fio gen intubated heent pupils reactive bilat cataracts bilat resp bibasilar crackles no wheeze card regular no murmurs appreciated abd bs soft non distended no hsm ext lower ext edema w erythema over lower ext consistent with venous stasis changes mild warmth dp pulses neuro sedated moving all four extrmities pertinent results ekg hr a fib lad new rbbb st seg depression v v relatively unchanged from prior imaging cxr cardiac silhouette is enlarged there are increased interstitial opacities with prominence and of the pulmonary vasculature consistent with interstitial edema the et tube is in place terminating cm above the carina defibrillator pad is in place on the right partially obscuring evaluation of the right lung there is right lung volume loss and post surgical changes from right upper lobectomy unchanged head ct wet read no ich no mass effect loss of white matter differentiation in the l front parietal area consistent w encephalomalacia echo study is severely technically limited biventricular systolic function appears grossly preserved in suboptimal views regional wall motion could not be adequately assessed mild aortic regurgitation is detected the valves are not well seen mitral and tricuspid regurgitation could not be adequately assessed brief hospital course patient is a year old male h o copd s p r lung resection presumed diastolic heart failure htn obesity and likely diabetes mellitus type now status post cardiopulmonary resuscitation given vf arrest reintubated for worsening respiratory status twice to mucus plugging s p spinal fixation extubated two days ago with increasing respiratory distress pt refuses reintubation respiratory failure pt with previous pulmonary history of copd and prior lung resection was intubated s p v fib arrest and had multiple failed extubations he had previous been extubated and reintubated twice for worsening acidemia and hypercarbia likely due to poor ms and possibly too much o use causing co retention pt has completed steroid tapers for possible copd component and has been diursed for many days pt with serratioa marrascens initially treated with unasyn and changed to meropenem on due to concern for thrombocytopenia repeat sputum on demonstrated serratia as well finished day course of meropenem on further cultures continued to grow serratia patient was extubated and overnight felt fatigued at times with some difficulty clearing secretions levofloxacin was started to attempt to clear any remaining serratia pt respiration assited with bipap diuresis nebs and chest pt despite attempts pt continued to be unable to clear secretions and retained co multiple extensive discussions with patient and family and in end pt refused re intubation and was made cmo pt died approximatedly days after third extubation code status extensive discussions and again patient initially desired not to be re intubated however after discussions with family stated he would want to be intubated if needed after further discussions pt again refused intubation despite conversations with family icu staff and pcp was not intubated and eventually made cmo s p vf arrest contrast echo did not demonstrate any focal wall motion abnormalities given suboptimal study per study it appears that systolic function is intact were planning for icd after stabilization in consultation with ep thrombocytopenia dropped from to to am extensive workup for variety of diagnosies including hit ttp itp sequestration etc including consultation of heme onc pt continued to have plt and often despite transfusion and removal of all thrombocytopenic drugs including diamox lasix zosyn heparin dependent ab positive serotonin release assay negative so hit very unlikely pt was removed from all heparin and line was replaced with heparin free pic with no resolution pt was treated with steroids and ivig in event that thrombocytopenia was immune mediated no response u s revealed mildly enlarged spleen no liver lesions making sequestration unlikley dic and hemoysis labs were negative as well as fact that upper and lower extremity ultrasounds negative for dvt and there were no schistocytes on smear patient underwent bm biopsy which showed normal megakaryocytes at this time felt to be multifactorial from medication effects chronic illness in general pt transfused u of plt at at ime to keep plt count above plt count would initially bump and then return to low level no hla antibodies so that was not a source of destroying plt atrial fibrillation patient frequently in atrial fibrillation rate was controlled with labetalol mg po tid atrial fibrillation is chronic and patient had not been previously anticoagulated metoprolol had been stopped previously as a home medication given patient s fatigue on metoprolol as well as patient s copd held any anticoagulation given ongoing thrombocytopenia anemia bleeding difficulties rate control at goal presently anemia previously anemic now stable possible sources stools guaiac positive some serosangeous secretions hematuria and general coagulopathy from decreased platlets pt transfused to maintain hct hypernatremia treated with free water boluses as needed oral thrush nystatin s s hypertension had labile blood pressure ranging from s s which responded well to labetaolol captopril was added and then transitioned to lisinopril mg with good effect hydralazine mg was used prn for additional control renal failure he was noted to have a minor creatinine bump post op to which quickly returned to range at likely prerenal given urine na with good uop hyperglycemia hba c indicating poor glycemic control over last two to three months insulin ss and nph adjusted per fsbgs spinal injury s p hardware fixation of t t moving all fours logroll precautions had been removed and pt was sitting up in chair with ot and pt consluts heparin was for thrombocytopenia copd patient continued on albuterol and ipratropium nebulizers standing as well as albuterol prn finished steroid taper x fen tube feeds with nutren pulmonary at goal with free water boluses as needed for hypernatremia ppx ppi while intubated eventually d c to ensure not cause of thrombocytopenia had bowel regimin titrated as needed access picc line a line communication wife cell home medications on admission torsemide alternating mg mg every other day verapamil sr mg daily aspirin mg daily combivent albuterol ipratropium inhaler qd advair fluticasone salmeterol inhaler qd discharge medications none discharge disposition expired discharge diagnosis deceased discharge condition deceased discharge instructions deceased followup instructions deceased,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2012-12-25"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Heparin""
],
""attendingChiefComplaint"": ""V fib arrest"",
""chiefComplaintHistory"": ""V fib arrest"",
""historyOfPresentIllness"": ""YO male with hx of a fib not on coumadin copd who was with his wife at an appt in the building who had a witnessed v fib arrest per pcp patient abruptly lost consciousness and stopped breathing and seized while sitting in a chair code was called and chest compressions performed until defibrillator available noted to be in vf and was shocked joules with rhythm return he was intubated in the clinic and transferred to"
4941,admission date discharge date date of birth sex f service neonatology history of present illness is the former kilogram product of a and week gestation pregnancy born to a year old gravida para woman prenatal screens revealed blood type o positive antibody negative rubella immune rapid plasma reagin nonreactive hepatitis b surface antigen negative and group b strep status unknown the pregnancy was notable for in fertilization dichorionic diamniotic twins the pregnancy was complicated by preterm labor and cervical shortening requiring a cerclage placement she was also treated with terbutaline at weeks gestation she received a complete course of betamethasone on the day of delivery she presented in labor with cervical changes and was taken for cesarean section due to the known breech positioning of twin ii twin i emerged with good tone and cry with apgar scores were at one minute of age and at five minutes of age she was admitted to the neonatal intensive care unit for treatment of prematurity physical examination on presentation physical examination upon admission to the neonatal intensive care unit revealed weight was kilograms length was cm and head circumference was cm all th to th percentile for gestational age in general the infant was a pink active nondysmorphic female skin was well perfused head eyes ears nose and throat examination revealed anterior fontanel was open and flat palate was intact positive red reflex bilaterally chest revealed comfortable respirations with equal breath sounds cardiovascular examination revealed normal first heart sounds and second heart sounds without murmurs femoral pulses were the abdomen was benign genitalia revealed normal premature female neurologic examination was nonfocal and age appropriate examination musculoskeletal examination revealed hips were normal the spine was intact concise summary of hospital course by issue system respiratory issues the infant was on room air for her entire neonatal intensive care unit admission she did not have any episodes of spontaneous apnea cardiovascular issues the infant has maintained normal heart rates and blood pressures no murmurs have been noted fluids electrolytes nutrition issues the infant was initially nothing by mouth and maintained on intravenous fluids enteral feeds were started on day of life two and gradually advanced to full volume she required additional calories and was to be discharged home on breast milk to calories with calories by enfamil powder she breast feeds well her intake has been cc kg per day minimum her most recent weight was kilograms with a length of cm and a head circumference of cm serum electrolytes were checked on day of life two and were within normal limits infectious disease issues due to the unknown etiology of the preterm labor and unknown group b strep status the infant was evaluated for sepsis white blood cell count was with polys and bands a blood culture was obtained prior to starting intravenous ampicillin and gentamicin the blood culture was no growth at hours and antibiotics were discontinued gastrointestinal issues the infant required treatment for unconjugated hyperbilirubinemia with phototherapy her peak serum bilirubin occurred on day of life four with a total bilirubin of and a direct bilirubin of mg dl phototherapy was initiated and continued for approximately four days her phototherapy was discontinued on and her rebound bilirubin the following day was total bilirubin and a direct bilirubin of hematologic issues hematocrit at birth was the infant has not had any transfusions of blood products she was to be discharged home on supplemental iron neurologic issues the infant has maintained a normal neurologic examination during this admission there were no neurological concerns at the time of discharge audiology sensory issues a hearing screen was performed with automated auditory brain stem responses and the infant passed bilaterally condition at discharge condition on discharge was good discharge status to home with parents primary pediatrician the primary pediatrician is dr pediatrics telephone number care recommendations at the time of discharge feeding breast feeding or taking breast mild to calories per ounce by bottle and calories by enfamil powder medications poly vi cc by mouth once per day ferrous sulfate mg ml solution cc by mouth once per day car seat position screening was performed and the infant maintained adequate oxygen saturations and did not show any episodes of spontaneous apnea or bradycardia for minutes a state newborn screen was sent on and on the day of discharge no notification of abnormal results to date have been received immunizations hepatitis b vaccine was administered on immunizations recommended synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria born at less than weeks gestation born between and weeks gestation with plans for day care during respiratory syncytial virus season with a smoker in the household or with preschool siblings and or with chronic lung disease influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age before this age the family and other care givers should be considered for immunization against influenza to protect the infant discharge instructions followup followup with dr within three days of discharge discharge diagnoses prematurity at and week gestation twin i of twin gestation suspicion for sepsis ruled out unconjugated hyperbilirubinemia m d dictated by medquist d t job,"[
{
""date"": ""2019-10-10"",
""type"": ""N/A"",
""subtype"": ""N/A"",
""admission_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-13"",
""date_of_birth"": ""2019-10-10"",
""sex"": ""Female"",
""service"": ""Neonatology"",
""history_of_present_illness"": ""admission date discharge date date of birth sex f service neonatology history of present illness is the former kilogram product of a and week gestation pregnancy born to a year old gravida para woman prenatal screens revealed blood type o positive antibody negative rubella immune rapid plasma reagin nonreactive"
15725,admission date discharge date date of birth sex f service csurg allergies patient recorded as having no known allergies to drugs attending chief complaint cad with vessel disease major surgical or invasive procedure sp cabg x sp repair and evacuation of external iliac artery history of present illness f presenting with months of worsening angina and dyspnea on exertion cardiac catheterization with iabp placement on showed vessel disease past medical history htn hypercholesterolemia mitral valve prolapse osteoporosis thyroid goiter sp l hip replacement sp appy social history married retired no etoh physical exam nad no jvd bruits rrr iii sem ctab soft nt edema pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt inr pt am blood pt ptt inr pt pm blood alt ast ck cpk alkphos pm blood ck mb notdone ctropnt pm blood ck mb ctropnt am blood ck mb notdone ctropnt pm blood ctropnt am blood heparin dependent antibodies pm glucose urea n creat sodium potassium chloride total co anion gap brief hospital course hospital stay was significant for external iliac artery bleed post iabp pull on the pt iabp was dc d this was complicated by external iliac aretery bleed the pt required bllod products for a low hct and responded appropriately the pt was taken to the or by vascular surgery for repair and evacuation of external iliac artery on the pt tolerated this procedure well the jp output upon dc was day and the pt was dc s to rehab with instructions to record the output and to dc it when cc hr post operative atrial fibrillation on post operative day the pt converted to atrial fibrillation with a ventricular response in s pt was treated with lopressor and amiodarone and was rate controlled the pt converted into sinus rhythm s the pt went back into rate controlled atrial fibrillation on pod the pt was given another amiodarone bolus and her lopressor was increased the pt was started on coumadin on with dosing to be adjusted at rehab no haparin was started see dc medications on discharge the pt was tolerating a cardiac healthy diet and ambulating on her own and working with physical therapy the pt s chest tubes pacing wires and foley catheter were all dc d without a problems the pt had good pain control the pt kg over her preop weight and was dc d to rehab on lasix and potassium supplements medications on admission asa evista verapamil toprol lasix tiw celebrex prilosec lipitor glucosamine qday discharge disposition extended care facility at discharge diagnosis sp cabg x sp repair and evacuation of external iliac artery post operative atrial fibrillation htn hypercholesterolemia mitral valve prolapse osteoporosis thyroid goiter sp l hip replacement sp appy discharge condition stable discharge instructions please call physician if experiencing fever chills redness drainage from the incision nausea vomiting chest pain shortness of breath please do not lift lbs x weeks do not drive while on narcotic pain medications follow up with pcp regarding coumadin and lasix dosing post operatively followup instructions please call the office for an appointment with dr in weeks please follow up with your pcp cardiologists in weeks inr checks coumadin dosing per pcp volume status and lasix dosing after weeks with pcp completed by,"[
""admission_date"" : ""2019-1-22"",
""discharge_date"" : ""2019-1-27"",
""date_of_birth"" : ""2026-10-10"",
""sex"" : ""F"",
""service"" : ""Csurg"",
""allergies"" : ""Patient recorded as having no known allergies to drugs"",
""attending_chief_complaint"" : ""CAD with vessel disease major surgical or invasive procedure sp CABG x sp repair and evacuation of external iliac artery"",
""history_of_present_illness"" : ""F presenting with months of worsening angina and dyspnea on exertion cardiac catheterization with IABP placement on showed vessel disease past medical history H"
30005,unit no admission date discharge date date of birth sex f service nb history girl was born at weeks gestation to a year old g p now blood type b antibody negative hbsag negative rubella immune rpr nonreactive gbs unknown beta complete and was conceived via iui assisted di di twins the pregnancy was complicated by cervical shortening a cerclage was put in at weeks gestational diabetes on insulin polycystic ovary syndrome and rupture of membranes on the patient was born by c section and was the first twin the second twin was breech apgars were and the reason for delivery was progression of labor there was no maternal fever the infant emerged with a weak cry but then became apneic and required positive pressure ventilation with a heart rate of less than initially which improved the patient was intubated with a et tube at approximately minutes of life the infant was admitted to the nicu discharge physical examination vital signs weight was g th percentile length cm th percentile head circumference cm th percentile general comfortable in open crib alert no apparent distress heent palate intact good suck anterior fontanelle open soft and flat normocephalic red reflex present bilaterally no obvious strabismus respiratory clear to auscultation bilaterally no wheeze or rhonchi cardiac regular rate and rhythm s s no murmur abdomen soft nontender nondistended no mass no organomegaly positive bowel sounds gu normal female extremities warm well perfused moved all extremities spontaneously good pulses negative barlow ortolani and galeazzi signs spine straight no lesions very small pigmented lumbar nevi sacral dimple bottom easily visible neurologic alert active good tendon reflexes no focal deficits summary of hospital course respiratory the patient initially became apneic and required intubation the patient was intubated with a et tube and remained intubated until day of life when she was extubated to cpap and remained in cpap until day of life at which time the patient was continued on room air till discharge she was on caffeine until the end of when it was discontinued secondary to tachycardia the patient did have occasional apnea and bradycardic spells which required several spell countdowns she was without apnea or bradycardia for days prior to her diacharge cardiovascular no pressors were necessary to maintain blood pressure a uvc was placed on day of life but was removed on day of life fluids electrolytes and nutrition the patient was started on parenteral nutrition on day of life was started on pg feeds on day of life and was on all pg feeds by day of life after which the parenteral nutrition was discontinued she began p o feeds on day of life and was on all p o feeds by day of life she was discharged home on enfacare kcal oz formula and she demonstrated good weight gain on that formula gi the patient required phototherapy for days for a max bilirubin of hematology the patient suffered some anemia during her course in the nicu on the patient had a hematocrit of but the retic count was no transfusion was given on cbc was rechecked with a hematocrit of there was no further anemia throughout the hospital course the patient was on iron and vitamin e vitamin e was discontinued at discharge infectious diseases shortly after delivery the patient had cultures which were negative and she required rule out sepsis with hours of ampicillin and gentamicin neurology the patient had normal head ultrasounds one on and one on sensory audiology hearing screen was performed with automated auditory brain stem responses results were normal in both ears ophthalmology mature the eyes were examined most recently on and a follow up exam is recommended in months psychosocial social work was involved with the family the contact social worker can be reached at follow up will be provided if desired condition on discharge stable discharge disposition home primary care pediatrician md phone number fax number care recommendations feeds the plan was to continue enfacare calorie feeds until to months of age corrected medications no medications other than iron iron and vitamin d supplementation iron supplementation is recommended for preterm and low birth weight infants until months of age continue her mg kg supplementation until months of age she will be receiving adequate vitamin d supplementation of international units daily on her current enfamil car seat positioning screening passed state newborn screening initial newborn screen was sent on and showed increased amino acids repeat screen was sent on and was normal immunizations the patient received pediarix on hepatitis b vaccine on dtap on and pneumococcal vaccine on the patient also received synagis on synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria born at less than weeks born between and weeks with of the following daycare during rsv season a smoker in the household neuromuscular disease airway abnormalities school age sibling chronic lung disease hemodynamically significant chd influenza immunization is recommended annually in the fall for all infants once they reach months of age before this age and for the first months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers this infant has not received a rotavirus vaccine the american academy of pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least weeks but fewer than weeks of age follow up appointments the patient will follow up on at a m with dr and will also have a vna visit on discharge diagnoses prematurity at weeks respiratory distress syndrome twin gestation rule out sepsis apnea of prematurity hyperbilirubinemia m d dictated by medquist d t job,"{
""name"": ""Girl"",
""dateOfBirth"": ""2017-03-20"",
""dateOfDeath"": ""2017-03-20"",
""sex"": ""Female"",
""service"": ""NICU"",
""history"": ""Girl was born at weeks gestation to a year old G P now blood type B antibody negative Hbsag negative rubella immune RPR nonreactive GBS unknown beta complete and was conceived via IUI assisted di di twins. The pregnancy was complicated by cervical shortening a cerclage was put in at weeks gestational diabetes on insulin polycystic ovary syndrome and rupture of membranes. On the patient was born by C section and was the first twin. The second twin was breech apgars were and the"
31432,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness f htn hypoth diverticulitis s p partial collectomy for diverticulitis presents with llq pain stated it started as sharp llq pain last night no diarrhea black bloody stools reported in ed ct abd revealed diverticulitis she was doing well until am she reported cp with bp s and hr s ce were sent ekg with anterolateral st depression also had erythema immediately following flagyl dose benadryl mg iv given given patient had history of similar reaction to ciprofloxacin ciprofloxacin dose was also canceled before she received a significant amount pepcid given ivf started received total of l in ed patient was mentating but very drowsy another l ivf bolus given although sbp in the s for prior hrs with no intervention except ivf patient remained persistently hypotensive despite fluids l ivf total was started on dopamine peripherally sbp improved to s bedside echo on dopamine showed no hypokinesis no regional wma ef no effusion cxr was unchanged to prior ct abdomen confirmed acute uncomplicated diverticulitis on floor on mcg min dopamine bp hr rr o sat on on l nc t patient was transferred to the intensive care unit for further care past medical history s p colectomy for diverticulitis c b incisional hernia requiring repair chronic diarrhea bm a day since colectomy s p l mastectomy xrt s p melanoma excision at neck s p gall bladder resection in hypothyroidism on meds for years htn on meds for years social history patient is a retired russian language and literature high school teacher she moved to the us at yo to live with her brother currently she lives by herself as her brother passed away last year and her son lives in she enjoys the arts and paints at home denied etoh and tobacco family history her brother died of stroke brother had no known cardiac disease physical exam vs hr bp rr ra gen pleasant well appearing nad good english neuro aao to person place situation heent perrl op clear neck no elevation in jvd cards brady regular no m g r lungs ctab abd bs bilateral tenderness to palpation in the lower abdomen large abdominal hernia easily reducible nd no rebound ext no c c e dp pertinent results ekg sinus brady rate nl axis qtc sti v v with slight st depressions v v improved from prior imaging ct abd acute uncomplicated sigmoid diverticulitis fibroid uterus spigelian hernia containing unremarkable small bowel loops echo the left atrium is normal in size left ventricular wall thicknesses are normal the left ventricular cavity size is normal regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present labs admission hospitalization pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood glucose urean creat na k cl hco angap pm blood alt ast alkphos amylase totbili am blood ck mb notdone ctropnt am blood ck mb notdone am blood ctropnt am blood ck mb ctropnt am blood calcium phos mg iron am blood cholest am blood triglyc hdl chol hd ldlcalc am blood caltibc ferritn trf labs on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood glucose urean creat na k cl hco angap am blood calcium phos mg cultures blood cultures no growth urine culture negative brief hospital course year old russian literature teacher with past medical history significant for htn hypoth diverticulitis s p partial collectomy for diverticulitis diverticulitis h o diverticulitis w s p partial resection of large bowel patient initially treated with vancomycin zosyn this was changed to ciprofloxacin flagyl with no evidence of allergic reaction noted in the emergency department patient was on intravenous cipro flagyl while in micu that was transitioned to po upon tranfer to the floor initally planned day course cipro flagyl cardiology recommended discontinuing cipro given risk of prolonged qtc and patient recent bradycardia cipro was changed to bactrim patient tolerated full low residue diet patient ready to go home on hypotension bradycardia micu course precipitated by bradycardic hypotensive episode thought to be a question of sinus node dysfunction patient was started on dopamine to keep maps and was slowly weaned off the dopamine by was stable for greater than hours off pressors at time of discharge patient states her hr always runs in low s she was ruled out by ce cardiology was consulted who did not recommend any intervention at this time patient hemodynamically stable continued asa statin patient found to have high cholesterol will have close outpatient follow up and ett as outpatient hypothyroid tsh continue with levothyroxin anemia patient anemic at baseline hct s p l in micu recommended outpatient follow up work up with pcp fen low residue diet h o htn hold lisinopril for now set up appt with pcp and defer restarting to that time sbp s ppx ppi hepsq code full dispo to home with cards and pcp medications on admission levothyroxine qd lisinopril discharge medications levothyroxine mcg tablet sig one tablet po daily daily aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills bactrim ds mg tablet sig one tablet po twice a day for days disp tablet s refills discharge disposition home discharge diagnosis primary diverticulitis bradycardia hypotension secondary hypothyroid discharge condition tolerating po pain greatly improved discharge instructions you were admitted for diverticulitis and treated with antibiotics you have greatly improved please eat a diet high in fiber and drink plently of water please complete the full course of your antibiotics please follow up with your primary care physican as stated below at that time you should discuss your cholesterol as it was slightly elevated during your hospitalization you had an episode of low blood pressures for which you were admitted to the intensive care unit your blood pressures are good now but please do not restart your lisinopril your blood pressure medication due to your low blood pressure and your slow heart rate we have scheduled you for an exercise treadmill test and an appointment with a cardiologist if you have fevers t chills nausea vomiting increase in the amount of your diarrhea lightheadedness dizziness chest pain or pressure or shortness of breath please contact your primary care physican if she is not available and you are concerned please go to the local hospital emergency room or call you have been started on the following new medications in addition to the antibiotics for your diverticulitis aspirin please take daily baby aspirin followup instructions provider md phone date time provider exercise lab phone date time they will send you information in the mail regarding this appointment and a translator has been set up for you provider md phone date time,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""dateOfBirth"": ""2014-12-29"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Ciprofloxacin""
],
""admissionDate"": ""2015-01-03"",
""dischargeDate"": ""2015-01-05"",
""dateOfDeath"": ""2015-01-05"",
""serviceOfAdmission"": ""Hypotension"",
""chiefComplaint"": ""Abdominal pain"",
""historyOfPresentIllness"": ""This is a 40 yo female with htn, hypothyroidism, and diverticulitis who presents with ab"
20733,admission date discharge date service neurosurgery history of present illness this year old man had developed imbalance with difficulty in word finding and verbal memory and had become somewhat reticent and depressed he was having absence type seizures frequently at night he was found to have a cm meningioma in the left anterior was made to carry out definitive surgery with a left sided craniotomy at this time the problem was complicated by his history of coronary artery disease and insulin dependent diabetes mellitus which was poorly controlled he was evaluated by cardiology with an angioplasty of a stent placement the week prior to his admission he was on plavix and aspirin which was stopped on the first of in preoperative decadron until the time of surgery past medical history he had known coronary artery disease and had two myocardial infarctions in the past he had prior angioplasty in and again the week prior to the admission with a stent placed he had known hypertension he had high cholesterol he had insulin dependent diabetes mellitus he had a tonsillectomy as a child but no other surgery social history he did not use tobacco or alcohol allergies he had no known drug allergies medications he was taking mg of leustatin each day and mg of losartan each day and was taking novolin units in the morning and units at night he was taking mg of atenolol each day he was taking mg of plavix and mg of aspirin which he had stopped on he was taking mg of dilantin physical examination his vital signs blood pressure with a pulse of height of and a weight of pounds his head eyes ears nose and throat exam were normal his neck was supple with no adenopathy no thyromegaly and trachea to midline his chest was clear to percussion and auscultation his cardiac exam showed a regular rate and rhythm with a normal s s and no murmurs his abdominal exam showed no organomegaly no masses or tenderness and normal bowel sounds to be present his extremities showed no joint deformities no peripheral edema and full pulses throughout his neurological exam showed him to be alert and oriented but with difficulty with hearing he had slight nystagmus on lateral gaze in either direction his motor exam showed normal tone and strength but left hand coarse tremor with extension and almost a pill rolling type of movement his sensory exam was intact to sharp testing his deep tendon reflexes were and symmetric in the upper and lower extremities his gait was markedly ataxic he tended to walk with a wide base and to be quite unsteady single leg stance was not tested it was impossible for him to even consider standing on a single leg laboratory data his admission cbc showed hematocrit of only this dropped down to over the first postoperative day and he received two units of packed red cells which brought him back up to mid range his white count was in the normal range her had serial electrolytes and bun and creatinine and blood glucose levels which were normal except for the glucose level which were periodically elevated to over but were well controlled in the range by the diabetes mellitus clinical team from clinic he was on steroids intraoperatively and postoperatively but on a fairly rapid taper and was almost off the decadron at the time of discharge he was getting mg twice per day at that point in time hospital course following admission the patient was immediately taken to the operating room where the left anterior temporal meningioma was removed without complication it was quite vascular as expected but good hemostasis was achieved and maintained because of his preoperative hematocrit he did require transfusion to try to keep him with the optimum red blood count considering his serious coronary problems in the past his mental status was one of some confusion and confabulation initially particularly at night but this cleared considerably by the time of discharge he was able to ambulate with assistance of a walker he still had a hearing deficit postoperatively his naming of objects improved considerably over the course of his hospitalization he still had his greatest problem with proper nouns otherwise he was quite well oriented his neurologic exam showed no focal deficits final discharge diagnoses left temporal meningioma epilepsy secondary to diagnosis number one hypertension coronary artery disease insulin dependent diabetes mellitus hypercholesterolemia discharge status approved disposition discharged home with follow up appointments to be arranged m d dictated by medquist d t job,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-14"",
""service"" : ""NEUROSURGERY"",
""history_of_present_illness"" : ""this year old man had developed imbalance with difficulty in word finding and verbal memory and had become somewhat reticent and depressed he was having absence type seizures frequently at night he was found to have a cm meningioma in the left anterior was made to carry out definitive surgery with a left sided craniotomy at this time the problem was complicated by his history of coronary artery disease and insulin dependent diabetes mellitus which was poorly controlled he was evaluated by cardiology with an angioplasty of a stent placement the week prior to his ad"
11040,admission date discharge date service history of present illness the patient is an year old greek man who presented to the emergency room with an episode of large volume coffee ground emesis immediately following his dinner he brought a sample of the emesis which was hemoccult positive the patient also mentioned that he had he had no emesis once he got to the emergency room and he states this never happened to him before he does occasionally take pepcid but not chronically he has no history of liver disease or alcoholism he does have a history of breast cancer which was resected ten years ago and without recurrence the patient also noted decrease in feeling well for the last one to two weeks no change in his stool to a darker color over the past few weeks the son did state that his father appeared to have lost some weight the patient denied any dizziness but had noted some fatigue he had no chest pain epigastric or abdominal pain no nausea short of breath no fever or chills he did have a upper respiratory infection three weeks ago no other symptoms past medical history coronary artery disease status post percutaneous transluminal coronary angioplasty greater than years ago type ii diabetes mellitus breast cancer status post surgery ten years ago on the right allergies no known drug allergies medications enteric coated aspirin q day accupril mg q day amaril mg twice a day social history the patient is a retired shoemaker he drinks occasional wine he lives with his son in the sons name is quit smoking years ago he has an active lifestyle family history no history of cancer physical examination the patient was afebrile at degrees heart rate of blood pressure of respiratory rate of oxygen saturation of on room air on general exam he was alert and oriented but pale in no apparent distress head eyes ears nose and throat exam showed normocephalic atraumatic head with pupils being equal round and reactive his extraocular movements intact his oropharynx was dry neck was supple with no thyromegaly and no lymphadenopathy no jugular venous distention his heart was regular rate and rhythm with a systolic diastolic murmur at the right upper sternal border and normal s and s his lungs were clear to auscultation bilateral his back showed no spinal tenderness and no cvat his abdomen was nondistended nontender with hyperactive bowel sounds his liver span was about cm not palpable below the costal margin he had no splenomegaly or tenderness no caput medusa per the emergency room he was guaiac positive with brown stool his extremities showed no cyanosis clubbing or edema radials and dorsalis pedis pulses bilateral neurologic exam his cranial nerves through were intact his motor and sensory examination was grossly intact his deep tendon reflexes were and symmetrical skin showed no erythema pale mucosa no spider angiomata were appreciated laboratory the patient s white blood count was with a hematocrit of over baseline of to in and platelets of sodium was potassium chloride bicarbonate bun and creatinine electrocardiogram showed normal sinus rhythm at with normal axis normal intervals and t wave inversion in avr as well as q s in v through v tall r s in v hospital course the patient was admitted to the micu initially for workup of an upper gastrointestinal bleed he was transfused a total of three units of packed red blood cells with good results he had no further episodes of hematemesis and his stool was brown throughout the hospitalization given the low hematocrit and the patient s history of coronary artery disease he was ruled out for myocardial infarction with cks of and and troponin s less than each time on the patient underwent a esophagogastroduodenoscopy which showed a single crater of cm ulcer in the stomach body lesser curvature with thickened edematous edges and stigmata of recent bleeding although no blood was seen in the stomach or duodenum cold forceps biopsies were taken both for histology and for h pylori otherwise the patient s esophagogastroduodenoscopy was normal to the second part of the duodenum the patient s non steroidal anti inflammatory drugs were stopped and these were not restarted he was started on twice a day protonix the patient did well in the intensive care unit and was sent out to the general medical floor in good condition on he was hemodynamically stable his hematocrit was stable in the range the patient did well but on the night of noted acute sudden onset of pain in his right first metatarsal pharyngeal joint felt to be most consistent with gout rheumatology consult was called who agreed this most likely represented an episode of gout given that the patient had no history of prior gout they did not feel that long term treatment with allopurinol was warranted at this time given the fact that the patient could not be started on non steroidal anti inflammatory drugs or systemic steroids and that colchicine with its gastrointestinal toxicity should also be avoided at this time the rheumatology service injected the metatarsal phalangeal joint with mg of depo medrol with good effect the patient s pain actually improved overnight he was also given ultram and tylenol for pain and he was discharged with prescriptions for these medications the physical therapy service walked with the patient and did not feel the patient needed any further intervention and he was able to walk well for follow up for the gastrointestinal issues the patient was scheduled for gastrointestinal follow up with the gastrointestinal service on and the patient was discharged to home in good condition on with the biopsy result and h pylori results still pending following discharge the h pylori antibody titer came back as negative later that day the gastrointestinal service notified the primary team that biopsy of the stomach ulcer showed poorly differentiated adenocarcinoma the patient has already had a scheduled follow up with gastrointestinal on which is one week after discharge the patient s pcp salamis was contact with this diagnosis and he will contact the patient and set up him up with outpatient oncology follow up likely at and decisions for further care can be made at that time discharge condition good discharge status full code medications on discharge protonix mg twice a day accupril mg q day amaril mg twice a day ultram mg p o q to hours p r n for pain discharge diagnosis upper gastrointestinal bleed secondary to stomach ulcer from poorly differentiated gastric adenocarcinoma see past medical history md dictated by medquist d t job cc,"[
""admission_date"" : ""2140-10-10"",
""discharge_date"" : ""2140-10-11"",
""service"" : ""HOSPITAL WARD"",
""allergies"" : [
""Penicillins""
],
""attending_doctor"" : ""JOHN SMITH"",
""chief_complaint"" : ""vomiting"",
""history_of_present_illness"" : ""This is a 71 year old man with a history of breast cancer who presented to the emergency room with an episode of large volume coffee ground emesis immediately following his dinner.  He brought a sample of the emesis which was hemoccult positive.  He also mentioned that he had no emesis once he got to the emergency room and he states this never happened to him before."
78533,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint m s p mechanical fall last night went to ed for right orbital laceration but did not stay for head ct as one hour wait this am was going back for ct but became very lethargic comes to ed with large acute sdh on ct with effacement of ventricle and midline shift major surgical or invasive procedure left craniotomy for sdh history of present illness m s p mechanical fall the night before admission went to ed for right orbital laceration but did not stay for head ct due to the one hour wait time the morning of admission he was going to get his ct scan but became very lethargic he came to ed with large acute sdh that was found on ct with effacement of ventricle and midline shift past medical history pericarditis dm sleep apnea high chol left leg cellulitis social history lives in with wife works real estate family history nc physical exam exam upon admission gen obese in hard collar examined in ed heent pupils bilat extrem warm and well perfused neuro lethargic snoring tries to open eyes to voice but could not did follow commands with left upper and bilat lower extremeties non verbal motor normal bulk and tone bilaterally no abnormal movements tremors right upper ext appears weaker than left but was antigravity spontaneously no pronator drift appreciated on left unable to assess on right sensation intact to light touch pertinent results ct head there is a large approximately mm left subdural hematoma this is causing significant mass effect and midline shift of mm there is subfalcine herniation there are periventricular ischemic changes along with small old lacunar infarct there is no skull fracture there is mild mucosal thickening in the ethmoid sinuses conclusion large left subdural hematoma with significant midline shift as described echo the left atrium is mildly dilated left ventricular wall thickness cavity size and global systolic function are normal lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded tissue doppler imaging suggests a normal left ventricular filling pressure pcwp mmhg there is abnormal septal motion position the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be determined there is an anterior space which most likely represents a fat pad impression suboptimal image quality normal biventricular cavity sizes with preserved global biventricular systolic function dilated ascending aorta ct head findings again noted are post operative changes related to the evacuation of the left sided subdural hematoma there is no significant change in the size of the left temporal intraparenchymal hematoma as well as subdural hematoma noted along the left occipital region there is no significant change in the surrounding edema and the mass effect on the left lateral ventricle and possible uncal herniation on the left side effacement of the left side of the perimesencephalic cistern is again seen there is no evidence of cerebellar tonsillar herniation mild shift of the midline structures to the right side is unchanged no new areas of hemorrhage are noted impression no significant change in the post operative changes left temporal hematoma and left occipital subdural hematoma along with surrounding edema mass effect on the left lateral ventricle and left sided uncal herniation small amount of fluid in the sphenoid sinus and the left maxillary sinus and ethmoid air cells are noted and new brief hospital course pt was taken emergently to the or on the date of admission for a left sided craniotomy for sdh evacuation he was extubated post operatively on pod he had a mucus plug in the icu leading to a respiratory arrest and subsequent asystolic event and re intubation cardiology consult was obtained there was no indication of a myocardial infarction rather the arrest was due to his respiratory status on there was a family meeting in which they decided they would like to rehab for the patient he had a trach and peg on and was screened for rehab the patient s exam was slightly improved that day he was opening his eyes and tracking the examiner he moved spontaneously but did not follow commands while in the icu the patient removed peg tube and required tpn for days after bowel rest he was again fed by ngt dophoff he pulled several of these out he was able to be transferred to the stepdown unit a few days prior to discharge speech and swallow evaluated him and recommended a modified diet he therefore does not need a peg at this time he is currently on a trach mask and requiring infrequent suctioning secretions are pink tinged at times however he is able to clear his airway effectively the patient was evaluated by pt and ot who recommended rehab he was discharged to rehab in the afternoon on medications on admission lipitor metformin er lasix asa discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed docusate sodium mg ml liquid sig one po bid times a day heparin porcine unit ml solution sig one injection tid times a day senna mg tablet sig one tablet po bid times a day as needed atorvastatin mg tablet sig one tablet po daily daily nystatin unit ml suspension sig five ml po qid times a day as needed albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed acetaminophen mg tablet sig one tablet po q h every hours as needed for fever white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed docusate sodium mg ml liquid sig one po bid times a day heparin porcine unit ml solution sig one injection tid times a day senna mg tablet sig one tablet po bid times a day as needed white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed levetiracetam mg tablet sig two tablet po bid times a day insulin regular human subcutaneous meropenem mg recon soln sig one recon soln intravenous q h every hours end vancomycin in dextrose gram ml piggyback sig one intravenous q h every hours end date furosemide mg ml solution sig one injection daily daily metoprolol tartrate mg ml solution sig one intravenous q prn as needed for sytstolic over discharge disposition extended care facility discharge diagnosis acute sdh resp failure respiratory arrest cardiac arrest coma hemiparesis anemia protein calorie deficiency discharge condition neurologically stable discharge instructions general instructions take your pain medicine as prescribed exercise should be limited to walking no lifting straining or excessive bending increase your intake of fluids and fiber as narcotic pain medicine can cause constipation we generally recommend taking an over the counter stool softener such as docusate colace while taking narcotic pain medication unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil or ibuprofen etc please check with your physician to see when you can resume your asprin if you have been prescribed dilantin phenytoin for anti seizure medicine take it as prescribed and follow up with laboratory blood drawing in one week this can be drawn at your pcp s office but please have the results faxed to if you have been discharged on keppra levetiracetam you will not require blood work monitoring call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion lethargy or change in mental status any numbness tingling weakness in your extremities pain or headache that is continually increasing or not relieved by pain medication new onset of the loss of function or decrease of function on one whole side of your body followup instructions follow up appointment instructions please call to schedule an appointment with dr to be seen in weeks you will need a ct scan of the brain without contrast prior to your appointment this can be scheduled when you call to make your office visit appointment completed by,"[
""admission_date"" : ""2019-12-10"",
""discharge_date"" : ""2019-12-12"",
""date_of_birth"" : ""2047-1-1"",
""sex"" : ""Male"",
""service"" : ""Neurosurgery"",
""allergies"" : [
""Patient recorded as having no known allergies to drugs.""
],
""attending_chief_complaint"" : ""Ms. P mechanical fall"",
""chief_complaint"" : ""Ms. P mechanical fall"",
""history_of_present_illness"" : [
""Ms. P mechanical fall the night before admission went to ED for right orbital laceration but did not stay for head CT as one hour wait this am was going"
74482,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint dyspnea on exertion major surgical or invasive procedure none history of present illness y o female with asthma htn hld critical as and chf who presented for valvuloplasty now transferred to ccu for elective intubation prior to valvuloplasty per admission note patient remarks that she has had progressive dyspnea on exertion over the last few years she was offered surgical avr in but declined she states that she is now symptomatic with minimal exertion only able to walk several feet without becoming severely short of breath she has never had a syncopal event but states that she does become lightheaded at times she denies any chest pain she notes that her legs have become very edematous recently she denies any orthopnea or pnd overnight patient was given mg iv lasix and states that her breathing improved after patient transferred to ccu for elective intubation prior to valvuloplasty in the ccu patient notes improved breathing without chest pain or other symptoms on review of systems she denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools she denies recent fevers chills or rigors she denies exertional buttock or calf pain all of the other review of systems were negative past medical history cardiac risk factors hypertension hyperlipidemia cardiac history critical aortic stenosis severe two vessel cad s p nstemi congestive heart failure other past medical history pulmonary hypertension asthma anemia depression h o right leg fracture s p orif s p knee replacement social history lives at nursing home limited ambulation daughter supportive lives about min away retired from clerical work denies alcohol and tobacco family history mother died at age and father died at from heart disease physical exam on admission vs afebrile bp hr rr so ra general comfortable at rest aaox heent ncat mmm neck jvp at cm cardiac pmi laterally displaced rrr diffuse sem iii vi loudest at rusb audible s and s lungs unlabored respirations no accessory muscle use scant crackles at the bases abdomen s nt nd bs extremities bilateral lower extremity edema skin no stasis dermatitis ulcers scars or xanthomas pulses right dp pt left dp pt on discharge vs tmax t current hr rr bp o sat l np gen sleeping comfortably nad heent mmm supple jvd at cm cv rrr iii iv murmur at rusb resp ctab no wheezing or rales abd s nt nd bs extr peripheral edema distal pulses neuro a o pertinent results admission labs wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap calcium phos mg discharge labs wbc rbc hgb hct mcv mch mchc rdw plt ct wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap calcium phos mg other results ct c a p results pending dipyridamole stress test impression no anginal type symptoms or ischemic ekg changes nuclear report sent separtely cardiac perfusion persantine impression fixed moderate sized perfusion defect in the apical inferior wall global hypokinesis with depressed ejection fraction and chamber enlargement cardiac ultrasound impression less than stenosis of the bilateral extracranial internal carotid arteries ekg sinus normal axis pr prolongation interventricular conduction delay lvh twi v v with flattening in v v compared to prior t wave flattening and inversion new tte impression critical aortic valve stenosis cm symmetric left ventricular hypertrophy with regional systolic dysfunction c w multivessel cad moderate pulmonary artery systolic hypertension at least moderate mitral regurgitation increased pcwp pcwp mmhg dilated ascending aorta compared with the prior study images reviewed of regional and global left ventricular systolic function is now depressed and the severity of aortic regurgitation and estimated pulmonary artery systolic pressure have increased the severity of aortic valve stenosis and mitral regurgitation are similar ct chest severe dense calcification of the aortic valve all major coronary vessels and mitral annulus atherosclerotic calcification involving the ascending aorta arch and descending aorta mild dilatation of the ascending aorta measuring cm brief hospital course y o female with asthma htn hld critical as and chf who presented for elective valvuloplasty active issues critical as pt presented for corevalve procedure however due to pt s significant ar safety of procedure was called into question until further evaluation could be completed geriatrics was consulted and carefully reviewed risks benefits of procedure pt continued to make clear that she was aware of the potential risks and would still like to undergo a procedure to fix her valve pt had complete evaluation during hospitalization including carotid ultrasound persantine perfusion scan dipyridamole stress test and ct chest abdomen pelvis results of studies will be presented to corevalve board to determine her eligibility for study participation acute exacerbation of chronic systolic heart failure on admission to hospital pt was edematous and weighed pounds over baseline to improve pt s condition for procedure pt was aggressively diuresed over the course of her hospital stay with iv lasix her volume status was followed by serial exams to determine efficacy of diuresis pt was then re started on her home dose of mg po lasix daily and remained euvolemic pt was not started on beta blocker during hospitalization given low heart rate of ace inhibitors were also held given patient s renal status and decreased creatinine clearance chronic issues anxiety frequent episodes of anxiety were relieved by pt s home regimen of xanax cad s p nstemi stable continued pt s home regimen of asa mg po daily isosorbide mononitrate mg po daily and started rosuvastatin mg po daily beta blockers were held because of bradycardia asthma stable continued pt s home regimen of fluticasone salmeterol advair diskus puffs inh montelukast singulair mg po daily and fluticasone spray nu daily for allergies depression stable continued pt s escitalopram mg po daily anemia hct remained stable transitional issues pt will be discharged back to residential nursing home she will be contact by dr once her eligibility for the corevalve trial has been established she must be compliant with diet and diuretics to remain euvolemic should she be deemed eligible it is very important that she be weighed daily as her diuretic regimen has been increased medications on admission escitalopram mg po daily rehab list says mg but pharmacy says geriatric dose shouldn t exceed mg fluticasone spray nu daily fluticasone salmeterol mg mg advair diskus puffs inh isosorbide mononitrate mg po daily montelukast singulair mg po daily potassium chloride meq po daily rosuvastatin mg po daily not on rehab list simvastatin mg po daily is on rehab list spironolactone aldactazide mg mg po daily not on rehab list ascorbic acid mg po daily aspirin mg po daily per rehab list home list states mg vitamin e units po daily lasix mg po daily has been receiving lasix mg po for last three days multivitamin tab po daily trazodone mg po qhs xanax mg po bid discharge medications escitalopram mg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig one spray nasal daily daily fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day isosorbide mononitrate mg tablet extended release hr sig one tablet extended release hr po daily daily montelukast mg tablet sig one tablet po daily daily spironolactone mg tablet sig tablet po daily daily ascorbic acid mg tablet sig one tablet po once a day aspirin mg tablet chewable sig one tablet chewable po daily daily furosemide mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po once a day rosuvastatin mg tablet sig one tablet po daily daily alprazolam mg tablet sig one tablet po bid times a day as needed for anxiety trazodone mg tablet sig one tablet po hs at bedtime as needed for insomnia senna mg tablet sig one tablet po hs at bedtime as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day pt may refuse acetaminophen mg tablet sig two tablet po q h every hours as needed for pain or fever outpatient lab work please check cbc and chem on thursday discharge disposition extended care facility at discharge diagnosis primary diagnosis acute on chronic systolic congestive heart failure no ace inhibitors because of aortic stenosis aortic stenosis aortic regurgitation secondary diagnosis asthma coronary artery disease anemia anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions it was a pleasure taking care of you at you were admitted to for a valvuloplasty that would improve the function of your heart valve it was found that this was not an appropriate procedure for you so we have started the evaluation for a percutaneous aortic valve replacement called a corevalve procedure you underwent an imaging study to see if you were eligible for this procedure a stress test showed that although you have some blockages in your coronary arteries you are not at risk for a heart attack now and do not need any procedures to fix this a ct scan of your chest was done results are pending at this time dr or will be in touch to arrange for further care also please weigh yourself every morning call dr if weight goes up more than lbs in day or pounds in days the following medication changes were made during your hospital stay decrease lexapro to mg daily dosage for elderly people should be no more than mg stop potassium and vitamin e for now start spironolactone mg for your congestive heart failure and to help with the shortness of breath start senna and colace to prevent constipation decrease aspirin to mg daily start tylenol as needed for pain increase lasix to mg daily followup instructions dr or np will contact you about a follow up appointment completed by [NEW_RECORD] admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint corevalve placement major surgical or invasive procedure corevalve placement repeat right and left heart catheterization temporary pacemaker placement history of present illness year old caucasian female with cad nstemi pulmonary htn and known critical aortic stenosis aova cm ef now symptomatic with increasing chest pain sob and dizziness patient had been seen in and declined surgical intervention at that time she was also admitted for chf exacerbation lbs over her baseline in and considered for valvuloplasty however this was not done due to concerns regarding significant aortic regurgitation she underwent a complete evaluation for tavi during the stay including carotid ultrasound presantine perfusion scan dipyridamole stress and ct of the chest abdomen and pelvis recently the patient has been experiencing decline in her functional status due to worsening sob and lightheadedness and is limited to walking to the bathroom adapted from aortic valve service history physical at baseline patient has a history of anxiety nyha class iii aortic valve replacement was uneventful and the lvedp was measured at the patient required units of prbcs upon arriving to the floor patient became acutely dyspnic gasping for breath with saturations in the mid s simultaneously the patient had increased blood pressures measured at s s by arterial line initial abg was drawn and demonstrated ph pco po an urgent chest x ray demonstrated acute pulmonary edema with no evidence of pneumothorax and was treated with mg lasix iv echo showed ar mr and mild paravalvular leak patient was given albuterol and ipratropium nebulizer treatments followed by mg methylprednisolone and patient was put on a non rebreather mask patient was also given mg morphine sulfate mg lorazepam repeat abg demonstrated increasing academia and hypercarbia and patient was transitioned to bipap repeat abg after minutes of bipap showed and patient was weaned off the bipap past medical history cardiac risk factors hypertension hyperlipidemia cardiac history critical aortic stenosis severe two vessel cad s p nstemi congestive heart failure other past medical history pulmonary hypertension asthma anemia depression h o right leg fracture s p orif s p knee replacement social history lives at nursing home limited ambulation daughter supportive lives about min away retired from clerical work denies alcohol and tobacco family history mother died at age and father died at from heart disease physical exam admisson exam tmax c f hr bpm bp mmhg rr insp min spo heent nc at sclera anicteric mmm pupils dilated jvp unable to assess with pacing wire in right neck but appears flat on left lungs patient is gasping for air with labored breathing upper airway sounds present with poor air movement cardiac tachycardic with no murmurs heard abdomen soft non tender non distended positive bowel sounds extremities no edema pulses dp pt no edema discharge exam general comfortable in no acute distress heent perrla no pharyngeal erythemia mucous membs moist no lymphadenopathy jvp non elevated right next with mod bruising and cm hematoma from large central line that is slowly resolving chest ctabl no wheezes no rales no rhonchi at bases cv s s nl systolic murmur at rusb abd soft non tender non distended bs normoactive no rebound guarding ext wwp no edema dps pts neuro cns ii xii intact strength in u l extremities dtrs bl biceps achilles patellar skin no rash pertinent results admission labs pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk sm pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt pm albumin calcium pm ck mb probnp pm alt sgpt ast sgot ck cpk alk phos tot bili discharge labs pertinent studies tte the left atrium is dilated overall left ventricular systolic function is mildly depressed with basal inferior and basal to mid lateral hypokinesis lvef right ventricular chamber size and free wall motion are normal an aortic corevalve prosthesis is present the transaortic gradient is normal for this prosthesis moderate aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is a very small pericardial effusion there are no echocardiographic signs of tamponade tte the left atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild regional left ventricular systolic dysfunction with focal inferior and basal to mid inferolateral hypokinesis the remaining segments contract normally lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg right ventricular chamber size is mildly dilated and free wall motion is normal the diameters of aorta at the sinus ascending and arch levels are normal an aortic corevalve prosthesis is present the transaortic gradient is higher than expected for this type of prosthesis moderate aortic regurgitation is seen the aortic regurgitation jet is eccentric the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion compared with the prior study images reviewed of the severity of tricuspid and mitral regurgitation have increased the trans corevalve gradient is higher while the severity of aortic regurgitation is unchanged pericardial effusion is smaller the right ventricle appears mildly dilated tte overall left ventricular systolic function is mildly depressed lvef there is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats right ventricular chamber size is normal with borderline normal free wall function an aortic corevalve prosthesis is present the transaortic gradient is higher than expected for this type of prosthesis a paravalvular aortic valve leak is present mild to moderate aortic regurgitation is seen the aortic regurgitation jet is eccentric moderate mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a trivial physiologic pericardial effusion cardiac cath elevated lvedp mild to moderate aortic insufficiency no gradient across the corevalve no aortic stenosis mild to moderate pulmonary hypertension from diastolic dysfunction brief hospital course primary reason for admission year old caucasian female with cad nstemi pulmonary htn and known critical aortic stenosis aova cm ef s p corevalve active diagnoses corevalve patient s perioperative course was complicated by flash pulmonary edema after units prbcs in the cath lab she was treated with diuresis and bipap with succesful weaning onto nasal canula hours after placement echo demonstrated high trans gradients and continued aortic regurgitation the picture was complicated by decreased maps below and urine output to cc h and creatinine increasing to patient was clinically stable throughout with no further episodes of dyspnea patient was started on dopamine drip at mcg kg min with increase in uop and maps above on reassessment in cath lab with pcwp was mmhg and the pa systolic pressure was mmhg the ra pressure was the lved was mmhg due to diastolic dysfunction and unchanged from pre and there was a minimal trans aortic gradient patient began to clinically improve with activity around the ccu including walking she was weaned of the dopamine gtt subsequent tte showed continued ar but the patient remained stable and was transferred to the floor and then rehab wenchibach with persistent bradycardia likely etiolgy is sick sinus syndrome patient was evaluated by ep team with decision made to not place a pace maker cad patient was continued on aspirin mg daily plavix mg daily and crestor mg daily she was not on bb secondary to sinus bradycardia asthma pt was continued on fluticasone salmeterol diskus and montelukast mg daily chf furosemide mg was started within hours of corevalve placement with spironolactone hctz was discontinued she was started on lisinopril mg day during this admission geriatric care pt was continued on home trazadone for sleep throughout her course she intermittently required benzos for anxiety which she tolerated well anxiety insomnia we continued home escitalopram and trazadone trazodone was briefly discontinued due to prolongation of qt on one ekg but was restarted with no incident medications on admission medications prescription alprazolam mg tablet one tablet s by mouth twice daily escitalopram lexapro prescribed by other provider mg tablet tablet s by mouth once a day fluticasone flonase prescribed by other provider dosage uncertain fluticasone salmeterol advair diskus prescribed by other provider dosage uncertain furosemide mg tablet one tablet s by mouth daily isosorbide mononitrate prescribed by other provider mg tablet extended release hr one tablet s by mouth once a day montelukast singulair prescribed by other provider mg tablet tablet s by mouth once a day rosuvastatin crestor prescribed by other provider mg tablet one tablet s by mouth once a day spironolacton hydrochlorothiaz aldactazide prescribed by other provider mg mg tablet tablet s by mouth once a day trazodone mg tablet one tablet s by mouth at bedtime medications otc ascorbic acid vitamin c prescribed by other provider mg tablet tablet s by mouth once a day aspirin prescribed by other provider otc mg tablet chewable tablet s by mouth once a day vitamin e prescribed by other provider unit capsule capsule s by mouth once a day discharge medications clopidogrel mg tablet sig one tablet po daily daily lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety escitalopram mg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig two spray nasal daily daily fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day furosemide mg tablet sig one tablet po daily daily montelukast mg tablet sig one tablet po daily daily rosuvastatin mg tablet sig one tablet po daily daily trazodone mg tablet sig one tablet po hs at bedtime aspirin mg tablet chewable sig one tablet chewable po daily daily lisinopril mg tablet sig one tablet po daily daily discharge disposition extended care facility at discharge diagnosis critical aortic stenosis coronary artery disease systolic congestive heart failure hypertension anemia bradycardia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions you had a percutaneous replacement of your aortic valve the procedure went well and the valve is functioning appropriately you had some slow heart rhythms after the procedure that has now resolved we expect that the shortness of breath with gradually improve over the next month weigh yourself every morning call dr if weight goes up more than lbs in day or pounds in days we made the following changes to your medicines stop taking imdur aldactazide vitamin c and vitamin e start lisinopril to help your heart pump better change aprazolam to lorazepam to treat your anxiety followup instructions department cardiac services when friday at pm with md building sc clinical ctr campus east best parking garage department cardiac services when friday at am with echocardiogram building sc clinical ctr campus east best parking garage,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""1953-12-15"",
""sex"": ""F"",
""service"": ""Medicine"",
""admission date"": ""2019-12-16"",
""discharge date"": ""2019-12-20"",
""service date"": ""2019-12-16"",
""chief complaint"": ""Dyspnea on exertion"",
""history of present illness"": ""Female with asthma, HTN, HLD, critical as and CHF who presented for valvuloplasty now transferred to CCU for elective intubation prior to valvuloplasty per admission note.  Patient remarks that she has had progressive"
42430,admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint code stroke l sided weakness major surgical or invasive procedure intubated history of present illness cc code stroke l sided weakness code activated pm patient examined pm nihss best gaze forced to r visual complete l hemianopia facial palsy partial on l motor l arm l leg sensory severe total loss on l dysarthria mild dysarthria extinction profound inattention to l side total hpi patient is a yo rhm with afib but not on coumadin htn dm and hx of stroke over years ago with some residual l sided weakness who was found down per vna at pm with l slurred speech and l sided weakness per report he was taken by ambulance to where his initial bp was extremely elevated with sbp into s for which he was given labetalol x head ct was negative for hemorrhage then patient was transferred to for further care per patient he woke up around am and ate breakfast which was delivered per meals on wheels he did not speak to anybody he lives alone and ambulates with a walker and reports to have vna once or twice weekly he then fell around am he is unable to recall why he fell but he thinks he may have tripped but he could not get up hence was on the floor until vna found him at pm he denies any recent illness fever cough n v d or ha he reports to be smoking as much as possible ppd which he has been doing over years and not taking any of his meds he reports to have not taken any meds for over months at least however per who is also his hcp she reports that his meds are overseen per vna hence he may be more compliant than he reports also she recalls that when she accompanied him to his pcp appt about months ago his pcp may have told him that he can take asa instead of coumadin for his afib of note patient was in nursing home about weeks ago for pt and rehab after vascular surgery for rle artery occlusion past medical history stroke over yrs ago initially could not move l side talk or walk per patient afib htn dm oral only s p abdominal surgery to remove tumor pvd s p bypass surgery in rle s p cataract repair bilaterally social history lives alone with weekly vna for assistance and has meals delivered per meals on wheels walks with walker at baseline and does not leave the house much reports to smoke as much as possible ppd for the past years divorced and has grown children out in west coast nearest and hcp is in full code confirmed per hcp family history nc physical exam exam t bp hr rr o sat l nc gen lying in bed disheveled appearing yo man heent no teeth does not wear dentures per patient neck no carotid or vertebral bruit cv irregularly irregular but difficult to auscultate due to very faint heart sounds lung clear anteriorly abd well healed abdominal scar with ventral hernia reducible bs soft and nontender ext no edema scar over r interior thigh neurologic examination mental status awake and alert cooperative with exam normal affect oriented to person place and month fluent speech with mild dysarthria no dysnomia with high frequency words and intact repetition cranial nerves ii r pupil slightly larger than l and more asymmetric s p bilateral cataract both are reactive but l more brisk than r no blinking to visual threat on l iii iv vi forced deviation to r v decreased sensation on l to lt and pp vii l facial droop viii hearing intact to finger rub bilaterally x palate elevation symmetrical xii tongue midline motor normal bulk slightly higher tone on l than r and more on lue than lle no adventitious movements unable to move l side but appears full strength on r withdraws to noxious stim on l but not anti gravity sensation intact to light touch pinprick and cold on r but decreased near total absence on l body although intact to noxious stim reflexes for lue and for rue none for patellar or achilles in either lower legs toes upgoing bilaterally pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood ck mb notdone ctropnt am blood calcium phos mg am blood calcium phos mg am blood triglyc hdl chol hd ldlcalc am blood tsh echo the left atrium is dilated the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is moderately depressed lvef secondary to hypokinesis of the inferior septum and akinesis of the inferior free wall and posterior wall the basal inferior and posterior walls are thin and fibrotic there is no ventricular septal defect right ventricular chamber size is normal with depressed free wall contractility the aortic valve leaflets are mildly thickened there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened the supporting structures of the tricuspid valve are thickened fibrotic moderate tricuspid regurgitation is seen the tricuspid regurgitation jet is eccentric and may be underestimated there is moderate pulmonary artery systolic hypertension there is no pericardial effusion cta head and neck and perfusion impression likely embolic occlusion of the m segment of the right middle cerebral artery with perfusion findings of infarct involving virtually the entire right mca distribution just over stenosis of the proximal left common carotid artery moderate atherosclerotic disease at the carotid bifurcations bilaterally with likely an ulcerated plaque involving the proximal right external carotid artery and extensive soft plaque within the carotid bulb on the right mm nodular soft tissue density within the left paraglottic fat may be a lymph node but is of unclear etiology and should be correlated with clinical findings and or direct visualization associated mild thickening of the lingual tonsils glossoepiglottic fold and anterior surface of the epiglottis extensive degenerative changes of the cervical spine severe atrophy and evidence of old cortical embolic infarcts extensive chronic microvascular ischemic change ct head impression evolving acute and virtual complete right middle cerebral artery territory infarction with hemorrhagic transformation and extension of the hemorrhage into the right lateral and third ventricles layering in bilateral occipital horns significant leftward shift of midline structures with marked subfalcine herniation and less marked uncal herniation comment a wet read was also provided on at and dr was notified of the results at on the study and the report were reviewed by the staff radiologist brief hospital course the patient is a yo rhm with afib not on coumadin but possibly asa htn dm and hx of stroke with some residual l sided weakness who smokes ppd found per vna at home down on the floor with slurred speech and l sided weakness around pm patient initially presented to ed then transferred here for further care patient seen and examined pm hrs after presumed onset of symptoms his initial nihss score was for r gaze deviation l sided weakness and sensory deficit his ct of head shows dense r mca with likely m level occlusion and loss of white matter differentiation over the distribution his inr was but patient reports not to have taken meds including coumadin for possibly over months the patient was admitted to the neurology icu for further care he was initially started on a heparin drip but follow up ct scan showed a large size of infarct and it was determined that the risk of bleeding outweighed the benefits of heparin in addition the patient had an episode of emesis and possible aspiration on the patient was less esponsive to commands and was tachypneic a cxr showed a worsening infiltrate in the right lower lobe his respiratory status worsened and he required intubation later in the afternoon the patient was found to have an fixed and dilated right pupil a head ct was obtained showing a large hemorrhagic coversion the bleed was catastrophic and the patient had negative brainstem reflexes by the time he returned from the scan the patient was terminally extubated on the prognosis was discussed in detail and he was extubated he expired on medications on admission has not taken any meds over months per patient metoprolol coumadin asa metformin discharge medications none discharge disposition expired discharge diagnosis right middle cerebral artery stroke discharge condition expired discharge instructions you were admitted with left sided weakness and slurring of your speech you were found to have a large stroke on the right side of your brain this was likley a blood clot from your heart as a result of your irregular heart beat and not taking a blood thinning you also had an episode were you vomitted and likely aspirated requiring you to be started on antibiotics and intubated followup instructions none,"[
""admission_date"" : ""2022-10-14"",
""discharge_date"" : ""2022-10-17"",
""date_of_birth"" : ""2030-1-1"",
""sex"" : ""Male"",
""service"" : ""Neurology"",
""allergies"" : [
""Patient recorded as having no known allergies to drugs.""
],
""attending_chief_complaint_code"" : ""Stroke-L sided weakness"",
""admission_chief_complaint"" : ""L sided weakness"",
""history_of_present_illness"" : ""Patient is a yo RHM with afib but not on coumadin Htn DM and hx of stroke over years ago with some residual L"
48821,admission date discharge date date of birth sex m service cardiothoracic allergies amiodarone attending chief complaint chest pain major surgical or invasive procedure cabg x lima lad svg diag svg pda history of present illness mr is a year old gentleman with a complex medical history that is relevant for known coronary artery disease his last coronary angiogram in showed a total occlusion of the right coronary artery a stenosis of the left circumflex artery with significant left anterior descending disease a past attempt in was made to intervene on the left anterior decending artery however the intervention was unsuccessful of note he has a heavily calcified aorta and his last cardiac catheterization was complicated by embolic disease to his kidneys and lower extremities recently he has been having worsening episodes of angina which occur daily and require daily nitroglycerin he is also dyspneic with minimal activity his chest pain is always relieved with nitroglycerin however it can occur at rest he has not had a recent cardiac cathterization given the risk associated with the procedure in regards to his aortic atherosclerotic disease he presents today to discuss high risk surgical options versus percutaneous intervention given his decompensated state and poor quality of life past medical history past medical history coronary artery disease peripheral vascular disease significant claudication carotid disease with occluded left carotid artery renal artery stenosis s p prior left renal artery stent in in end stage renal disease on hemodialysis tuesdays fridays creat complex aortic atheroma hyperlipidemia atrial fibrillation with sick sinus syndrome status post permanent pacemaker in complicated by subsequent amiodarone toxicity history of cholesterol embolization syndrome hypothyroid congestive heart failure pneumonia currently uses oxygen to sleep and as needed during day likely diabetes in setting of elevated triglycerides and fasting glucose past surgical history ppm placement for sick sinus syndrome abdominal port placement av fistula placement with history of multiple peritoneal dialysis procedures renal artery stent cholecystectomy cataract surgery partial right toe amputation failed angioplasty in social history race caucasian last dental exam once yearly lives with his family occupation retired tobacco denies tobacco use though significant second hand smoke from his wife s chronic smoking history etoh occasional alcohol family history family history significant for both brother and sister having coronary artery disease sister with cabg in her s physical exam pulse resp o sat ra b p right left av fistula height weight general wdwn in nad mildly pale skin warm dry and intact no clubbing or cyanosis heent perrla x eomi x sclera anicteric oropharynx benign teeth in fair repair neck supple x full rom x chest lungs clear bilaterally x heart no m r g ii vi systolic murmur abdomen soft x non distended x non tender x bowel sounds x well healed abdominal incisions extremities warm x well perfused x trace le edema left upper extremity av fistula with good thrill left upper chest well healed pacer pocket varicosities slight varicosities noted below knee bilaterally along gsv tract neuro grossly intact pulses femoral right left dp pt weak palp left weakly palp radial right left carotid bruit right none appreciated left high pitched bruit pertinent results admission am urine rbc wbc bacteria yeast none epi am urine blood neg nitrite neg protein glucose ketone neg bilirubin neg urobilngn neg ph leuk neg am urine color straw appear clear sp am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am hba c eag am albumin calcium phosphate magnesium am lipase am alt sgpt ast sgot ld ldh alk phos amylase tot bili am glucose urea n creat sodium potassium chloride total co anion gap discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt inr pt am blood pt ptt inr pt am blood pt inr pt am blood glucose urean creat na k cl hco angap date time at interpret md md echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left atrium four chamber length cm cm right atrium four chamber length cm cm left ventricle septal wall thickness cm cm left ventricle inferolateral thickness cm cm left ventricle diastolic dimension cm cm left ventricle ejection fraction to left ventricle stroke volume ml beat left ventricle cardiac output l min left ventricle cardiac index l min m left ventricle lateral peak e m s m s left ventricle septal peak e m s m s left ventricle ratio e e aorta sinus level cm cm aortic valve peak velocity m sec m sec aortic valve lvot vti aortic valve lvot diam cm mitral valve e wave m sec mitral valve e wave deceleration time ms ms pulmonic valve peak velocity m sec m sec findings left pleural effusion seen left atrium moderate la enlargement right atrium interatrial septum moderately dilated ra a catheter or pacing wire is seen in the ra and extending into the rv normal interatrial septum no asd by d or color doppler left ventricle normal lv wall thickness normal lv cavity size mild global lv hypokinesis no resting lvot gradient no vsd right ventricle rv not well seen paradoxic septal motion consistent with prior cardiac surgery aorta normal aortic diameter at the sinus level aortic valve mildly thickened aortic valve leaflets no as mitral valve mildly thickened mitral valve leaflets no mvp no ms mild to moderate mr tricuspid valve mildly thickened tricuspid valve leaflets no ts moderate tr indeterminate pa systolic pressure pulmonic valve pulmonary artery no ps pericardium very small pericardial effusion no echocardiographic signs of tamponade general comments resting tachycardia hr bpm conclusions the left atrium is moderately dilated the right atrium is moderately dilated no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal there is mild global left ventricular hypokinesis lvef there is no ventricular septal defect the aortic valve leaflets are mildly thickened but aortic stenosis is not present the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild to moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a very small pericardial effusion there are no echocardiographic signs of tamponade electronically signed by md interpreting physician radiology report chest pa lat study date of pm chest pa lat clip medical condition year old man with cabg final report pa and lateral chest right ij line tip ends in the lower svc intact pacemaker leads terminate in the right atrium and in the right ventricle mediastinal wires are intact bilateral pleural effusion is unchanged moderate on the left and small on the right mild perihilar haziness and fluid in the minor fissure is consistent with mild fluid overload unchanged from prior study retrocardiac opacity on the left is unchanged there is no pneumothorax moderate cardiomegaly is stable the mediastinal and hilar contours are stable impression unchanged bilateral pleural effusion moderate on the left and small on the right moderate cardiomegaly and mild fluid overload are stable the study and the report were reviewed by the staff radiologist dr dr brief hospital course mr was admitted to for coronary bypass grafting he is a renal failure patient and was therefore admitted one day pre operatively for hemodialysis prior to his scheduled surgery on he was brought to the operating room where he had coronary bypass grafting x please see operative report for details in summary he had coronary artery bypass grafting x left internal mammary artery grafted to the left anterior descending reverse saphenous vein graft to the posterior descending artery and diagonal branch his bypass time was minutes with a crossclamp time of minutes he tolerated the operation well and was transferred to the cardiac surgery icu in stable condition he remained hemodynamically stable in the immediate post operative period and was extubated on the day of surgery he stayed in the cardiac surgery icu for an additional days for hemodynamica monitoring and pulmonary support on pod he was transferred to the floor for continued care once on the floor he worked with the nursing and physical therapy staff to advance his physical activity he was progressing nicely until pod when he had an episode of rapid atrial fibrillation associated with mild hypotension during his hemodialysis run he was treated with increased bblockers amiodarone was not used due to previous episode of amiodarone toxicity additionally he was restarted on his coumadin at his pre op dose he was brought back to the icu for observation overnight where he remained hemodynamically stable and the following day he returned to the stepdown floor the remainder of his hospital stay was uneventful on pod he was discharged home with visiting nurses he is to have followup with dr and with dr of vascular surgery medications on admission medications at home vitamin d mg daily fish oil mg daily imdur mg daily synthroid mcg daily lorazepam p r n protonix mg b i d atenolol mg one half tablet b i d diovan mg q a m sublingual nitroglycerin mg p r n lipitor mg daily coumadin mg as directed cardiology follows coumadin aspirin mg daily norvasc mg daily zolpidem mg qhs prn ntg sl prn discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills levothyroxine mcg tablet sig one tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills warfarin mg tablet sig as directed to keep inr tablets po once a day inr for afib dose as directed by cardiologist disp tablet s refills warfarin mg tablet sig one tablet po once a day for days doses then as directed by cardiologist disp tablet s refills discharge disposition home with service facility of s discharge diagnosis s p coronary artery bypass grafting x left internal mammary artery grafted to the left anterior descending reverse saphenous vein graft to the posterior descending artery and diagonal branch pmh coronary artery disease peripheral vascular disease occluded left carotid artery renal artery stenosis s p prior left renal artery stent hemodialysis tuesdays fridays creat complex aortic atheroma hyperlipidemia sss paf status post permanent pacemaker in complicated by subsequent amiodarone toxicity history of cholesterol embolization syndrome hypothyroid chf pneumonia currently uses oxygen to sleep and as needed during day niddm abdominal port placement av fistula placement with history of multiple peritoneal dialysis procedures cholecystectomy cataract surgery partial right toe amputation discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with ultram incisions sternal healing well no erythema or drainage leg right large area of eschar x cm dopplerable pulse followed by vascular surgery dressing with adaptic edema in right leg no edema in left leg discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments cardiac surgeon dr md phone date time vascular surgeon dr md phone date time you have a wound check on in one week the nurse will advise you as to the date and time please call and schedule the following appointments your primary care dr in weeks your cardiologist dr in weeks please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies amiodarone attending chief complaint hypoxemia olecranon bursitis renal failure major surgical or invasive procedure picc incision and drainage of abscess left elbow history of present illness mr is a year old m w h o cad s p cabgx dm esrd chf af on coumadin and sss s p ppm who is transferred to from osh with hypoxemia and concern for septic bursitis patient presented to hospital on from skilled care with complaint of drainage from left elbow plain films were not suggestive of osteomylitis and patient was started on vancomycin empirically for olecrenon bursitis cultures of fluid reportedly grew mssa but also documented as resistant to penicillin and antibiotics were transitioned to zosyn prior to this he had been having swelling of his lue after his av fistula placement after his angioplasty a compression bandage was placed to help with the swelling and not removed for an unknown period of time when removed skin was removed as well shortly after this he developed what sounds like a superficial cellulitis that continued to progress patient was transferred from osh floor to icu after developed hypoxemia w worsening bilateral infiltrates on cxr blood gas showed pao of on fio on venti mask was diuresed with mg lasix w uop of and received another mg of lasix this am w improvement of oxygenation with sats in high s on l bilateral infiltrates were attributed to pulmonary edema secondary to cardiac etiology h o chf reportedly preserved ef on echo in past months vs sepsis bursitis patient has been afebrile over past hours but with rising wbc count most recently blood pressures in the s s systolic with home anti hypertensives held plan was to i d olecrenon bursitis pending inr reversal received vitamin k mg x with improvement of inr from to however patient also with acute on chronic kidney failure on hd refusing to see nephrologists so was transferred to for further management on transfer afebrile bps s s hr s s atrial fibrillation rr s o sat on l nc in the icu initial vs were on nrb he was complaining of shortness of breath that is slowly improving denies any cp n v d abdominal pain fever chills also complaining of some left arm pain with movement past medical history coronary artery disease s p cabg x peripheral vascular disease significant claudication diabetes mellitus on lantus and iss at home carotid disease with occluded left carotid artery renal artery stenosis s p prior left renal artery stent in in pmr on prednisone at home end stage renal disease previously on hd stopped in followed by nephrology at medical center baseline creatinine complex aortic atheroma hyperlipidemia atrial fibrillation with sick sinus syndrome status post permanent pacemaker in complicated by subsequent amiodarone toxicity h o cholesterol embolization syndrome hypothyroidism congestive heart failure ef in home oxygen to sleep and as needed during day past surgical history ppm placement for sick sinus syndrome abdominal port placement av fistula placement with history of multiple peritoneal dialysis procedures renal artery stent cholecystectomy cataract surgery partial right toe amputation failed angioplasty in social history lives with his family occupation retired tobacco denies tobacco use though significant second hand smoke from his wife s chronic smoking history etoh occasional alcohol illicits denies family history family history significant for both brother and sister having coronary artery disease sister with cabg in her s physical exam physical exam on admision vitals t bp p r o general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema pertinent results labs on admission pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos nuc rbcs pm hypochrom anisocyt poikilocy normal macrocyt microcyt polychrom pm sed rate pm crp pm calcium phosphate magnesium pm alt sgpt ast sgot ck cpk alk phos tot bili pm glucose urea n creat sodium potassium chloride total co anion gap pm urine hours random urea n creat sodium potassium pm urine osmolal pm urine color yellow appear hazy sp pm urine blood mod nitrite neg protein glucose ketone neg bilirubin neg urobilngn neg ph leuk mod pm urine rbc wbc bacteria few yeast none epi pm urine granular hyaline pm urine amorph rare pm urine mucous rare pm urine eos negative micro microbiology wound culture staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin s oxacillin s trimethoprim sulfa s blood cultures pending urine culture no growth imaging cxr impression ap chest compared to most recent prior chest radiograph moderate cardiomegaly mediastinal widening a small right pleural effusion and interstitial abnormality predominantly in the right lung are most readily explained by biventricular heart failure intervening chest radiograph should be consulted to see if this is consistent with the recent course transvenous right atrial and right ventricular pacer leads are in expected locations no pneumothorax tte the left atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size regional left ventricular wall motion is normal there is mild global left ventricular hypokinesis lvef there is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats the right ventricular cavity is mildly dilated with mild global free wall hypokinesis there are three aortic valve leaflets the aortic valve leaflets are moderately thickened there is a minimally increased gradient consistent with minimal aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse moderate mitral regurgitation is seen moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression symmetric left ventricular hypertrophy with mild global systolic dysfunction mild right ventricular systolic dysfunction minimal calcific aortic stenosis moderate mitral and tricuspid regurgitation moderate pulmonary hypertension compared with the prior study images reviewed of pulmonary hypertension is now detected the other findings are similar renal us no evidence of hydronephrosis bilaterally multiple anechoic right renal lesions consistent with simple cysts bilateral cortical thinning left greater than right left extremity us limited evaluation of the area of concern was performed using grayscale and color flow ultrasound there is subcutaneous edema there is no evidence of a defined abscess collection the av fistula was not evaluated impression subcutaneous edema without evidence of abscess formation cxr findings in comparison with the study of there is little change in the diffuse bilateral pulmonary opacifications bilaterally the right central catheter has been pulled back into the axillary region other monitoring and support devices remain in place lenis impression no evidence of dvt in bilateral lower extremity veins ct chest impression confluent upper lobe peribronchiolar opacification overlying diffuse ground glass and reticular opacification that is new since and raises concern for superimposed infection in the setting of pulmonary edema moderate bilateral left greater than right pleural effusions the study and the report were reviewed by the staff radiologist cxr findings picc line is terminating into lower svc there is asymmetric improvement in the moderate to severe pulmonary edema left side more than right side since pleural effusions bilaterally are persistent without interval increase left pectoral dual lead chest wall pacemaker leads are terminating into the right atrium and right ventricle heart size is enlarged and unchanged cardiomediastinal contours is stable brief hospital course mr is a m with a complicated pmh including cad s p cabg pmr on prednisone af s p ppm and esrd previously on hd through left av fistula who was transferred from hospital with a left upper extremity abscess with overlying cellulitis distal to his av fistula lue cellulitis cellulitis secondary to skin breakdown from recent trauma no underlying abscess or joint involvement wound cultures grew out mssa and patient started on vancomycin for d course day got final dose on blood cultures were negative decided not to switch to nafcillin because of high salt load and actively trying to diurese patient patient remained afebrile during admission swelling improving on exam per transplant surgery outlet stenosis and avf are likely making pt susceptible to wounds of the area and ultimate management will involve angioplasty of stenosis vs tying off fistula ortho and wound care teams have followed the fistula and provided wound care recommendations underwent bedside i and d near left elbow while in the icu by orthopedics he will need continued wound care respiratory distress hypoxemia acute on chronic systolic chf cad ct chest shows residual pulmonary edema despite ongoing diuresis pulmonary edema likely combined cardiogenic chf and due to capillary leak secondary to inflammatory process patient was initially on l nasal cannula and oxygen by face mask but eventually respiratory status improved with diuresis los fluid balance from the icu was negative l here likely was hypervolemic on transfer dry weight unknown when patient was discharged from icu was satting on l which appears to be his baseline diuresis was continued he used l oxygen intermittently as he does at home but reported that his breathing felt back to baseline continued asa beta blocker fenofibrate not on statin or ace inhibitor he was on lasix mg twice daily with nearly matched i os at home was on mg in am mg in pm he was maintained at mg twice daily given mildly low blood pressures asymptomatic atrial fibrillation afib has history of a fib on coumadin rates were controlled with diltiazem and metoprolol diltiazem dose was reduced to mg daily rather than mg daily on admission warfarin dosing was adjusted for goal inr diabetes mellitus dm type ii on levemir units and iss at home insulin glargine lantus was administered and titrated ultimately to a dose of units in the evening he was still having blood sugars in s in the afternoon but fasting blood sugars s need to be titrated up further though may in part be due to prednison renal failure acute on chronic acute renal failure arf patient was very hypervolemic on admission and was started on a lasix gtt for diuresis bun and cr continue to slowly climb in setting of diuresis but still within baseline range diuresis was continued with furosemide cr stabilized in range which is lower than recent value pre hospitalization he has a av fistula in the left arm but no imminent plan for dialysis had been on dialysis previously this was stopped in mental status agitation in the icu patient repeatedly became agitated overnight taking off his oxygen becoming hypoxemic and getting more agitated he was initially given ativan which controlled his symptoms but made him confused eventually he was transitioned to po tylenol standing to prevent pain while not making patient somnolent on the general medical there were no episodes of agitation and he remained calm alert and oriented polymyalgia rheumatica patient takes prednisone prescribed by outpatient rheumatologist the patient was on prednisone mg at his appointment weeks ago planned to taper to mg now for weeks then continue to taper down dose adjusted to prednisone mg daily on wed next planned taper anemia hct stable in mid s below baseline of no transfusions this admission stool guaiac negative hemolysis labs negative for hemolysis likely secondary to renal failure dyslipidemia cholesterol triglyceride lipid disorder continue home fenofibrate hypothyroidism continue levothyroxine mcg home dose sacral wounds will need continued wound care esophageal ulcers gerd continued ppi medications on admission metoprolol mg q h solu medrol mg daily pantoprazole mg iv daily fenofibrate mg daily levothyroxine mcg daily furosemide mg iv daily piperacillin tazobactam g iv q h haloperidol mg iv q h prn confusion fentanyl mcg iv h prn pain norco apap hydromorphone tab q hr prn insulin sliding scale feosol mg daily sucralfate gm before meals and qhs discharge medications fenofibrate micronized mg tablet sig one tablet po daily levothyroxine mcg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig tablets po bid times a day as needed for constipation polyethylene glycol gram dose powder sig seventeen grams po daily daily as needed for constipation prednisone mg tablet sig one tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours metoprolol tartrate mg tablet sig two tablet po tid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily acetaminophen mg tablet sig two tablet po q h every hours bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po bid times a day as needed for constipation diltiazem hcl mg capsule extended release sig one capsule extended release po daily daily trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia furosemide mg tablet sig one tablet po qpm once a day in the evening warfarin mg tablet sig one tablet po once daily at pm furosemide mg tablet sig one tablet po qam once a day in the morning insulin glargine unit ml cartridge sig thirty four units subcutaneous at bedtime multivitamin tx minerals tablet sig one tablet po daily daily discharge disposition extended care facility pines discharge diagnosis hypoxemia chf acute on chronic systolic cad s p cabg lue cellulitis secondary diagnoses atrial fibrillation diabetes mellitus type controlled with complications acute on chronic renal failure polymyalgia rheumatica anemia hypothyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted for low oxygen levels and cellulitis infection of the skin your oxygen levels improved with lasix and may in part have been due to fluid on your lungs the infection of your skin also improved with antibiotics you will need ongoing physical therapy and therefore will go to rehab followup instructions rehab will schedule follow up with pcp you should also schedule follow up with your nephrologist and address the need for ligating the av fistula,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Male"",
""service"": ""Cardiothoracic"",
""allergies"": [
""Amiodarone""
],
""chiefComplaint"": ""Chest pain"",
""historyOfPresentIllness"": [
""Mr. [**Known lastname 1031**] is a year old gentleman with a complex medical history that is relevant for known coronary artery disease.  His last coronary angiogram in showed a total occlusion of the right coronary artery, a stenosis of the left circumflex artery with significant left anterior descending disease, a past attempt in was made to intervene on the left anterior descending artery however the intervention was unsuccessful.  Of note he has"
46884,admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint pulmonary venous ablation complicated by right temporo parietal ich major surgical or invasive procedure right craniotomy evacuation of right ich decompressive right craniectomy evacuation of right ich tracheostomy eg feeding tube history of present illness ms is a yo f with h o paf and svt who initially presented for isolated pulmonary venous ablation she was intubated and heparinized prior to procedure during the procedure she had avnrt and her act was per verbal report blood pressures were transiently as high as mmhg during the procedure pericardial tap revealed cc s of bloody fluid but no effusion on intracardiac echo her anticoagulation was reversed at the end of the procedure patient was transferred to ccu for observation after the procedure on arrival to the ccu patient was found to be somnolent and not responding to commands not moving her right leg she began to complain of a headache stat head ct revealed large temporo parietal iph with mm midline shift neurosurgery was called to assess the patient on initial evaluation by neurosurgery patient was found to be somnolent eyes opening to loud voice and sternal rub she was moaning complaining of headache not following commands she was able to state her last name only face was symmetric and pupils were equal and reactive she spontaneously moved her upper extremities and left leg right leg not moving past medical history paroxysmal atrial fibrillation irregular palpitations associated with dyspnea and fatigue for the last years paf noted on holter with rvr up to bpm can last up to hours treated with atenolol diltiazem and flecainide which have all been discontinued due to inefficacy and fatigue usually occurs three or four times a month usually lasting hours with associated palpitations and some labored breathing and resolves spontaneously palpitations x years svt since her s regular rapid palpitations with presyncope at onset and self terminates within a few seconds no actual syncope holter demonstrated narrow complex tachycardia at bpm with va relationship and short pr interval and negative p waves occurs more during menstruation and with prior pregnancies very infrequent once a month or so normal ef by echo with lvef of and no significant valvular abnormalities normal stress test social history she lives at home with her husband and has kids all of whom are of young adult age she is a lifelong nonsmoker she does not drink caffeine and rarely has any alcoholic beverages she is of faith family history brother has atrial fibrillation diagnosed in his s father was diagnosed with atrial fibrillation in his s physical exam admission physical exam gen eyes shut opens to loud voice and occasional and sternal rub heent pupils bilateral reactive eoms unable to test neck supple mental status moans complains of headache mumbles was able to state last name only does not follow any commands cranial nerves face appears symmetric and tongue is midline strength spontaneously moving upper extremities briskly noted to wiggle left foot not moving lower extremities to command has bil knee immobilizers in place toes downgoing bilaterally discharge physical exam eo to voice restless fluent spontaneous speech but confused and with waxing attentiveness rue purposeful and follows commands some movment lue to noxious moves ble spontaneously pertinent results noncontrast head ct pm right frontoparietal and left parietal parenchymal hematomas with fluid fluid levels mild vasogenic edema surrounding the largest hematoma in the right temporoparietal lobe with approximately mm leftward shift of midline structures intraventricular and subarachnoid extension of bleed without hydrocephalus no evidence of brain herniation post craniotomy noncontrast head ct pm status post partial evacuation of a right temporoparietal parenchymal hematoma with expected post surgical changes stable intraventricular extension of hemorrhage with mild increase in the intraventricular component mild increase in the left frontal parenchymal hematoma stable leftward shift of midline structures transthoracic echo the left atrium is normal in size no atrial septal defect is seen by d or color doppler left ventricular wall thickness cavity size and regional global systolic function are normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation the pulmonary artery systolic pressure could not be determined there is a trivial physiologic pericardial effusion there are no echocardiographic signs of tamponade noncontrast head ct status post partial evacuation of right temporoparietal parenchymal hematoma with stable appearance of the residual hematoma interval increase in the surrounding vasogenic edema mass effect and leftward shift of midline structures which is now approximately mm previously mm left high frontal hematoma although similar shows mild increase in the surrounding vasogenic edema stable intraventricular extension of hemorrhage with mild dilatation of the left lateral ventricle as before noncontrast head ct again noted is minimal increase in surrounding vasogenic edema of the right temporoparietal parenchymal hematoma with the hematoma itself appearing stable in size there is mild increased effacement of the adjacent right lateral ventricle there is leftward shift of the normally midline structures by mm stable intraventricular extension of the hemorrhage with mild dilatation of left lateral ventricle post craniectomy head ct status post right frontoparietal craniectomy with outpouching of frontoparietal parenchyma through the calvarial defect new frontoparietal x cm hematoma with surrounding vasogenic edema stable size of right temporo parietal parenchymal hematoma and left frontal hematoma with stable intraventricular extension of hemorrhage mild increase in surrounding vasogenic edema leftward shift of the normally midline structures now measures mm prior mm noncontrast head ct increased herniation of more edematous brain parenchyma through the right parieto occipital craniotomy without evidence of new or increasing hemorrhage stable mild leftward shift of the midline structures stable left frontal hemorrhage with mild surrounding edema stable intraventricular hemorrhage with no evidence of developing hydrocephalus stable right frontal hypodensities without new foci of hemorrhage portable cxr worsening of left lower lobe atelectasis right pleural effusions larger on the right side have markedly decreased ble dopplers negative for dvt bilaterally portable cxr tracheostomy tube nasogastric tube and left subclavian catheter are in standard positions there is no interval change in left lower lobar atelectasis and small to moderate left pleural effusion but otherwise clear lungs no pneumothorax is seen with normal cardiomediastinal contours portable cxr the dobbhoff feeding tube now courses below the stomach with tip projecting over the expected location of the stomach left subclavian central line has its tip in the mid svc unchanged and tracheostomy tube remains in satisfactory position stable cardiac and mediastinal contours the lungs are relatively well inflated there is suggestion of paucity of vessels in the apices which may represent underlying emphysema there is increasing airspace opacity at both bases which may reflect pulmonary edema although worsening pneumonia or aspiration would be also of concern clinical correlation is advised no pneumothorax is seen on the right the left cannot be adequately assessed given the absence of the apex on this image portable cxr worsening multifocal airspace opacities concerning for multifocal pneumonia in the appropriate clinical setting noncontrast head ct apparent interval increase lateral herniation of brain through the right frontoparietal craniotomy stable distribution of left frontal and right frontoparietal hematomas with associated edema and left intraventricular hemorrhage as well as concurrent subarachnoid component eeg this is an abnormal continuous icu monitoring study because of continuous focal slowing breach artifact and frequent epileptiform discharges in the right posterior quadrant these findings are indicative of a potentially epileptogenic focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also frequent brief runs of frontal intermittent rhythmic delta activity these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically nonspecific there are no electrographic seizures portable cxr progressive consolidation right lower lobe initially developing on is pneumonia previous left lower lobe collapse has resolved feeding tube ends in the stomach heart size top normal pulmonary vascular congestion is mild borderline pulmonary edema has improved tracheostomy tube in standard placement eeg this is an abnormal continuous icu monitoring study because of continuous focal slowing breach artifact and frequent epileptiform discharges in the right posterior quadrant these findings are indicative of a potentially epileptogenic focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also frequent brief runs of frontal intermittent rhythmic delta activity these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically nonspecific there are no electrographic seizures compared to the prior day s recording epileptiform activity is less frequent but there is no other change eeg this is an abnormal continuous icu monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also frequent brief runs of frontal intermittent rhythmic delta activity these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically non specific there are no electrographic seizures compared to the prior day s recording epileptiform activity is no longer seen eeg this is an abnormal continuous icu monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also frequent brief runs of frontal intermittent rhythmic delta activity these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically nonspecific there are no electrographic seizures compared to the prior day s recording there is no significant change ekg atrial fibrillation with rapid ventricular response diffuse non specific st t wave changes compared to the previous tracing of atrial fibrillation has now appeared portable cxr improving but persistent right lower lung pneumonia with near complete resolution of pneumonia in the left base eeg this is an abnormal continuous icu monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow there is excess diffuse theta activity and there are frequent brief runs of frontal intermittent rhythmic delta activity firda these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically nonspecific there are no electrographic seizures compared to the prior day s recording there is no significant change noncontrast head ct evolution of hemorrhagic products within right fronto parietal temporal parenchyma and left frontal lobe with similar surrounding vasogenic edema improved left occipital hemorrhage resolution of subdural hematoma along the falx similar degree of subarahnoid hemorrhage especially along the left cerebral hemisphere unchanged herniation of the right hemispheric parenchyma hypodensity in the right temporal region likely representing edema versus subacute infarct is evolved since opacification of right mastoid portable cxr right basal consolidation continues to clear now almost radiographically undetectable lungs are otherwise clear heart is normal size persistent effacement of the aortopulmonic window since the end of be a normal anatomic variant or could be due to adenopathy in that location even though i see no indication of adenopathy elsewhere in the mediastinum neither is there any pleural abnormality tracheostomy tube is in standard placement feeding tube ends in the upper stomach left pic line tip projects at the origin of the svc eeg this is an abnormal continuous icu monitoring study because of frequent electrographic seizures continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of an epileptogenic focal structural lesion and skull defect in the right hemisphere with seizures arising from the right central region the electrographic seizures occur predominantly in a cluster between and am although there are rare seizures at other times the seizures are brief lasting less than seconds and have no clinical correlate over the left hemisphere there is predominantly theta and delta activity there are also abundant brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording there are now frequent electrographic seizures arising from the right central region with a total of approximately seizures mostly between and am there is also more slowing and rhythmic delta activity over the left hemisphere indicating worsening of diffuse cerebral dysfunction eeg this is an abnormal continuous icu monitoring study because of frequent focal electrographic seizures arising from the right central region there is continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also frequent brief runs of frontal intermittent rhythmic delta activity and occasional triphasic waves these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording right central electrographic seizures are less frequent particularly at the end of the study and the left hemisphere shows faster frequencies eeg this is an abnormal continuous icu monitoring study because of rare focal seizures continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant the seizures arise from the right central region c three seizures last less than seconds a fourth lasts minutes none of the seizures show an clinical correlate on video these findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also occasional brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording electrographic seizures are less frequent the one longer seizure had no clinical correlate ruq ultrasound normal right upper quadrant ultrasound noncontrast head ct postsurgical changes related to right temporoparietal craniectomy parenchymal herniation through the craniectomy defect appears improved since exam areas of intraparenchymal subarachnoid and intraventricular hemorrhage are largely unchanged since prior exam no new area of intracranial hemorrhage is detected no evidence of hydrocephalus however ventricular caliber has increased since exam eeg this is an abnormal continuous icu eeg monitoring study because of a single focal electrographic seizure continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant the brief seizure arises from the right central region c there is no clinical correlate on video these findings are indicative of an epileptogenic focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also occasional brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording electrographic seizures are less frequent and the overall background activity has improved eeg this is an abnormal continuous icu eeg monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact in the right posterior quadrant these findings are indicative of a focal structural lesion and skull defect in the right posterior quadrant over the left hemisphere the alpha rhythm is slow and there is excess diffuse theta activity there are also occasional brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically non specific compared to the prior day s recording no electrographic seizures are seen eeg this is an abnormal continuous icu eeg monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact along with an electrographic seizure arising from the right central region these findings are indicative of a focal epileptogenic structural lesion and skull defect in the right hemisphere the alpha rhythm is slow and there is excess diffuse theta activity on the left there are also occasional brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording one minute long electrographic seizure is seen along with three other runs of rhythmic activity in the right central region which do not clearly show evolution in frequency or morphology eeg this is an abnormal continuous icu eeg monitoring study because of continuous focal slowing attenuation of faster frequencies and breach artifact in the right central region these findings are indicative of a focal potentially epileptogenic structural lesion and skull defect in the right hemisphere the alpha rhythm is slow and there is excess diffuse theta activity on the left there are also occasional brief runs of frontal intermittent rhythmic delta activity these findings are indicative of moderate diffuse cerebral dysfunction which is etiologically nonspecific compared to the prior day s recording no electrographic seizures are present but there are still right central epileptiform discharges video swallow some penetration of nectar thick liquids and residue in vallecula no aspiration was noted noncontrast head ct established cystic encephalomalacia and white matter abnormality likely a combination of edema and gliosis in the right temporoparietal region overall extent of edema appears unchanged decreased mass effect on the occipital of the right lateral ventricle video swallow possible penetration with thin liquids otherwise normal oropharyngeal swallowing videofluoroscopy somewhat limited exam due to patient movement dilantin level corrected brief hospital course yo f with h o paf and svt who initially presented for pulmonary venous ablation which was complicated by right temporo parietal ich with intraventricular extension right temporo parietal ich patient was taken urgently to or for right craniotomy and evacuation of right ich post op head ct showed partial evacuation with expected post surgical changes and mild increase in intraventricular extension stable leftward midline shift mls patient was transferred to the icu overnight she had anisocoria repeat head ct showed mildly inceased vasogenic edema and small increase in mls mm mm she was extubated on am of hd and was able to clear her secretions over the course of the day she slowly became more responsive speaking and moving her right side but still with a moderate left hemiparesis on hd her lle became more paretic and her mental status worsened repeat head ct was performed showed worsening midline shift so patient was given mannitol g iv x and taken urgently to or for decompressive craniectomy post operatively she was started on hyperosmolar therapy with ns and day iv decadron taper post op head ct showed improvement in leftward mls mm mm but new right frontoparietal x cm hematoma with vasogenic edema by hd patient was able to open eyes to command her sutures were removed on pod incision appeared clean dry intact craniectomy could not be performed during hospitalization due to persistent transcalvarial edema eeg was negative for seizures and neurology felt that she was safe for discharge she will need outpatient follow up with her neurosurgeon dr for this procedure s p pulmonary venous ablation patient s cardiac enzymes downtrended appropriately after her procedure follow up tte was negative for significant pericardial effusion or wall motion abnormality lvef on hd patient had an episode of afi with rvr to s she was converted to sinus with iv lopressor and iv dilt she then returned to afib so started amiodarone bolus and drip and metoprolol was increased to mg iv tid she continued to have multiple runs of afib between hd which were managed with diltiazem and metoprolol boluses after this she spontaneously converted to sinus rhythm per cardiology recs her med regimen on discharge was amiodorone mg po daily metoprolol tartrate mg po bid asa mg daily was also restarted on hd with permission from neurosurgery patient will follow up as outpatient with dr nonconvulsive seizures patient was initially placed on keppra for seizure prophylaxis due to the cortical location of her ich due to persistently depressed mental status in the icu continuous eeg was started on hd which initially showed diffuse cerebral dysfunction with epileptiform discharges but no seizures her keppra was uptitrated to mg po bid and she was started on dilantin dilantin was briefly held while patient febrile concern for drug fever but on hd eeg showed frequent seizures no clinical seizure on video eeg so she was re loaded with dilantin and started on a tid dose on discharge her anti epileptic regimen is keppra mg po bid dilantin mg po tid corrected dilantin level on discharge is delirium while patient s mental status and neuro exam continued to slowly improve during hospitalization her sleep wake cycle was persistently deranged and she developed delirium superimposed on her organic brain injury this was managed with supportive care and medications will be discharged on seroquel for sleep expect this to resolve as she transitions out of the hospital environment id patient had persistent fevers during her icu stay initially treated empirically for vap with vanc cefepime tobramycin then narrowed to cefazolin when urine cultures showed a pan sensitive e coli uti she completed her course of antibiotics but then developed a second uti with pan sensitive pseudomonas so underwent a second antibiotic course with iv cefepime for a day course completed on respiratory patient suffered from respiratory failure secondary to her neurologic deficits causing inability to tolerate secretions tracheostomy was performed on hd with placement of passey muir valve for speech gi patient repeatedly failed bedside swallow evaluations and initially required tube feeds via ngt peg tube was placed on hd and patient began continuous and then cycled tube feeds on hd she had video swallow which showed she was no longer aspirating so her diet was advanced to ground solids and nectar thickened liquids video swallow on was improved see results and diet instructions transition of care please check dilantin level on as a trough prior to am dose goal level is medications on admission asa mg daily discharge medications amiodarone mg po daily aspirin mg po daily metoprolol tartrate mg po bid hold for sbp hr sarna lotion appl tp qid prn pruritis apply to abdomen miconazole powder appl tp qid prn irritation perineal senna tab po bid constipation heparin unit sc tid acetaminophen mg po q h prn pain bisacodyl mg po pr daily constipation docusate sodium liquid mg po bid albuterol neb soln neb ih q h prn chest tightness hydroxyzine mg po q h prn itching levetiracetam mg po bid quetiapine fumarate mg po qhs prn insomnia phenytoin suspension mg po q h discharge disposition extended care facility institute for rehabilitation discharge diagnosis paroxysma atrial fibrillation right mca infarct right aca infarct left frontal ich cerebral edema with uncal herniation transcalvarium herniation right intracerebral hemorrhage intraventricular hemorrhage mental status change hypernatremia seizures dysphagia respiratory failure requiring trach urinary tract infection vap discharge condition mental status confused always level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair discharge instructions ms you were admitted to the hospital for a pulmonary venous ablation to treat your cardiac arrythmia your procedure was complicated by a brain hemorrhage you underwent emergent craniotomy with evacuation of the hemorrhage followed by hemicraniectomy removal of half the skull to release pressure on the brain you had a tracheostomy breathing tube in the neck and peg feeding tube placed you had seizures caused by the brain bleed so you were placed on anti epileptic medications you are now being discharged to rehab where you will work closely with physical therapy to continue the recovery process you will need to return to in months to be evaluated for repair of your craniotomy please schedule the recommended follow up appointments with cardiology and neurosurgery see below for phone numbers other instructions please wear your helmet at all times when you are up and out of bed have a friend or family member check your craniectomy site for signs of infection such as redness or drainage daily take your pain medicine as prescribed if needed you do not need to take it if you do not have pain exercise should be limited to walking no lifting lbs straining or excessive bending increase your intake of fluids and fiber as narcotic pain medicine can cause constipation we generally recommend taking an over the counter stool softener such as docusate colace while taking narcotic pain medication do not take any anti inflammatory medicines such as motrin aspirin advil or ibuprofen etc until follow up do not drive before your second surgery dilantin level should be checked on as a trough prior to am dosing followup instructions please call dr to schedule cardiology and electrophysiology follow up within the next month he plans to come to rehab for your follow up appointment please call the neurosurgery department to schedule a follow up appointment with dr within months after discharge you will need a head ct scan prior to your appointment which can be scheduled when you call to make the follow up appointment completed by,"{
""date"": ""2019-10-10"",
""discharge_date"": ""2019-10-11"",
""service"": ""Neurosurgery"",
""allergies"": [
""No Known Allergies""
],
""adverse_drug_reactions"": [
""No Known Adverse Drug Reactions""
],
""chief_complaint"": ""Pulmonary venous ablation complicated by right temporo parietal ICH major surgical or invasive procedure right craniotomy evacuation of right ICH decompressive right craniectomy evacuation of right ICH tracheostomy EG feeding tube history of present illness Ms is a yo F with H/O PAF and SVT who initially presented for isolated pulmonary venous ablation she was"
30455,unit no admission date discharge date date of birth sex m service neonatology post discharge name burns history of present illness is an ex and week baby boy by induced vaginal delivery to a year old g p now mother she was induced secondary to pregnancy induced hypertension the infant s birth weight was grams maternal history and pregnancy was otherwise unremarkable until at weeks she developed hypertension prenatal screens blood type b positive antibody negative rpr nonreactive hepatitis surface antigen negative rubella immune and gbs unknown at delivery the infant emerged vigorous with spontaneous cry routine resuscitation was administered apgars were and he was admitted to the nicu for management of prematurity hospital course by systems respiratory the infant has remained on room air since birth he has not had any significant apneas bradycardias or desats intermittently he has had some brief episodes of bradycardia that are self resolving he was thus on a spell count just prior to discharge he has not required any caffeine administration cardiovascular the infant has remained hemodynamically stable not requiring any pressor support no murmur was ever appreciated and therefore work up and treatment for pda was not necessary fluids electrolytes and nutrition the infant initially was on iv fluids and started enteral feeds on day of life he quickly worked up to full volume via pg feeds and presently is now taking breast milk k cals per ounce ad lib by mouth and takes approximately cc kg day along with breast feeding hematology the infant had elevated bilirubin on day of life requiring phototherapy phototherapy was discontinued on day of life without subsequent increases the infant has not required any blood transfusions infectious disease given that there were no maternal risk factors present and the infant was well appearing the infant was not started on any antibiotics and has not required any courses in the stay in the neonatal intensive care unit neurology since he is greater than weeks the infant did not require head ultrasound sensory audiology hearing screening was performed with automated auditory brain stem responses he passed the screening bilaterally ophthalmology the infant was greater than weeks he did not require an eye examination discharge disposition the infant will be discharged to home name of primary pediatrician dr of pediatrics fax discharge physical exam on the day of discharge the infant weighed grams which is at the th percentile the length was cm between the th and th percentile head circumference cm just at the th percentile on examination general appearances the infant is active and vigorous moving all extremities head and neck anterior fontanel is open and flat red reflexes are intact bilaterally the infant s palate is intact pulmonary clear to auscultation bilaterally cv s and s regular rate and rhythm no murmur appreciated abdomen is soft nondistended no masses extremities warm and well perfused plus femoral pulses genitourinary normal male genitalia testes are descended bilaterally circumcision site is healing anus is patent there is a small sacral dimple neuro positive suck positive moro appropriate for gestational age care and recommendations feeds at discharge the infant is being discharged home on breast milk k cals per ounce medications the infant is taking iron at mg kg per day as well as goldline multi vitamins ml by mouth daily iron and vitamin d supplementation iron supplementation is recommended for preterm and low birth weight infants until months corrected age all infants fed predominantly breast milk should receive vitamin d supplementation at i u may be provided as a multi vitamin preparation daily until months corrected age car seat position screening was successfully performed state newborn screening was performed and results are pending immunizations received the infant received hepatitis b vaccine on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria at less than weeks between weeks and weeks with two of the following day care during rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings chronic lung disease or hemodynamically significant congenital heart disease influenza immunization is recommended annually in the fall for all infants once they reach months of age before this age and for the first months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers this infant has not received rota virus vaccine the american academy of pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least weeks but fewer than weeks of age follow up appointments the infant will be seeing the primary pediatric provider of pediatrics on wednesday at am vna services will also be visiting the infant shortly after discharge discharge diagnosis prematurity dictated by medquist d t job,"[
{
""date"": ""2019-10-10"",
""type"": ""N/A"",
""subtype"": ""N/A"",
""system"": ""N/A"",
""code"": ""N/A"",
""code_value"": ""N/A"",
""age"": 1,
""sex"": ""M"",
""service"": ""Neonatology"",
""admit_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-11"",
""date_of_birth"": ""2018-09-24"",
""service_name"": ""Neonatology"",
""disease"": ""N/A"",
""medication"": ""N/A"",
""allergy"": ""N/A"",
""history_"
61733,admission date discharge date date of birth sex m service cardiothoracic allergies sulfa sulfonamide antibiotics bee pollens attending chief complaint decreased exercise tolerance with dyspnea on exertion major surgical or invasive procedure coronary artery bypass graft x left internal mammary artery to left anterior descending saphenous vein graft to diagonal saphenous vein graft to posterior descending artery history of present illness the patient is a year old white male who recently has noticed a decrease in exercise tolerance as well as dyspnea on exertion stress test suggested ischemia cardiac catheterization and coronary angiography revealed vessel disease and the patient was referred for surgical revascularization past medical history coronary artery disease hyperlipidemia hypertension depression mild benign prostatic hypertrophy rash treated with cyclosporine past surgical history bilateral hernia repair right knee arthroscopy bilateral cataract surgery social history retired quit smoking yrs ago after pack year history drinks one alcoholic beverage per day lives with wife family history non contributory physical exam vitals lbs general no acute distress skin mild chronic rash neck supple full range of motion chest clear to auscultation bilaterally heart regular rate and rhythm with systolic murmur abd soft non tender non distended bowel sounds ext warm well perfused with large varicosities on left mild on right neuro grossly intact non focal pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood pt ptt inr pt pm blood urean creat cl hco am blood glucose urean creat na k cl hco angap am blood hct brief hospital course mr was a same day admit after undergoing pre operative work up prior to admission and was brought to the operating room where he underwent a coronary artery bypass graft please see operative report for surgical details following surgery he was transferred to the cvicu for invasive monitoring in stable condition later this day he was weaned from sedation awoke neurologically intact and extubated on post op day one he was transferred to the telemetry floor for further care chest tubes were removed on post op day two and epicardial pacing wires were removed on post op day three chest x ray following chest tube removal revealed small apical pneumothorax this remained stable the patient received two units of packed red blood cells for a hematocrit of this would rise to hospital course was uneventful and the patient was discharged home with vna services in good condition on pod medications on admission atenolol mg daily terazosin mg daily paxil mg daily zocor mg daily aspirin mg daily clonidine mg tab triamterene hctz mg daily discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills paroxetine hcl mg tablet sig one tablet po daily daily disp tablet s refills simvastatin mg tablet sig one tablet po daily daily disp tablet s refills cyclosporine mg capsule sig two capsule po q h every hours disp capsule s refills terazosin mg capsule sig two capsule po hs at bedtime disp capsule s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain disp tablet s refills triamterene hydrochlorothiazid mg tablet sig one tablet po once a day disp tablet s refills hydromorphone mg tablet sig tablets po q h every hours as needed disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills clonidine mg tablet sig tablet po twice a day disp tablet s refills discharge disposition home with service facility area vna discharge diagnosis coronary artery disease hyperlipidemia hypertension depression mild benign prostatic hypertrophy rash treated with cyclosporine past surgical history bilateral hernia repair right knee arthroscopy bilateral cataract surgery discharge condition good discharge instructions no driving for one month no lifting greater than pounds for weeks no lotions creams or powders on any incision shower daily and pat incisions dry call for fever greater than redness drainage weight gain of pounds in days or pounds in week followup instructions dr in weeks dr in weeks dr in weeks completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Male"",
""service"": ""Cardiothoracic"",
""allergies"": [
""Sulfa"",
""Sulfonamide"",
""Antibiotics"",
""Bee Pollens"",
""Attending Chief Complaint"": ""Decreased exercise tolerance with dyspnea on exertion"",
""Major Surgical or Invasive Procedure"": ""Coronary artery bypass graft (left internal mammary artery to left anterior descending saphenous vein graft to diagonal saphenous vein graft to posterior descending artery)"",
""History of Present Illness"": ""The patient is a year old white male who recently has noticed a decrease in exercise tolerance"
53331,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint fall with trauma to back loss of strength in both legs major surgical or invasive procedure t t laminectomy history of present illness sudden loss of sensation and strength in both legs following trauma and fall past medical history history of lumbar discectomy history of spinal cord trauma with paraplegia in physical exam in bilateral hip abductors iliopsoas quadriceps hamstrings ta fhl sensations absent below t reflexes absent blbocavernous reflex absent pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am calcium phosphate magnesium am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt brief hospital course patient was admitted to the spine surgery service and taken to the operating room for the above procedure refer to the dictated operative note for further details the surgery was without complication and the patient was transferred to the pacu in a stable condition teds pnemoboots were used for postoperative dvt prophylaxis intravenous antibiotics were continued for hrs postop per standard protocol initial postop pain was controlled with a pca diet was advanced as tolerated the patient was transitioned to oral pain medication when tolerating po diet foley was removed on pod physical therapy was consulted for mobilization oob to ambulate hospital course was otherwise unremarkable on the day of discharge the patient was afebrile with stable vital signs comfortable on oral pain control and tolerating a regular diet discharge medications acetaminophen mg tablet sig one tablet po q h every hours as needed for fever pain oxycodone mg tablet sig tablets po q h every hours as needed for pain cyclobenzaprine mg tablet sig one tablet po tid times a day as needed for spasm oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours famotidine mg tablet sig one tablet po bid times a day gabapentin mg capsule sig one capsule po tid times a day metformin mg tablet sig one tablet po bid times a day glyburide mg tablet sig one tablet po bid times a day ropinirole mg tablet sig two tablet po tid times a day as needed for rls hydrochlorothiazide mg capsule sig two capsule po daily daily meclizine mg tablet sig one tablet po tid times a day discharge disposition extended care facility medical center discharge diagnosis dorsal epidural hematoma with paraplegia discharge condition stable ambulating with support tolerating oral diet discharge instructions you have undergone the following operation thoracic decompression immediately after the operation activity you should not lift anything greater than lbs for weeks you will be more comfortable if you do not sit or stand more than minutes without moving around rehabilitation physical therapy o times a day you should go for a walk for minutes as part of your recovery you can walk as much as you can tolerate o limit any kind of lifting diet eat a normal healthy diet you may have some constipation after surgery you have been given medication to help with this issue brace you may have been given a brace this brace is to be worn when you are walking you may take it off when sitting in a chair or lying in bed wound care remove the dressing in days if the incision is draining cover it with a new sterile dressing if it is dry then you can leave the incision open to the air once the incision is completely dry usually days after the operation you may take a shower do not soak the incision in a bath or pool if the incision starts draining at anytime after surgery do not get the incision wet cover it with a sterile dressing and call the office you should resume taking your normal home medications you have also been given additional medications to control your pain please allow hours for refill of narcotic prescriptions so please plan ahead you can either have them mailed to your home or pick them up at the clinic located on we are not allowed to call in or fax narcotic prescriptions oxycontin oxycodone percocet to your pharmacy in addition we are only allowed to write for pain medications for days from the date of surgery follow up o please call the office and make an appointment for weeks after the day of your operation if this has not been done already o at the week visit we will check your incision take baseline x rays and answer any questions we may at that time start physical therapy o we will then see you at weeks from the day of the operation and at that time release you to full activity please call the office if you have a fever degrees fahrenheit and or drainage from your wound followup instructions follow up in weeks with dr please call to make an appointment md completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-11"",
""date_of_birth"" : ""2043-1-1"",
""sex"" : ""Male"",
""service"" : ""Surgery"",
""allergies"" : ""Patient recorded as having no known allergies to drugs"",
""attending_chief_complaint"" : ""Fall with trauma to back, loss of strength in both legs"",
""chief_complaint"" : ""Fall with trauma to back, loss of strength in both legs"",
""history_of_present_illness"" : ""sudden loss of sensation and strength in both legs following trauma and fall past medical history history of lumbar discectomy"
26789,admission date discharge date date of birth sex f service medicine allergies a c e inhibitors attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness hpi f with afib asthma chf pacer diverticulitis biba after falling on her r leg in the bathroom no loc did not hit head also c o days epigastric abd discomfort day sob and cm r leg laceration in the ed initial vitals on l had lac repair ct abdomen concerning for ischemic colitis but surgery opting for medical management they asked for icu admission to optimize her hemodynamics for a concern for alow flow state cardiology did not think she has a low flow state given normal renal function given cipro flagyl for empiric coverage nebs morphine hd stable the entire ed stay admitted to the icu for close monitoring of hemodynamics as recommended by surgical consult on arrival to the icu it was difficult to obtain a history through a phone translator the patient was tearful increasingly anxious and confused did not complain of any abdominal pain cp sob on further questioning she admitted that she had abdominal pain previously but not during time of interview did complain of pain at laceration site her son phoned the icu and was able to provide more information stated his mother usually received her care at that she was hospitalized there recently and had been quite ill requiring intubation for water in her lungs a problem with her pacemaker she was there for weeks discharge about weeks ago he thought that since then she had been complaining of abd pain no associated n v d no fevers she had presented to ed several days ago with same and was discharged from the er dpta she had gotten oob to br during the night and had falled and cut her leg which precipitated this presentation addendum per conversation w np on pt had icd placed at end of presented mid end of w sob cp found to have pericarditis to procedure put into right heart failure most recent echo ef intubated for several weeks had enlarging pericardial effusion which resolved w out window she was d c ed to son works there there for days went home this past weds at home visit thurs fri was fluid overload got lasix those two days saturday was seen at ed for abd pain has been c o abdominal pain for years neg abd ct had o sats in of note pt very anxious at baseline doesn t use o at home but is on cpap set med list and recent d c summary will be faxed to sicu cc c but pt is on cozar lopressor xr synthroid clonopin mg asa zoloft past medical history hypertension paroxysmal atrial fibrillation s p tee and cardioversion in dilated cardiomyopathy chf with ef on on diverticulitis status post low anterior resection osteoarthritis status post bilateral total knee replacement recent rlq cellulitis tx with two courses of keflex social history the patient denies tobacco alcohol or intravenous drug use the patient lives in alone and is spanish speaking family history mother died of colon ca at age physical exam physical exam vs t hr bp rr sat on l nc gen anxious plethoric appears confused heent perrl eomi anicteric dry mm op neck no supraclavicular or cervical lymphadenopathy jvd to angle of her jaw resp poor air movement bibasilar crackles diffuse wheezes cv irreg irreg tachy no m r g abd obese nd b s soft nt no masses or hepatosplenomegaly ext cm lac across r shin w sutures no drainage trace bilateral tender le edema to knees skin no rashes erythema around pacer pocket pertinent results chest u s small fluid collection in the region of left chest wall pacemaker cxr slight increase in right hazy lower lung zone opacity representing pleural effusion similar appearance of remainder of chest since yesterday r le tib fib very limited assessment of the right ankle joint is grossly unremarkable no subcutaneous emphysema is seen no soft tissue loss is identified no abnormal periosteal reaction is evident echo suboptimal image quality dilated right ventricular cavity with free wall hypokinesis moderate pulmonary artery systolic hypertension severe tricuspid regurgitation compared with the prior study images reviewed of the left ventricular systolic function is slightly improved right ventricular cavity size systolic function and estimated pa systolic pressure are similar ct head there is no acute intracranial hemorrhage shift of normally midline structures or major vascular territorial infarct prominence of the ventricles and sulci is consistent with age related involutional changes there is no calvarial fracture or soft tissue abnormality the visualized paranasal sinuses and mastoid air cells are well aerated ct abd pelvis ct of the pelvis sigmoid colon and rectum are decompressed with sigmoid diverticulosis the distal ureters bladder and adnexae are normal patient appears to be post hysterectomy an unusual clustering of left inguinal lymph nodes is unchanged from comparison of there are no suspicious lytic or sclerotic lesions multilevel degenerative changes involving the lower thoracic and lumbar spine are noted ct abd nonspecific colonic wall thickening involving the splenic flexure raising the possibility of ischemic colitis from a low flow state in this watershed region infectious etiologies are possible though less likely given the focality of this finding marked cardiomegaly with distention of ivc and reflux of contrast into the ivc and hepatic veins suggesting elevated right heart pressure increasing small bilateral pleural effusions with partial loculation of the right sided effusion bibasilar atelectasis diverticulosis of the right left and sigmoid colon no diverticulitis cxr no definite areas of consolidation although if indicated right lower lobe opacity may be followed with repeat pa and lateral chest x ray wbc rbc hgb hct mcv mch mchc rdw plt ct neuts bands lymphs monos eos baso atyps metas myelos hypochr anisocy poiklo normal macrocy normal microcy normal polychr plt ct blood pt ptt inr pt am blood glucose urean creat na k cl hco angap lipase calcium phos mg lactate am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ck cpk alkphos totbili pm blood ck cpk am blood lipase pm blood ctropnt am blood ctropnt am blood ck mb probnp am blood calcium phos mg am blood asa neg ethanol neg acetmnp bnzodzp neg barbitr neg tricycl neg am blood type art po pco ph caltco base xs am blood lactate am blood k brief hospital course abdominal pain chronic on presentation she complained of a diffuse abdominal pain without rebound guarding much of this is reportedly chronic and related to her anxiety a ct was performed and found circumferential thickening around the colon at the splenic flexure concerning for watershed ischemia of the colon less likely was the possibility of infectious colitis given that the patient had some diarrhea and a wbc count with a left shift however she was afebrile throughout the hospital stay and the clinical presentation was more consistent with chronic abdominal pain and the incidental finding of ischemic colitis likely an old event she never had bloody stools blood stool cultures o p lab studies were pending at discharge and we will notify your institution if they are positive urine tests to evaluate for the possibility of a uti causing abdominal pain were negative initially the lfts were increased ast alt c w possible alcoholic liver disease but no etoh was present in serum the specimen was hemolyzed and repeat lfts were normal we monitored her abdominal exams serially in conjunction with surgery who felt that the patient did not have acute ischemic colitis for a conservative approach we did continue the cipro flagyl for empiric coverage but this can be stopped after days if she remains stable she was given morphine for pain control systolic heart failure her exam was notable for some evidence of acute on chronic systolic heart failure including elevated jvp le edema crackles on exam and an elevated bnp an echo on showed an ef of fluid status was monitored closely throughout the admission with daily goals of l negative per day she was given dose of lasix iv mg low dose metoprolol was initiated she was subjectively less short of breath and overloaded at the time of transfer chest wall fluid collection pt had an area of erythema and warmth over the icd site a chest wall u s showed a tiny fluid collection in the region of the aicd the patient did not endorse tenderness and exam was not significant for fluctuance so we do not think this represents active infection but this should be monitored afib on admission she was subtherapeutic on her inr despite the son s report that she was supposed to be on coumadin she was rate controlled with beta blockers which were newly added because we were concerned for the possibility of additional procedures we held the coumadin but this should be restarted when she is stable leg laceration she sustained a laceration after a fall which was sutured in the emergency department an xray of the leg was grossly unremarkable without evidence of subcutaneous emphysema or soft tissue loss she was kept on fall precautions during her hospitalization dm we note that the patient had a hba c of in although the son denies a history of diabetes for this concern of possible diabetes she was kept an a regular insulin sliding scale anxiety she has chronic anxiety and was given ativan as needed oral candidiasis she was noted to have oral thrush and was treated with nystatin s s f e n she has been kept npo since admission ppx bowel regimen ppi while npo sq heparin access piv code status full communication son medications on admission unk via interpreter pt states that she gets her medications from the on st presumably this is the in left a message with them to call back with meds provider phone discharge medications metoprolol tartrate mg tablet sig tablet po bid times a day heparin porcine unit ml solution sig one injection tid times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours insulin regular human unit ml solution sig one injection asdir as directed docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po bid times a day nystatin unit ml suspension sig five ml po tid times a day for days acetaminophen mg tablet sig one tablet po q h every hours as needed aspirin mg tablet sig one tablet po daily daily ciprofloxacin mg ml solution sig one intravenous q h every hours metronidazole in nacl iso os mg ml piggyback sig one intravenous q h every hours lorazepam mg ml syringe sig one injection q h every hours as needed for anxiety morphine mg ml solution sig one intravenous every six hours as needed for pain discharge disposition extended care discharge diagnosis primary diagnoses chronic mesenteric ischemia acute on chronic systolic congestive heart failure secondary dignoses paroxysmal atrial fibrillation leg laceration diabetes mellitus anxiety oral candidiasis discharge condition afebrile stable discharge instructions you were treated at for chronic mesenteric ischemia with bowel rest and rehydration therapy and will be transferred to for further treatment followup instructions please f u with your pcp completed by,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""dateOfBirth"": ""2012-12-28"",
""sex"": ""F"",
""service"": ""Medicine"",
""allergies"": [
""Aspirin""
],
""attendingChiefComplaint"": ""abdominal pain"",
""chiefComplaintHistory"": ""abdominal pain"",
""historyOfPresentIllness"": ""This is a 65 year old female with a history of asthma, CHF, pacer, diverticulitis, and biba who presents with abdominal pain.  She states that she fell on her right leg in the bathroom yesterday and has had increasing abdominal pain since then.  She states that she has not had any abdominal pain in the past 24 hours"
64036,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint worst headache of life major surgical or invasive procedure bilateral suboccipital craniectomy evacuation of cerebellar hemorrhage placement of right frontal external ventricular drain removal of right frontal external ventricular drain placement of left frontal ventricular drain tracheostomy peg placment ventricular peritoneal shunt placement history of present illness year old male who was complaining of headache for the past few days his headache progressed enough that he presented to hospital when there a head ct was done which showed a cerebellar hemorrhage upon presentation he was awake and alert x and his only deficit was minor expressive aphasia per his wife was intubated for airway protection and was medflighted to for further management in flight prior to getting sedation he was following commands per personnel past medical history dm htn social history social hx lives with wife and children works as a corrections officer family history family hx noncontributory physical exam physical exam gen intubated sedated heent ncat pupils perrl bilaterally eoms unable to assess neuro mental status intubated and sedated cranial nerves i not tested ii pupils equally round and reactive to light mm to mm bilaterally iii xii unable to assess motor trace withdrawal to noxious in all extremities toes downgoing bilaterally on discharge arousable to voice follows simple commands answeres questions by giving thumbs up pupils mm bilaterally eomi moves all four extremities to command pertinent results chest portable ap study date of am final report indication year old male with intracranial bleed status post intubation evaluate et tube placement comparison no prior study available for comparison supine portable view of the chest lung volumes are low endotracheal tube terminates cm above the carina and should be pulled back by approximately or cm no focal consolidation retrocardiac opacity likely represents atelectasis allowing for low lung volumes cardiomediastinal silhouette is normal no appreciable pleural effusion or pneumothorax findings discussed with dr at am on the study and the report were reviewed by the staff radiologist ct head w o contrast study date of am final report indication year old male with cerebellar bleed evaluate for progression comparison at a m from hospital for which no report is available in pacs technique contiguous axial images were obtained through the brain no contrast was administered findings there is a large irregular shaped hyperdense collection in the posterior fossa the lesion is bilobed and the larger portion of the lesion is approximately x cm similar to prior hyperdense products track along the tentorium and posterior portion of the brainstem in addition there is slight increase in blood products within the bilateral occipital horns and third ventricle the size of the ventricles is similar to the scan performed two hours prior there is surrounding edema and effacement of the cerebellar folia and mass effect on the fourth ventricle there is effacement of the perimesencephalic cisterns no major vascular territory infarction globes and lenses are intact mild bilateral ethmoid mucosal thickening osseous structures are unremarkable impression overall no change in large irregular shaped posterior fossa hemorrhage compared to the prior study slight increase in intraventricular blood products in the bilateral occipital horns with slight increase in the diameter of the lateral ventricles compared to the prior study mild unchanged tonsillar and ascending transtentorial herniation cta should be consider to rule out underlying vascular lesion or mass cta head w w o c recons study date of am findings cta head there has been no significant interval change in the large irregular shaped hyperdense collection within the posterior fossa when compared with the prior non contrast ct examination performed earlier the same day at a m hyperdense blood products are again seen layering along the tentorium and posterior portion of the brainstem there has been interval right frontal ventriculostomy catheter placement with tip in the body of the right lateral ventricle there is intraparenchymal hemorrhage surrounding the ventriculostomy catheter with greatest dimension cm ap x cm transverse in the right frontal lobe and new mass effect on the right lateral ventricle there is no significant shift of the normally midline structures there has been interval increase in intraventricular blood products within the right lateral ventricle there are stable blood products within the third ventricle and right occipital again seen is effacement of the perimesencephalic cisterns with probable mild right sided uncal herniation there is no cerebellar tonsillar herniation there is no evidence of acute territorial infarction the vertebrobasilar system is diminutive but patent which may be reflective of arterial vasospasm the posterior cerebral arteries are patent but diminutive which also may be secondary to vasospasm there is no evidence of flow limiting stenosis occlusion aneurysm greater than mm or arteriovenous malformation the patient is intubated the tip of the endotracheal tube is within the right mainstem bronchus there is fluid within the nasopharynx and esophagus cta neck the great vessels at the level of the aortic arch are within normal limits the vertebral artery origins are unremarkable the paired vertebral arteries are diminutive in their entirety but patent the common internal and external carotid arteries are normal in course and caliber without evidence of flow limiting stenosis occlusion or dissection there are numerous bilateral cervical chain lymph nodes none of which are enlarged by ct criteria the thyroid gland is heterogeneous and enlarged right greater than left there are biapical atelectatic changes cross sectional analysis of the internal carotid arteries is as follows on the right proximal d min mm distal d min mm on the left proximal d min mm distal d min mm impression stable appearance of the large irregularly shaped posterior fossa intraparenchymal hemorrhage when compared with the previous examination no evidence of aneurysm or arteriovenous malformation to suggest etiology of this hematoma status post right frontal approach ventriculostomy shunt catheter placement with surrounding intraparenchymal hematoma and new mass effect on the right lateral ventricle interval increase in intraventricular blood products multinodular goiter ultrasound may be obtained for further evaluation if not already performed the tip of the endotracheal tube is within the right mainstem bronchus questionable vasospasm of the posterior circulation recommend continued short term interval follow up ct head w o contrast study date of am findings the patient is status post suboccipital craniectomy and evacuation of a left cerebellar hematoma pneumocephalus in the posterior fossa and subcutaneous emphysema are expected in the setting of recent surgery a linear hyperdensity in the surgical bed consistent with blood products is new since the prior study residual blood is seen in the right cerebellar hemisphere and layering along the tentorium there is unchanged effacement of the cerebellar folia with compression of the fourth ventricle a left frontal approach ventricular shunt catheter ends in the frontal of the left lateral ventricle there has been an interval decrease in the size of the lateral and third ventricles extensive hemorrhage in the right lateral ventricle is unchanged there is increased blood in the left lateral and third ventricles the right frontal intraparenchymal hemorrhage with surrounding edema at the site of a prior ventriculostomy catheter has not significantly changed since the prior study allowing for differences in technique and angulation there is mild degree of cerebral swelling with effacement of the quadrigeminal cistern unchanged since prior study there is no evidence of an acute major vascular territorial infarction fluid in the nasal cavity likely relates to the intubated status of the patient impression new blood products in the surgical site in the left cerebral hemisphere interval reduction in the size of the ventricles with a left frontal approach shunt catheter in place slightly increased intraventricular blood stable right frontal hematoma at the site of a prior ventriculostomy liver or gallbladder us single organ port study date of am final report reason for exam fever of unclear etiology rule out cholecystitis comparison none technique limited images of the right upper quadrant were obtained portably findings the liver is diffusely echogenic no definite liver mass is seen there is no intrahepatic biliary ductal dilatation the gallbladder is collapsed and not seen pancreatic head is grossly unremarkable pancreatic body and tail are obscured by overlying bowel gas decompressed stomach is interposed between pancreas and liver the common bile duct is not visualized the left kidney measures cm in length there is no hydronephrosis there is a x x cm cyst in the interpolar region of the left kidney spleen measures cm and appears unremarkable the right kidney measures cm in length there is no hydronephrosis portal vein is patent impression echogenic liver compatible with fatty infiltration please note that other types of liver disease such as hepatic cirrhosis fibrosis cannot be excluded on the basis of this exam gallbladder is not seen may be collapsed no intrahepatic biliary ductal dilatation the common bile duct is not seen patent portal vein left renal cyst the left kidney is larger than right measuring cm normal color flow is demonstrated in the left kidney no hydronephrosis m radiology report ct head w o contrast study date of pm ct head w o contrast final report indication posterior fossa hemorrhage status post evacuation ct enlarged right frontal intracranial hemorrhage please evaluate for progression comparison technique non contrast head ct findings again is noted a large right frontal intraparenchymal hemorrhage with surrounding vasogenic edema the hematoma measures x cm compared to prior x cm there is mild leftward shift of the septum pellucidum measuring mm compared to prior comparative re measurement of mm measured at series image there is related compression of the left frontal of the lateral ventricle with continued effacement of the right occipital of the lateral ventricle there is a ventriculostomy catheter via left frontal approach terminating in the left lateral frontal of the lateral ventricle abutting the septum pellucidum left cerebellar intraparenchymal hemorrhage measuring x cm is slightly smaller than the prior measurement of x cm associated small subarachnoid hemorrhage along the folia is unchanged small amount of blood is also seen layering along the tentorium unchanged additionally small subarachnoid hemorrhage is present in bilateral inferior frontal lobes and this could be due to redistribution new there is no intraventricular extension post surgical changes from prior suboccipital craniectomy are present there are bur holes in bilateral frontal lobes remainder of the osseous and soft tissue structures is unremarkable impression unchanged to slightly smaller multifocal intraparenchymal small subarachnoid and subdural hemorrhage unchanged right frontal peri hemorrhagic edema with an mm leftward subfalcine herniation slightly more prominent than prior comparative re measurement of mm no hydrocephalus follwo up as clinically indicated some degree of diffuse cerebral and cerebellar edema as before the study and the report were reviewed by the staff radiologist leni s impression no dvt head ct impression largely unchanged multifocal intraparenchymal subarachnoid and subdural hemorrhage with improved leftward subfalcine herniation no hydrocephalus or intraventricular extension persistent mild cerebral edema cxr tracheostomy in standard placement no pneumothorax or mediastinal widening left lower lobe collapse has worsened right lower lobe atelectasis is mild no appreciable pleural effusion heart size top normal right jugular line ends centrally brief hospital course the pt was recieved to ed via tranfer from osh for cerebellar hemorrhage he was intubated for safety airway protection before he had a right external ventricular drain placed in the ed his blood pressure was elevated in the ed it was noted that the csf from the evd had turned bloody he was brought emergently to the ct scanner which revealed hemorrhage along the track of the right evd as well as a cerebellar avm with hemorrhage he was brought emergently to the or for decompression the right sided evd was removed after placment of a left frontal evd the pt was brought to the icu for recovery sz prophylaxis and close neuro monitoring he remained intubated for the first two days then a wean was initiated his exam slowly improved over the course of the first two post operative days he was demonstrating left upper extrmeity weakness on exam this was expected given the hemorrhage in the right fronto parietal region his mannitol and decadron were weaned on post op day he was brought to the angio suite to embolize any potentially remaining cerebellar avm there was nothing to embolize this could be secondary to swelling and a second angio is planned on patient spiked fevers and was pancultured csf was sent and he was switched to keppra from dilantin for fevers his exam remains stable he follows commands r l and was distally in bue infectious disease was consulted for fevers which they thought his fevers were due to aspiration pna all cultures are negative to date no antibiotics were started his evd was raised to and then a clamping trial was attempted in which patient s icp were elevated and drain was re opened patient was trached and peged on and then taken to the or for vps placement on evd still in place to make sure vps draining adequately and will be discontinued in one to two days if icps remain stable evd was removed and a final csf culture was sent patient s cxr from noted to have lll collapse which was brought up to the sicu team cefazolin was discontinued patient s exam remains stable now on trach mask and was transferred to step down unit head ct after evd was removed was stable and there for no evidence of hemorrhage pt and ot were consulted and recommended discharge to acute rehab on a cxr was obtained which revealed worsening opacification at the left base with obscuration of the hemidiaphragm this is consistent with increasing left lower lobe collapse and probable small pleural effusion neurological exam remained stable the foley catheter was removed but the patient was not able to completely empty his bladder therefore it was replaced on a medical consult was obtained for concern regarding his cxr and they recommended no antibiotics unless patient had a fever spike of or greater along with an elevated wbc he should have a cxr again in one weeks time to evaluate his pulmonary status or sooner if a fever should develop medications on admission unknown discharge medications glucagon human recombinant mg recon soln sig one recon soln injection q min as needed for hypoglycemia protocol albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheezing docusate sodium mg ml liquid sig one po bid times a day heparin porcine unit ml solution sig one injection tid times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for fever senna mg tablet sig one tablet po bid times a day oxycodone mg tablet sig tablets po q h every hours as needed for pain methocarbamol mg tablet sig one tablet po qid times a day metoprolol tartrate mg tablet sig two tablet po tid times a day levetiracetam mg tablet sig three tablet po bid times a day lisinopril mg tablet sig one tablet po daily daily hydromorphone dilaudid mg iv q h prn breakthrough pain dextrose gm iv prn hypoglycemia protocol insulin regular human unit ml cartridge sig one injection every six hours albuterol sulfate mcg actuation hfa aerosol inhaler sig six puff inhalation q h every hours as needed for wheezing famotidine mg tablet sig one tablet po bid times a day bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation discharge disposition extended care facility discharge diagnosis aterio venous malformation cerebellar hemorrhage right frontal hemorrhage non communicating hydrocephalus left hemiparesis respiratory failure dysphagia left renal cyst discharge condition mental status clear and coherent level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair discharge instructions general instructions wound care you or a family member should inspect your wound every day and report any of the following problems to your physician keep your incision clean and dry you may wash your hair with a mild shampoo hours after your sutures are removed do not apply any lotions ointments or other products to your incision do not drive until you are seen at the first follow up appointment do not lift objects over pounds until approved by your physician diet usually no special diet is prescribed after a craniotomy a normal well balanced diet is recommended for recovery and you should resume any specially prescribed diet you were eating before your surgery medications take all of your medications as ordered you do not have to take pain medication unless it is needed it is important that you are able to cough breathe deeply and is comfortable enough to walk do not use alcohol while taking pain medication medications that may be prescribed include o narcotic pain medication such as dilaudid hydromorphone o an over the counter stool softener for constipation colace or docusate if you become constipated try products such as dulcolax milk of magnesia first and then magnesium citrate or fleets enema if needed often times pain medication and anesthesia can cause constipation if you have been prescribed dilantin phenytoin for anti seizure medicine take it as prescribed and follow up with laboratory blood drawing in one week this can be drawn at your pcp s office but please have the results faxed to if you have been discharged on keppra levetiracetam you will not require blood work monitoring if you were on a medication such as coumadin warfarin or plavix clopidogrel or aspirin prior to your surgery you may safely resume taking this on xxxxxxxxxxx unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc as this can increase your chances of bleeding activity the first few weeks after you are discharged you may feel tired or fatigued this is normal you should become a little stronger every day activity is the most important measure you can take to prevent complications and to begin to feel like yourself again in general follow the activity instructions given to you by your doctor and therapist increase your activity slowly do not do too much because you are feeling good you may resume sexual activity as your tolerance allows if you feel light headed or fatigued after increasing activity rest decrease the amount of activity that you do and begin building your tolerance to activity more slowly do not drive until you speak with your physician do not lift objects over pounds until approved by your physician avoid any activity that causes you to hold your breath and push for example weight lifting lifting or moving heavy objects or straining at stool do your breathing exercises every two hours use your incentive spirometer times every hour that you are awake when to call your surgeon with any surgery there are risks of complications although your surgery is over there is the possibility of some of these complications developing these complications include infection blood clots or neurological changes call your physician immediately if you experience confusion fainting blacking out extreme fatigue memory loss or difficulty speaking double or blurred vision loss of vision either partial or total hallucinations numbness tingling or weakness in your extremities or face stiff neck and or a fever of f or more severe sensitivity to light photophobia severe headache or change in headache seizure problems controlling your bowels or bladder productive cough with yellow or green sputum swelling redness or tenderness in your calf or thigh call or go to the nearest emergency room if you experience sudden difficulty in breathing new onset of seizure or change in seizure or seizure from which you wake up confused a seizure that lasts more than minutes important instructions regarding emergencies and after hour calls if you have what you feel is a true emergency at any time please present immediately to your local emergency room where a doctor there will evaluate you and contact us if needed due to the complexity of neurosurgical procedures and treatment of neurosurgical problems effective advice regarding emergency situations cannot be given over the telephone should you have a situation which is not life threatening but you feel needs addressing before normal office hours or on the weekend please present to the local emergency room where the physician there will evaluate you and contact us if needed followup instructions follow up appointment instructions please make an appointment to be seen in the clinic with dr at you will need a repeat angiogram in aprox one month please ask to see if dr would like to see you before this procedure you will need a ct scan of the brain without contrast completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-14"",
""date_of_birth"" : ""2050-1-1"",
""sex"" : ""M"",
""service"" : ""NEUROSURGERY"",
""allergies"" : [
""Patient recorded as having no known allergies to drugs.""
],
""chief_complaint"" : ""Worst headache of life"",
""major_surgical_or_invasive_procedure"" : ""Bilateral suboccipital craniectomy, evacuation of cerebellar hemorrhage, placement of right frontal external ventricular drain, removal of right frontal external ventricular drain"
78797,admission date discharge date date of birth sex f service medicine allergies ampicillin compazine tegaderm tincture of benzoin attending chief complaint shortness of breath hypoglycemia major surgical or invasive procedure broncoscopy esophagastroduodenoscopy intubation removal of lap band history of present illness the patient is a year old female with a past medical history of type ii diabetes on an insulin pump complicated by gastroparesis osa htn s p gastric banding and several food and drug allergies that presented to clinic with hypoglycemia and shortness of breath dr brought the patient to the ed where she was given salumedrol epinephrine benadryl and pepcid for suspected allergic reaction the patient was in respiratory distress and began having altered mental status her respiratory effort increased and she was noted to have an o sat of she was placed on nrb and sats improved to she continued to have increased work of breathing and worsening respiratory distress she was placed on niv and shortly after she began vomiting with suspicion for aspiration anesthesia was called and the patient was intubated for protection of her airway review of systems were not obtained due to the patient s sedation past medical history obesity bmi s p gastric banding tightening dr hypertension congestive heart failure type i diabetes uses insulin pump dm neuropathy dyslipidemia djd osa on bipap h o le osteomyelitis s p toe amps breast dcis s p excision h o bowel obstruction tx ng decompression h o left plantar ulcer s p abx and debridement social history lives with cat never smoked no etoh born and raised in she has a college degree she has never married but raised adopted children she lives alone and has a cat she works out of her home as an organizational consultant family history her father has cardiac disease and her sister has ovarian cancer mother died at the age of of complications of a long history with hypertension and diabetes mellitus she was also obese her father died at the age of of coronary artery disease and had had a cabg at the age of she had one younger sister who died of ovarian cancer ms has had genetic testing and did not have the gene for familial ovarian and breast cancer she is not aware of any other disorders that run in her family physical exam exam on admission general obese female sedated on propofol not responding to stimuli or commands heent normocephalic atraumatic no conjunctival pallor no scleral icterus perrla eomi mmm op clear poor dentition neck supple no lad no thyromegaly cardiac regular rhythm normal rate normal s s no murmurs rubs or jvp difficult to assess due to body habitus lungs diffusely rhonchorus poor air movement biaterally abdomen nabs obese soft nt nd midline epigastric scar no hsm extremities cool extremities distally with palpable radial and dp pulses no edema or calf pain skin no rashes lesions ecchymoses neuro intubated and sedated not responding to commands on discharge pt was alert and oriented faint sem lungs with faint bibasilar crackles pertinent results on admission pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood ctropnt pm blood calcium phos mg pm blood type art peep po pco ph caltco base xs intubat intubated vent controlled pm blood lactate pm blood hgb calchct pm blood freeca on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl am blood calcium phos mg am blood type art po pco ph caltco base xs intubat not intuba am blood lactate cxr on admission bibasilar opacities most prominent in the left retrocardiac area considerations include atelectasis or infectious consolidation these might be distinguished with a repeat study with better inspiration ct chest large distention of the esophagus with a coiled nasogastric tube this tube should be removed extensive bilateral pulmonary consolidations with aspirated material visualized in the left mainstem bronchus and in distal segmental airways as above dense atherosclerotic calcification involving the mitral annulus and coronary arteries scattered pulmonary nodules these should be followed up with a dedicated ct of the chest in six months after acute presentation resolves abd film moderate amount of stool in the sigmoid and descending colon consistent with constipation there is no evidence of large or small bowel obstruction doppler ue no upper extremity deep venous thrombosis ct abd interval development of ground glass opacity in the lungs bilaterally this likely represents edema interval decrease in more focal solid consolidations in the left lung when compared to prior exam small bilateral pleural effusions extensive hilar lymphadenopathy as described above possibly reactive left thyroid gland nodule further non urgent thyroid ultrasound is recommended pulmonary nodules followup chest ct within six months is recommended indeterminate left renal lesion in the lower pole incompletely characterized further evaluation with ultrasaound is recommended fibroid uterus multilevel degenerative changes with moderate to severe canal stenosis particularly within the lumbar spine no evidence of bowel obstruction cta chest interval development of ground glass opacity in the lungs bilaterally this likely represents edema interval decrease in more focal solid consolidations in the left lung when compared to prior exam small bilateral pleural effusions extensive hilar lymphadenopathy as described above possibly reactive left thyroid gland nodule further non urgent thyroid ultrasound is recommended pulmonary nodules followup chest ct within six months is recommended indeterminate left renal lesion in the lower pole incompletely characterized further evaluation with ultrasaound is recommended fibroid uterus multilevel degenerative changes with moderate to severe canal stenosis particularly within the lumbar spine le doppler there is no ultrasound evidence of deep venous thrombosis of the left lower extremity barium swallow severe esophageal dysmotility which appears unchanged with the comparison study the appearance is not typical of achalasia cxr the tip and side port of the nasogastric tube are beyond the gastroesophageal junction within the fundus of the stomach cardiac silhouette is within normal limits the right ij central venous catheter has been removed there remained some mild prominence of the pulmonary interstitial markings without focal consolidation brief hospital course yo female with a past medical history for dm ii htn osa and multiple allergies transfered to the for respiratory failure aspiration and pneumonia in the context of lap band migration hypoxemic respiratory failure the patient was noted to be in respiratory distess with altered mental status in ed there was a concern for allergic reaction and the patient received epinephrine solumedrol benadryl and h blocker she was also found to be profoundly hypoxemic and was placed on nrb with transient imporvement in o sats and eventually on niv due to increased work of breathing shortly after she began vomiting and had to be intubated for protection of her airway abg was consistent with a mixed acid base disorder with primary respiratory acidosis and a metabolic alkalosis the latter likely secondary to her outpatient furosemide underlying etilogies include aspiration pna pneumonitis infectious processes such as bacterial and viral pneumonia on presentation to the patient was maintained on mechanical ventilation for protection of her airway her oxygenation status was monitored with serial abgs she received right ij cvl for access on day she was noted to have complete opacification of a left hemithorax on cxr likely secondary to mucus plug which improved significantly with suctioning the patient remained hemodynamically stable throughout and did not require pressors she received flexible bronchoscopy which revelealed mucus with inspissated food particles in lll segments some of the food particles were successfully removed at that time she was transferred to the icu for rigid bronchoscopy to remove remaining aspirated material at the time of transfer the patient is hemodynamically stable and is satting well on ac on micu pt received rigid bronchoscopy with good effect collapsed segments expanded pt was extubated on ceftriaxone was discontinued as it was felt to be redundant with levaquin for covg of cap at the time of tx to the floor she had completed days of vancomycin levaquin flagyl on the floor patient remained clinically stable with no further episodes of hypoxia and minimal oxygen requirements pneumonia on admission most likely diagnosis was aspiration pna given migration of lap band and esophageal obstruction aspiration pneumonitis was a possibility as well cap flu and other viral etiologies were considered as well the patient was noted to have dense consolidation in lll on imaging c w aspiration or cap the patient was also noted to have leukocytosis due to either an infectious process or steroid therapy that she received while in the ed the patient was started treatment with levofloxacin and flagyl for coverage of suspected pathogens based on etiologies described above vancomycin and ceftriaxone were added to cover for staph given h o diabetes as well as to double cover gnr she completed a day course of antibiotics and remained stable on the floor with no fever or respiratory distress wbc remained slightly elevated however with no localizing symptoms and clinical improvement abx were not restarted on discharge pt was satting well with nl wbc and no fever megaesophagus on admission the patient was noted to have markedly dilated esophagus she was evaluated by surgery and underwent removal of her gastric band due to extremely high risk of aspiration she tolerated the procedure well her hct remained stable she was transiently hypotenisve but responded well to ivf bolus and did not require pressors following surgery the patient was maintained npo and ngt was placed to suction after extubation barium swallow revealed extensive esophageal dysmotility and she was placed on a bariatric diet after several days of ppn she had no additional aspiration events after initiation of a bariatric diet and was discharged to rehab on stage of the diet hypoglycemia dm ii on admission the patient was hypoglycemic due to underlying infectious process vs pump malfunction pump was stopped and the patient was started on ssi for glucose control finger sticks were monitored q hours the patient became significantly hyperglycemic and had to be started on insulin gtt with hourly finger sticks on micu pt transitioned to lantus and humalog sub q she was maintained on units of glargine decreased to units given decreased po intake and aggressive iss on discharge sugars were running between and s she was discharged on glargine units and a humalog sliding scale hypertension on admission the patient s bp meds were held with the plan to give iv labetalol or hydralazine if the patient become hypertensive after extubation bp trended up even on home dose of diovan hydralazine was uptitirated to mg qid on transfer to the floor pressures somewhate elevated with home diovan and hydralazine hydralazine was discontinued and she was started on amlodipine and hctz as well as home dose of spironolactone which may need to be uptitrated as an outpatient for optimal bp control persistent fevers no organisms isolated from sputum or blood ua not striking for infxn it is conceivable that persistent fevers were the consequence of inflammation secondary to pneumonitis pna or line infection given that ij line was removed out of concern for pus draining from insertion site given ue edema svc thrombus and ue dvts were also excluded with cta and dopplers repectively fevers improved after abx lung nodules be due to aspiration event but would recommend out pt follow up with repeat imaging in month chf stable she was continued on her home dose of metoprolol thyroid nodule left thyroid gland nodule further non urgent thyroid ultrasound is recommended depression cymbalta was held in the micu and then not restarted given that it is unable to be crushed pt states that she did not feel that she needed it and was warned of possible adverse effect would use caution in restarting anti depressants as wk washout period is recommended to prevent seratonergic side effects rash new errythematous intertriginous rash on neck suspicious for fungal infection was treated with miconazole powder medications on admission celebrex mg q day mg ca with vit d q day furosemide mg spironolactone mg a day vitamin e u q day diovan mg prilosec otc mg q dat trilipix mg q day vitamin b q day niaspan mg q day aspirin mg q day vitamin c mg q day cymbalta mg q dday vesicare mg q day fiver capsule q day clonazepam mg alpha lipoic acid mg q day metoprolol tartrate mg mv omega glucosamine with msm trazadone mq q hs zantac mg q day simvastatin mg qhs insulin pump discharge medications acetaminophen mg tablet one tablet po q h every hours as needed for fevers pain valsartan mg tablet two tablet po bid times a day miconazole nitrate powder one appl topical tid times a day metoprolol tartrate mg tablet one tablet po bid times a day docusate sodium mg ml liquid one po bid times a day senna mg tablet one tablet po bid times a day as needed for constipation hydrochlorothiazide mg capsule one capsule po daily daily amlodipine mg tablet one tablet po daily daily mg tablet one tablet po twice a day as needed for allergy symptoms aspirin mg tablet one tablet po once a day calcium mg tablet one tablet po twice a day tablet s celebrex mg capsule one capsule po once a day clonazepam mg tablet one tablet po twice a day furosemide mg tablet one tablet po twice a day metamucil oral multivitamin tablet one tablet po once a day niacin mg tablet one tablet po twice a day omega fatty acids capsule one capsule po once a day simvastatin mg tablet one tablet po at bedtime trazodone mg tablet one tablet po at bedtime vitamin b oral vitamin c oral lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr once a day zantac mg ml syrup twenty ml po at bedtime vitamin e unit tablet one tablet po once a day vesicare mg tablet one tablet po once a day glucosamine msm oral vitamin d oral alpha lipoic acid oral insulin glargine unit ml solution thirty units subcutaneous at bedtime humalog unit ml solution one unit subcutaneous four times a day please give per insulin sliding scale spironolactone mg tablet one tablet po daily daily discharge disposition extended care facility health care center discharge diagnosis esophageal dysmotility aspiration pneumonia discharge condition stable tolerating stage of bariatric diet afebrile discharge instructions you were admitted for aspiration in the context of migration of your lap band which lead to pneumonia and required an icu admission you improved with supportive care and antibiotics your lab band was removed however you were found to have continued esophageal dysmotility therefore your diet was advanced cautiously you were tolerating stage of the bariatric diet on discharge please take your medications as prescribed and follow up with your doctors below your trilipix and cymbalta were held given that they cannot be administered as crushed pills however you may restart them once you resume a regular diet and you should contact your physician if you are feeling depressed additionally you were started on hydrochlorothiazide and amlodipine for your blood pressure and you were switched to insulin glargine and humalog for diabetes you will need to see surgery in weeks and should continue taking stage of the bariatric diet until that time please return to the hospital or call your doctor if you should experience increased difficulty swallowing aspiration new cough or fever or any other symptoms that are concerning to you followup instructions please follow up with surgery as below provider md phone date time additionally please schedule an appointment with dr after you leave the rehab facility and keep the following previously scheduled appointments provider intake one rooms bays date time provider clinic interventional pulmonary sb phone date time provider sacks licsw phone date time finally you were found to have a lung nodule as well as a thyroid nodule you will need to follow up with your primary care physician for further of these lesions md,"{
""name"": ""Jane Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Ampicillin"",
""Compazine"",
""Tegaderm"",
""Tincture of benzoin""
],
""attendingChiefComplaint"": ""Shortness of breath, hypoglycemia"",
""chiefComplaint"": ""Shortness of breath, hypoglycemia"",
""historyOfPresentIllness"": ""The patient is a year old female with a past medical history of type II diabetes on an insulin pump complicated by gastroparesis OSA, HTN s p gastric banding and several food and drug allergies that presented to clinic with hypoglycem"
549,admission date discharge date date of birth sex f service medicine history of present illness this is a year old female with previous history of hypertension atrial fibrillation and sick sinus syndrome status post pacemaker who originally presented to an outside hospital with acute pancreatitis secondary to gallstone she was treated at the outside hospital with intravenous fluids and was put npo for bowel rest however she subsequently developed worsening shortness of breath even though her pancreatitis was being adequately treated the thinking at that point was congestive heart failure versus pneumonia versus ards her hypoxia was slowly worsening and she was thus transferred to the on a regular floor she was originally being managed with antibiotics and diuresis however on the second day of admission the patient became severely hypoxic with o saturations of about to on nonrebreather she had a transthoracic echocardiogram which revealed an ejection fraction of thus leaving the most likely explanation to be ards the patient was transferred to the medical intensive care unit where she was intubated on the day of intubation which was she was also started on two pressors levophed and vasopressin at the same time there was a rising suspicion of worsening of her pancreatitis which could have lead to her ards because of this she was started on a day course of imipenem on the following day she was found to have a low cortisol a m level so she was started on hydrocortisone mg tid for renal insufficiency imaging studies at this point revealed the following head ct was negative for a bleed chest ct showed ards and abdominal ct revealed no evidence of abscess or necrosis in the pancreas on the patient had urine culture and sputum cultures growing yeast and she was started on a five day course of fluconazole which she completed without complications the patient s respiratory status slowly improved and after about days of intubation decision was made to try to extubate her however she appeared difficult to extubate and appeared sedated this situation however improved and finally on she was extubated at this point she was transferred to our care on the regular medical floor past medical history hypertension atrial fibrillation sick sinus syndrome status post pacemaker status post mitral valve replacement home medications prior to admission to outside hospital atacand lipitor digoxin zoloft coumadin lasix medications upon transfer to our floor coumadin mg qd digoxin mg qd zoloft mg qd erythropoietin units x a week heparin intravenous gtt regular insulin sliding scale lactulose ml q h prn dulcolax pr q hs prn allergies no known drug allergies social history she lives alone and is widowed her son is very involved in her care there is no use of tobacco or alcohol family history noncontributory physical exam vital signs temperature blood pressure pulse respiratory rate with saturations on liters nasal cannula general this is a chronically ill appearing woman smiling head ears eyes nose and throat pupils equal and reactive to light extraocular movements intact oropharynx is clear mucous membranes appear dry neck there is no lymphadenopathy jugular venous pressure elevated to about cm respiratory difficult to fully assess secondary to deconditioning however there are crackles about of the way up cardiovascular regular rate systolic ejection murmur best heard at the left upper sternal border there is a also a holosystolic murmur best heard at the right upper sternal border abdomen soft nontender nondistended with hyperactive bowel sounds no mass and no liver edge extremities lower extremities are puffy without pitting edema and pulses neurologic mental status alert and oriented to place but not to time comprehension appears intact language is fluent the patient is somewhat somnolent cranial nerves are intact motor and sensory difficult to test secondary to patient s noncompliance there were no focal abnormalities laboratories on transfer white count hematocrit platelets sodium potassium chloride bicarbonate bun creatinine glucose pt with inr of ptt alt ast alkaline phosphatase total bilirubin amylase lipase calcium phosphorus magnesium her last arterial blood gas and fio of showed ph pco po brief hospital course upon transfer cardiovascular the patient was deemed to be slightly volume overloaded when she experienced the hypertensive episode in the medical intensive care unit she received over liters of fluid to maintain hemodynamic instability as a consequence she has been volume overloaded ever since then but has been able to diurese without requiring administration of lasix we therefore continued this and patient was about to cc negative every day her blood pressure remained in the range of systolic to and diastolic to we therefore did not restore her outpatient atacand we continued her on lipitor and digoxin her rhythm remained to be chronic atrial fibrillation in this context we also started coumadin she was originally receiving mg of coumadin but after three days of that there was no significant improvement in her inr we therefore increased the dose of coumadin to she will require close follow up of her inr until it reached a therapeutic level between and gastrointestinal the patient s pancreatitis was considered clinically resolved by the time she was admitted to our service she had no complaints of abdominal pain nausea vomiting or any other signs to indicate a recurrence of infection she had received several days of tpn in the intensive care unit as well as a day of tube feeds she was receiving the tube feeds through a catheter placed in her jejunum for the first two hospital days on the floor she continued to receive tube feeds through the jejunal tube tpn however was discontinued on hospital day on the regular medical floor she was started on clear fluids after consultation with the gastroenterology service she tolerated this very well with no episodes of nausea or vomiting she was therefore advanced to full liquids and this subsequently was advanced to a diet as tolerated the patient is very well on solid foods without complaints of nausea vomiting abdominal pain or diarrhea in addition to this she had a speech and swallow study which revealed intact swallowing apparatus the study was performed given lengthy medical intensive care unit stay and possibility of damage to the swallowing apparatus following days of intubation pulmonary ards had resolved during her medical intensive care unit stay the patient had a very low oxygen requirement and subsequently was saturating to on room air her respiratory exam continued to have occasional crackles bilaterally at the bases which was attributed to a resolution of her ards anemia the patient has been mildly anemic however clear etiology for this anemia was not reached her hematocrit slowly increased from about to without any transfusions stool guaiac was checked and was negative neurology the patient s mental status has been of concern following her extubation she remains very somnolent most of the time not oriented to be place in addition her speech was very labored sometimes not intelligible upon careful neurological examination there was no focal weakness or any cranial nerve abnormalities that were detected she received a non contrast ct of the head which showed no intracranial bleed we therefore felt that her mental status was mostly resolved for prolonged intensive care unit stay and did not require further investigation at this point it is quite likely that her mental status will slowly improve with time discharge condition stable discharge status discharge to in acute care rehabilitation discharge diagnoses pancreatitis ards discharge medications zoloft mg po qd digoxin po qd lipitor mg po qd erythropoietin units x a week coumadin mg po qd tylenol to po q to hours prn lactulose ml po q h prn dulcolax mg prn q hs heparin intravenous guideline scale m d dictated by medquist d t job,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""2012-1-1"",
""sex"": ""Female"",
""service"": ""Medicine"",
""history of present illness"": ""This is a year old female with previous history of hypertension atrial fibrillation and sick sinus syndrome status post pacemaker who originally presented to an outside hospital with acute pancreatitis secondary to gallstone she was treated at the outside hospital with intravenous fluids and was put npo for bowel rest however she subsequently developed worsening shortness of breath even though her pancreatitis was being adequately treated the thinking at that point was congestive heart failure versus pneumonia versus ards her hypoxia was slowly worsening and she was thus transferred to the on a regular floor"
24023,admission date discharge date date of birth sex m service history of present illness this is a year old male with a known history of endocarditis who was recently discharged from on on ampicillin and gentamicin for an enterococcal bacteremia he represented to the hospital on with a temperature with ibuprofen use past medical history hepatitis c virus x years with interferon treatment gerd enterococcal bacteremia and endocarditis mitral regurgitation with torn mitral chordae history of iv drug use with being the last stated use congestive heart failure anemia medications on admission ampicillin grams iv q h gentamicin mg iv q h lasix mg once a day ferrous sulfate mg once a day ibuprofen mg p o x a day colace nicoderm patch td mg once a day seroquel mg twice a day with an additional mg dose every evening multivitamins and vitamin e social history patient is a current smoker with a pack year history and admitted to remote iv cocaine use remote alcohol abuse and he is a resident of a facility for rehabilitation he was admitted to the hospital on for evaluation of his fever on double iv antibiotics admission labs were a white count of hematocrit platelet count sodium k chloride bicarbonate bun creatinine with a blood sugar of peak and trough gentamicin studies were done additional blood cultures were done patient had a long preoperative course over the course of the approximately weeks prior to his surgery he completed a day course of ampicillin iv and a day course of gentamicin iv he had minor complications from this which included an episode of acute renal failure with his creatinine trending up to and then back down again before prior to surgery his blood cultures did show enterococcus which was treated with double antibiotic therapy he also developed vertebral osteomyelitis during his hospital stay which was diagnosed by mri and evaluated by neurosurgery which recommended only antibiotic therapy and no need to biopsy or pursue at this time he was followed daily by the infectious disease service as well as by cardiology service and was maintained for chf with originally lasix and ace inhibitor over the course of his stay preoperatively he also developed a right lower extremity peroneal vein dvt for which he was initially heparinized and then placed on coumadin at therapeutic doses for coverage of the dvt picc line was also placed during that weeks stay prior to surgery ultimately the patient also had a cardiac catheterization on which showed clean coronary arteries severe mitral regurgitation severe tricuspid regurgitation and severe pulmonary hypertension over the course of this stay it was also discovered the patient required dental extractions he was seen by the omfs service he was then transitioned from coumadin to lovenox and then ultimately as the inr dropped down to iv heparin in preparation for teeth extraction which took place on in addition during that time period he did complete his weeks course of antibiotics after his extractions he went back on coumadin on days prior to surgery he had a repeat tee which showed severe mr mild to moderate tr and no abscess present in his heart the patient was finally cleared for surgery a repeat mri was done in late which showed essentially no change in the vertebral osteomyelitis but with the official radiology that clinical findings often precede mr findings which lag behind dr accepted evaluation and when the patient had approximately days of negative blood cultures he agreed to do the mitral valve prolapse the patient had been off all antibiotics approximately days at that time laboratory studies the day prior to operation were as follows sodium k chloride bicarbonate bun creatinine with a blood sugar of anion gap white count hematocrit platelet count pt ptt on heparin drip with an inr of was then officially cleared for surgery and on the patient underwent mitral valve prolapse with a mm porcine mitral valve by dr he was transferred to cardiothoracic icu in stable condition on postoperative day patient had been extubated had a respiratory rate of saturating on nasal cannula postoperatively white count was hematocrit platelet count inr creatinine k his exam was unremarkable he began lopressor beta blockade and lasix diuresis again patient was transferred out to the floor that afternoon he was seen again by cardiology postoperatively and case management to help him set up his living situation postoperatively he had also been followed repeatedly by social work services preoperatively about months before surgery on postoperative day his creatinine remained stable at his white count rose slightly to he was sleepy but appropriate and with a nonfocal neurological exam he had some nausea and vomiting early that morning he continued on perioperative vancomycin his foley was removed his pacing wires were removed he started heparin for his dvt after his pacing wires were removed later that day id was again reconsulted for clarification of postop antibiotics white count was rechecked the following morning with a plan to panculture the patient if patient developed any fever however the patient had a temperature of only that morning patient was seen and evaluated by physical therapy and began to work on ambulation with support from pt and the nurses on postoperative day patient had already ambulated to level was on heparin at units an hour received his first dose of coumadin mg later that evening his lasix was switched over to p o he was encouraged to increase his activity level with a plan to discharge him to his outside living situation in approximately the next days central venous line was removed pacing wires had already been removed heart was regular rate and rhythm with a grade systolic ejection murmur sternum was stable incision was clean dry and intact he had a nonfocal neurologic exam and his lungs were clear bilaterally his weight was below his preoperative weight by kilograms rereening was completed on postoperative day the day of discharge he did a level his blood pressure was in sinus rhythm at with a respiratory rate of saturating on room air he continued on his heparin and received his coumadin to get him therapeutic from his dose the night prior he continued with his beta blockade with metoprolol mg p o b i d his exam was unremarkable the patient did have a bowel movement he was ready for discharge home and was progressing very well he had been receiving heparin and coumadin for his dvt prior to surgery but the nurse practitioner spoke with a primary care group dr who felt the patient did not need to be anticoagulated surveillance blood cultures were drawn and the patient was given instructions to followup with id in weeks with dr in weeks for his postop surgical visit and with dr in weeks postdischarge labs prior to discharge showed a white count of hematocrit platelet count creatinine coumadin was discontinued discharge diagnoses status post mitral valve replacement with mm porcine mitral valve hepatitis c x years intravenous drug abuse vertebral osteomyelitis enterococcus bacteremia with endocarditis mitral regurgitation with torn mitral chordae congestive heart failure anemia right lower extremity deep venous thrombosis status post dental extractions discharge medications lasix mg p o once daily x days ferrous sulfate mg p o once a day for month quetiapine fumarate mg p o twice a day nicotine mg hour patch apply patch transdermally daily metoprolol mg p o twice a day potassium chloride meq p o once a day for days colace mg p o twice a day aspirin enteric coated mg p o once a day percocet one to two tablets p o p r n q h for pain condition at discharge again the patient was discharged in stable condition on to his rehab facility m d dictated by medquist d t job,"[
""date"": ""2019-10-10"",
""type"": ""SPECIFIC_DATE"",
""subtype"": ""DATE""
},
""date"": ""2019-10-11"",
""type"": ""SPECIFIC_DATE"",
""subtype"": ""DATE""
},
""date"": ""2019-10-12"",
""type"": ""SPECIFIC_DATE"",
""subtype"": ""DATE""
},
""date"": ""2019-10-13"",
""type"": ""SPECIFIC_DATE"",
""subtype"": ""DATE""
},
""date"": ""2019-10-14"",
""type"": ""SPECIFIC_DATE"",
""subtype"": ""DATE""
},
""date"":"
7042,admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint headache major surgical or invasive procedure occipital creaniectomy ventricular drain placement mri mra cta history of present illness pt is a yo male w pmhx sig for hypercholesterolemia anxiety depression who is transferred from for cerebellar stroke the patient was in his usoh when on at am he woke with a left sided headache and throbbing pain behind the left eye he then felt nauseated and upon standing up felt that the room was spinning ems was called and the patient was brought to on the ambulance ride he had one bout of emesis mri scan was performed and showed a left pica infarct the patient was placed on aspirin mg and lipitor later in the day the patient complained of worsened headache and was sent for ct scan that showed edema with midline shift he was given mg of iv mannitol the patient s neurological exam remained stable but transfer was requested for patient to be monitored in a neuroicu bed pt still complains of peri stent headache that is currently a he denies numbness weakness visual changes dysarthria dysphagia diplopia fevers chills night sweats bowel bladder incontinence lifts heavy weights up to lbs and was lifting heavy bags of leaves hrs prior to event past medical history hypercholesterolemia anxiety depression social history works in it lives with wife an children no tobacco occasional etoh family history father mi in s physical exam vitals t bp p rr general lying in bed nad heent ncat moist mucous membranes neck supple no carotid bruit pulmonary cta b l cardiac regular rate and rhythm with no m r g carotids no blood flow murmur abdomen soft nontender non distended normal bowel sounds extremities no c c e neurological exam mental status a o x relays coherent history fluent speech with no paraphasic or phonemic errors adequate comprehension follows simple and multi step commands cranial nerves i not tested ii perrl mm with light vff iii iv vi eomi no nystagmus v vii facial sensation intact facial strength viii hearing intact b l to finger rubbing ix x palatal elevation symmetrical scm xii tongue midline without fasciculations motor normal bulk normal tone no pronator drift delt tri we wf fe ff ip qd ham df pf edb rt left sensation intact to pinprick light touch vibration and position sense reflexes bic t br pa ac right left toes downgoing bilaterally coordination left sided dysmetria pertinent results am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am triglycer hdl chol chol hdl ldl calc am hba c hgb done a c done mra head dissection of left vertebral artery at c with diminished flow signal and diminished flow signal in the basilar artery both posterior cerebral arteries are visualized and appear to be predominantly getting flow from the anterior circulation through posterior communicating arteries no abnormalities in the anterior circulation mra neck diminished flow signal within the left vertebral artery in its proximal cervical portion with evidence of dissection at the level of c right vertebral artery predominantly ends in posterior inferior cerebellar artery normal carotid arteries in the neck mri brain acute left cerebellar infarct with mass effect other changes as described above head ct on admission there is a large area of cytotoxic edema involving left cerebellar hemisphere producing mild to moderate hydrocephalus left to right shift of normally midline structures as well as tonsillar herniation there is no acute intracranial hemorrhage head ct post op interval placement of a ventricular catheter with interval suboccipital craniectomy with post operative pneumocephalus new small foci of hyperdense material present within the patient s left cerebellar infarct are consistent with acute blood products presumably post surgical brief hospital course neurologically exam was stable on arrival with findings of mild left worse than right ataxia dysmetria and impaired abduction bilaterally with left sided nystagmus on left lateral gaze received one dose of mannitol en route and started on gm q morning of admission ct from admission showed concern for mild mod hydrocephalus and tonsilar herniation as this was less than hours out from symptom onset there was great concnern for further edema and mass effect on brainstem structures as well as further development of hydrocephalus was taken to the or urgently on day of admission for decompression by craniectomy and also evd extraventricular drain placement no intraoperative complications cta and mra of neck showed left vertebral artery dissection at level of c extending upwards see report section for details decision to start anticoagulation was made patient received one does coumadin mg on evening of with anticipation of drain being pulled within hrs drain removal was postponed however so anticoagulation was post poned until drain discontinued was covered prophyactically with cefazolin while drain in place stayed in the neuro intensive care until with close monitoring of neurological exam and icp was continued on dexamethasone for days per neurosurgery request and had vent drain clamped on am follow up ct hrs later showed some development of hydrocephalus and was discussed to keep drain clamped and follow up with second catscan later afternoon exam remained stable was treated prophylactically in icu with asa and lipitor with plan to start anticoagulation after vent drain removal at which time asa to be stopped cardiovascular was on telemetry with no events in icu had echo which shoed ef and had negative bubble study had one negative set of cardiac enzymes from time of transfer was managed with antihypertensives labetolol and verapamil as well as some as needed doses in order to keep blood pressures within acceptable range respiratory no major issues endo hba c was covered prophylactically with regular insulin sliding scale and q hrs finger sticks infectious no infectious disease issues treated prophylactically with cefazolin while drain in place renal no issues gi no issues received zantac for prophylaxis and tolerated regular diet prophylaxis heparin sc zantac pneumoboots patient was cared for by dr while inpatient medications on admission wellbutrin mg q day neurontin mg anxiety discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily docusate sodium mg capsule sig one capsule po bid times a day atorvastatin mg tablet sig one tablet po daily daily gabapentin mg capsule sig two capsule po bid times a day heparin porcine unit ml solution sig units injection tid times a day senna mg tablet sig one tablet po daily daily acetaminophen mg tablet sig one tablet po q h every to hours as needed diazepam mg tablet sig one tablet po q famotidine mg tablet sig one tablet po q h every hours tramadol mg tablet sig one tablet po q h every to hours as needed for pain bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed warfarin mg tablet sig one tablet po hs at bedtime labetalol mg tablet sig one tablet po bid times a day enalapril maleate mg tablet sig one tablet po bid times a day skelaxin mg tablet sig two tablet po three times a day as needed for pain discharge disposition extended care facility discharge diagnosis stroke left cerebellum high blood pressure high cholesterol discharge condition neurologically stable discharge instructions please take all medications as prescribed keep all follow up appointments please return to the nearest ed if symptoms of weakness or numbness return you are on a medication warfarin which requires a frequent inr checks by you primary care doctor followup instructions provider md phd date time provider md phone please schedule for within weeks from discharge md,"[
""admission_date"" : ""2022-10-10"",
""discharge_date"" : ""2022-10-12"",
""date_of_birth"" : ""2049-10-10"",
""sex"" : ""Male"",
""service"" : ""Neurology"",
""allergies"" : [
""Patient recorded as having no known allergies to drugs""
],
""attending_chief_complaint"" : ""Headache"",
""chief_complaint"" : ""Headache"",
""history_of_present_illness"" : ""pt is a yo male w pmhx sig for hypercholesterolemia anxiety depression who is transferred from for cerebellar stroke the patient was in his usoh when on at am he w"
14215,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint swollen foot renal failure diarrhea anion gap acidosis major surgical or invasive procedure right ankle joint arthrocentesis history of present illness mr is a year old male with h o t dm chronic vasculitic renal failure who presents with diarrhea and swollen foot and question of dka mr was in his usoh until weeks ago when he developed cough sputum and vomiting nonbilious no blood or coffee grounds approximately qod then three days prior to admission he developed diarrhea bm d no blood no melena no floating but foul smelling watery he denies antibiotic usage recently his symptoms progressed to weakness and dyspnea with climbing one flight of stairs his wife notes some decreased level of consciousness days prior to admission and thereafter he states that he stopped taking insulin for last two days incidentally also notes swollen r foot lateral aspect over last two days otherwise denies fever chills night sweats dysuria difficulty urinating denies cp abdominal pain sick contacts food poisoning but does note polyuria and polydipsia denies any vision changes joint pains or rashes in ed started on insulin gtt however dc d after sugar u a sent hours after insulin gtt initiated and gap closed to initial anion gap past medical history chronic urticarial vasculitis hypocomplementemic vasculitis with chronic renal failure baseline cr h o polymyositis t dm hypertension social history lives in with wife w employment agency tobacco denies alcohol denies family history non contributory physical exam vs l general mildly ill appearing caucasian male nad heent perrl eomi om tacky neck jvp flat supple but tender diffuse shotty lymph nodes cardiovascular s s tachy i vi systolic lusb lungs dry crackles with inspiration in lower lung fields upper clear abdomen soft active bowel sounds nontender nondistended obese could not palpate spleen extremities warm no cce r foot cm diameter tender swollen erythematous warm patch on lateral aspect demarcated with marker no lesions between toes that may have been entry point neuro a ox strength and sensation grossly intact pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot ld ldh alk phos amylase tot bili pm lipase pm albumin calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm plt count pm lactate pertinent studies ekg sinus tachycardia t wave flattening in iii no stt changes imaging ct chest am overall slight increase in abdominal and pelvic lymph nodes shotty lymph nodes noted throughout the mediastinum and hila and right axilla single enlarged lymph node in the left axilla stable granuloma in left lower lobe echo study date of ef mild lvh cxr am the heart size and pulmonary vascularity are normal there is a small calcified granuloma present in the left midlung region the lungs are otherwise clear and there are no pleural effusions the bones are diffusely demineralized the lateral view is technically limited due to suboptimal positioning of the patient s arms limiting assessment of the normally clear retrosternal space cxr new right lower lobe opacities which may represent atelectasis infectious consolidation or infarction if there is a clinical concern for pulmonary embolism further evaluation may be performed by a chest ct angiogram bilateral lower extremity venous dopplers conclusion no dvt possible pes anserinus bursitis or bakers cyst ankle mortise the ankle mortise is definitely intact with no evidence of disruption and the cortical margin of the talus tibia and fibula are unremarkable the subtalar joint is also well preserved conclusion soft tissue swelling and question of slight widening of the first intermetatarsal space worrisome for early changes of osteoarthropathy lung scan vq scan impression no evidence of pe mri right foot results foot ap lat obl left comparison left foot radiograph there is marked soft tissues swelling about the left fifth toe there are expansile lucent lesions involving the phalanges of the left fifth toe which were also present previously but have apparently progressed the cortical margin of the distal aspect of the proximal phalanx and the proximal aspect of the distal phalanx both appear indistinct and were previously sharply marginated these findings are concerning for osteomyelitis additionally there is widening of the joint space which could represent involvement of the joint space by infection brief hospital course cellulitis the patient s cellulitis was concerning for an aggressive infection in the setting of diabetes and relative immunosuppression from mmf toxic granulations dohle bodies were present in his cbc in the micu mr was started with aggressive antibiotic treatment including vanco levo flagyl until a source was found blood cultures were positive bottles for group b strep bacteremia he was later switched to unasyn his cellulitis showed slow but steady improvement he was seen by rheumatology who performed an arthrocentesis on his ankle that was negative for crystals and negative for infection an mri of the foot was concerning for osseous lesion of the th metatarsal which was evaluated by podiatry podiatry felt that a biopsy and or i d was warranted but after talking with id felt that it could wait until rle cellulitis resolved after sensitivities returned id recommended he be switched to iv pcn g while he was in the hospital and discharging him home on pcn v po podiatry will see him in days for follow up and pursue further action based on imaging findings dka vs hyperosmolar hyperglycemia mr was started on an insulin drip in the emergency department for concern for dka his anion gap corrected within the first hours of hospitalization and the insulin drip was discontinued his anion gap was thought to be more likely from starvation ketosis than dka he was started on his regular home insulin regimen and he had no further problems with anion gap acidosis during his hospitalization diarrhea vomiting the etiology of mr diarrhea and vomiting were unclear his diarrhea and vomiting also resolved shortly after admission and no source was identified acute on chronic renal failure mr acute renal failure upon admission creatinine was thought to be a pre renal etiology in the setting of diarrhea vomiting polyuria and possibly insensible losses at home from infection he was given iv fluids for resuscitation and his creatinine returned to his baseline his hypocomplementemic vasculitic kidney disease was stable during this admission his mmr was stopped upon admission but was later restarted in consultation with the renal and rheumatology services his creatinine returned to baseline at time of discharge doe tachycardia mr complained of dyspnea on exertion required l nasal cannula to maintain his oxygen saturation and was persistently tachycardia hr but both the doe and tachycardia resolved concern was raised for a pe additionally the patient complained of a tender erythematous indurated rash with question of a venous cord on the medial aspect of his left thigh which was concerning for dvt the patient was briefly anticoagulated but this was discontinued after lenis were negative for dvt a vq scan was performed and read as low probability for pe a ct angiogram was not performed to rule out dvt given the patient s chronic renal failure from kidney disease as well as the low probability result from vq scan he was asymptomatic by discharge left foot with th toe gout mr also complained of a swollen red and edematous th toe the xray showed widening of the joint space and u s guided aspiraiton was done which showed needle shaped negatively birefringant crystals and k pmn consistent with gout he was started on mg po colchecine qod because of ckd he will follow up with rheumatology for gout rheum recommended a course of steroids if pain and inflammation worsened but it did not by time of discharged and he was discharged home on colchicine which he will be on until his follow up appointment with rheumatology medications on admission cellcept mg once daily calcitriol insulin norvasc mg po daily hctz mg po daily benicar olmesartan mg po daily discharge medications amlodipine mg tablet sig two tablet po daily daily hydrochlorothiazide mg tablet sig one tablet po daily daily colchicine mg tablet sig one tablet po every other day please continue until your rheumatology follow up appointment disp tablet s refills penicillin v potassium mg tablet sig one tablet po every six hours for days disp tablet s refills mycophenolate mofetil mg tablet sig one tablet po once a day discharge disposition home with service facility homecare discharge diagnosis group a beta strep right lower leg cellulitis discharge condition good the patient was discharged afebrile hemodynamically stable with appropriate follow up discharge instructions please follow up with your pcp dr or return to the ed if you have high fevers shaking chills or worsening of your leg infection please seek medical attention if you have the sudden onset of shortness of breath or chest pain followup instructions please call dr at for a follow up appointment within weeks please follow up with dr rheumatology on wednesday at am phone number is please call podiatry for a follow up appointment in days by calling please keep your appointment with dr nephrology in for follow up please follow up with infectious disease on at am in completed by [NEW_RECORD] admission date discharge date date of birth sex m service podiatry allergies patient recorded as having no known allergies to drugs attending chief complaint right foot swelling with open wound major surgical or invasive procedure right foot i d history of present illness y o male patient with significant pmh for dm ii presented to clinic with cc of right foot redness swelling patient states that his right foot has recently worsened the past days patient states a new opening to the right dorsal lateral aspect patient was recently admitted to hospital the for right le cellulitis patient states he was sent home on po abx consisting of pen vk patient states painful right foot on dorsal lateral aspect patient currently denies any fevers chills vomiting nausea or night sweats past medical history chronic urticarial vasculitis hypocomplementemic vasculitis with chronic renal failure baseline cr h o polymyositis t dm hypertension social history lives in with wife w employment agency tobacco denies alcohol denies family history non contributory physical exam nad aox sitting comfortably ctab rrr soft nt nd right foot with palpable pulses dorsal lateral wound c minimal drainage erythema noted w calor w guarding no probe to bone pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt pm tissue rt foot soft tissue gram stain final per x field polymorphonuclear leukocytes no microorganisms seen tissue final no growth anaerobic culture preliminary no growth pm swab source right foot gram stain final no polymorphonuclear leukocytes seen no microorganisms seen wound culture final no growth anaerobic culture preliminary no growth radiology preliminary report foot ap lat obl right am foot ap lat obl right reason assess bone on lateral aspect of foot medical condition year old man w dm s p right foot lateral aspect debridement packed open after finding tophi reason for this examination assess bone on lateral aspect of foot history status post right foot lateral debridement packed open after finding tophi assess bone lateral aspect of foot diabetes right foot three views there is a soft tissue defect along the lateral aspect of the foot there is an ovoid mixed lucent and sclerotic focus at the base of the fifth metatarsal with some overlying bony irregularity was this the site of prior debridement in addition a mm lucent focus is present in the distal portion of the medial cuneiform otherwise bones are within normal limits in mineralization and morphology there is soft tissue swelling and question small focus of subcutaneous emphysema along the dorsum of the foot impression cystic focus in medial cuneiform nonaggressive in appearance mixed lucent and sclerotic focus at base of the fifth metatarsal which could represent a gouty erosion but overall is nonspecific in appearance dr brief hospital course right le cellulitis patient was admitted to the podiatric surgery service and was worked up pre operatively patient was started on empiric antibiotic therapy consisting of vancomycin levo flagyl patients wcx was negative and patient was switched over to unasyn patient was brought to the operating room on hospital day for right foot i d it should be of note that tophaceous gout was found intra operatively patient tolerated procedure well and his initial surgical dressing was taken down on am rounds the following morning the packing was pulled and it was noted that the wound appeared to have clean viable edges and a red beefy base the patient was brought back to the or on hospital day for delayed primary wound closure the patient tolerated the procedure well please see operative report for full details patient s foot wound is now closed and patient is doing well to go home anemia patient s hct level was checked daily patient with a base line hct of after surgery patient s hct decreased to patient was transfused u prbc s patients hct was rechecked the next morning and came back up to patient stable upon hospital d c medications on admission cellcept mg qd calcitrol mg qd norvasc mg qd hctz mg qd benicar mg qd colchicine mg qd discharge medications calcitriol mcg capsule sig one capsule po daily daily amlodipine mg tablet sig two tablet po daily daily oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills colchicine mg tablet sig one tablet po qod tablet s augmentin mg tablet sig one tablet po twice a day for days disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis right foot infection discharge condition stable discharge instructions please keep all follow up appointments as scheduled please make sure to follow up with dr in the clinic please make sure you take the full course of your antibiotics please remain non weight bearing to the right foot please use your crutches and surgical shoe at all times please seek medical attention if you experience any fevers chills nausea night sweats or vomiting or if you notice any wound redness swelling or drainage followup instructions please call to schedule an out patient appointment with dr in days upon hospital discharge dpm completed by,"[**2141-1-1**] 12:37 PM
 Pt. admitted from ED with DKA, renal failure, and swollen foot.

### Instruction:
Extract medical entities as JSON.

### Record:
admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint swollen foot renal failure diarrhea anion gap acidosis major surgical or invasive procedure right ankle joint arthrocentesis history of present illness mr is a year old male with h o t dm chronic vasculitic renal failure who presents with diarrhea and swollen foot and question of dka mr was in his usoh until weeks ago when he developed cough sputum and vomiting nonbilious no"
8595,admission date discharge date date of birth sex f service neonatology history baby girl was admitted to the newborn icu for management of prematurity and concerns for history of a positive toxicology screen during pregnancy she was a week gestation baby born to a year old gravida p mother whose pregnancy was noted for treatment of chronic pain from fibromyalgia treated with tylenol with codeine mother was also treated with atenolol for hypertension during pregnancy a urine toxicology screen was positive for thc and narcotics she was followed by the social workers at the during pregnancy her prenatal screens were complete and unremarkable delivery was by c section for labor with a history of a myomectomy at delivery the infant emerged vigorous she was given blow by oxygen and stimulated with apgars of at minute and at minutes she was brought to the nicu after visiting with parents on exam baby was active and nondysmorphic she was pink and well perfused she was well appearing her skin was without lesions heent normal lungs clear cardiovascular normal s s no murmur anus patent hips normal spine intact neuro nonfocal and age appropriate weight was kilograms hospital course by systems respiratory baby has been in room air with saturations about she on day of life had apnea with desaturations noted which resolved spontaneously she has remained stable since that time without any apnea events or desaturations cardiovascular ap is s s blood pressures have been with a mean of she has been hemodynamically stable fen she began ad lib feeding with enfamil or breast milk and has been taking about ml per kilogram per day at least an ounce every hours and has been noted to have occasional spitting with burps glucose screens were all within normal range she has had normal urine and meconium stool passed weight gain has not yet been established weight on is about below birthweight at grams gi she had a bilirubin checked on day of life which was she started on single phototherapy on for bilirubin of this was the peak on day of l ife follow up bilirubin on was at am phototherapy was discontinued on at am heme id there were no concerns for sepsis therefore there was no blood work obtained upon admission neurologic due to concern for in utero opiate exposure the baby was started on neonatal abstinence and was noted to have mildly increased tone and irritability with scores up to a maximum of she has been treated with nonpharmacologic measures for developmental support and care a urine toxicology screen was sent upon admission which was positive for opiates presumably due to the tylenol with codeine taken during pregnancy she has not required medication for abstinence audiology hearing screening was passed in both ears prior to discharge psychosocial has been the social worker following this family she can be reached at a a was filed by on and on the department of social services determined that the disposition of baby would be to home with parents although advised that baby not medically ready for discharge due to ongoing weight loss parents chose to take baby home on the st parents address is front phone condition on discharge good discharge disposition home with parents against medical advice name of primary pediatrician is dr in phone fax feeds at discharge mom s milk or enfamil at least an ounce every hours require increased caloric density to or cal oz if no weight gain in the next few days medications none car seat position screening performed state newborn screen was obtained on day of life and results are pending at this time immunizations hepatitis b vaccine given follow up appointments recommended and scheduled with primary pediatrician the day following discharge will need frequent close daily monitoring of weight until steady weight gain is established early intervention referral in progress discharge diagnoses premature infant at weeks mild apnea of prematurity resolved monitoring for neonatal abstinence mild indirect hyperbilirubinemia status post phototherapy weight gain not yet demonstrated at days of age g m d dictated by medquist d t job,"{
""service"": ""neonatology"",
""history"": ""baby girl was admitted to the newborn icu for management of prematurity and concerns for history of a positive toxicology screen during pregnancy she was a week gestation baby born to a year old gravida p mother whose pregnancy was noted for treatment of chronic pain from fibromyalgia treated with tylenol with codeine mother was also treated with atenolol for hypertension during pregnancy a urine toxicology screen was positive for thc and narcotics she was followed by the social workers at the during pregnancy her prenatal screens were complete and unremarkable delivery was by c section for labor with a history of a myomectomy at delivery the infant emerged vigorous she was given blow by oxygen and stimulated with apgars of at minute and at minutes she was brought to the nicu after visit"
45846,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint bright red blood per rectum major surgical or invasive procedure s p egd and colonoscopy s p ivc filter placement history of present illness ms is a year old female with history of left leg dvt on warfarin who presented with two days of bright red blood per rectum she complained of weakness and dizziness for the past couple days and when her daughter visited her noticed she was pale and diaphoretic in the ed initial vs were t hr bp rr sao ra patient was given liters ns ivf units of ffp to reverse her inr of and one unit prbcs after a cc bolus her sbp increased from s to s and hr decreased from to s ng lavage was weakly positive with pink saline and small clots at end of suction a central line was placed and she received iv ppi prior to transfer vitals at transfer were ra in the she reports feeling better after being treated in the ed patient reports having a week of brbpr with clots approximately three weeks ago that spontaneously resolved her current bleeding episode started yesterday with bloody bowel movements afterwards she had some palpitations with exertion and felt fatigued she had three episodes of non bloody yellow emesis last night without any abdominal pain with some associated cold sweats patient has had some intermittent constipation baseline day with straining occasionally but this does not always occur prior to bloody bm no known sick contacts doe sob no current n v or abdominal pain she does complain of discomfort from the ng tube review of systems per hpi pound weight loss over last year denies fever or headache denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies current nausea vomiting diarrhea constipation abdominal pain denies dysuria frequency or urgency denies arthralgias or myalgias past medical history lle deep venous thrombosis hypertension type diabetes mellitus a c schizoaffective disorder hyperlipidemia social history pt is widowed and lives at an facility she is a non smoker and denies alcohol and illicit drug use emergency contact daughter work cell case manager cell family history non contributory physical exam vitals t bp p r o ra general alert oriented pale african american female in no acute distress heent eomi sclera anicteric with pale conjunctiva mmm oropharynx clear neck supple jvp not elevated no lad r ij in place lungs clear to auscultation bilaterally with decreased bs at bilateral bases no wheezes rales rhonchi cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly small reducible umbilical hernia gu foley in place ext cool digits with normal cap refill well perfused pulses no clubbing cyanosis or edema strength in ble extremities pertinent results wbc rbc hgb hct mcv plt count neuts lymphs monos eos basos glucose urea n creat sodium potassium chloride total co pt ptt inr pt ekg sinus tachycardia at with rbbb and lafb unchanged from prior chest x ray frontal view of the chest demonstrates cardiomegaly right ij catheter terminates in superior vena cava there is mild congestive failure intervential radiology impression normal anatomy of the ivc with a maximal caval diameter of cm no evidence of caval thrombus or aberrant caval anatomy successful placement of an infrarenal optease ivc filter egd normal anatomy no explanation for bleeding findings excavated lesions multiple diverticula were seen in the sigmoid colon diverticulosis appeared to be severe impression diverticulosis of the sigmoid colon otherwise normal colonoscopy to cecum pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct am blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili brief hospital course acute blood loss anemia gi bleed pt was admitted to the icu where she remained hemodynamically stable without evidence of ongoing bleeding her inr had been reversed with units of ffp and mg vitamin k she was transfused with more units of prbcs for a total of and her hematocrit bumped appropriately she was called out to the floor and underwent bowel prep on followed by egd on which did not show any evidence of ongoing bleeding though severe diverticulosis of the colon pt was monitored in house and remained hemodynamically stable with stable hct and no evidence of ongoing bleeding she was started on ferrous sulfate mg daily and continue on omeprazol mg daily she will need follow up with gi following psychiatric admission history of dvt pt has had two dvts most recent was diagnosed at an osh in and has been on warfarin since that time inr was in setting of acute gi bleed and it was reversed as above she underwent ivc filter placement on given the risk of anti coagulation after discussion with daughter gi decision was made to avoid restarting coumadin given her risk to rebleed and her delay in getting care in the setting of this bleed pt is scheduled to see her pcp after discharge to further discuss this issue schizoaffective disorder pt had a recent prolonged inpatient psych admission and was seen by psychiatry in house after discussion with outpatient providers decision was made to transfer to inpatient psych facility for further care pt was continued on fluoxetine donepezil lamotrigine and mirtazapine further discussions regarding her ability to care for self at home to be held at that time htn stable continue on home regimen of lisinopril dmii stable will resume home regimen of metformin mg please continue bs checks and pt instructed to stop if not taking regular meals medications on admission aricept mg qhs fluoxetine mg qday lamotrigine mg lisinopril mg daily glycolax gram dose daily mirtazapine mg qhs multivitamin omeprazole mg daily seroquel mg qhs warfarin mg daily discharge medications quetiapine mg tablet sig three tablet po qhs once a day at bedtime mirtazapine mg tablet sig one tablet po hs at bedtime lamotrigine mg tablet sig two tablet po bid times a day donepezil mg tablet sig one tablet po hs at bedtime fluoxetine mg capsule sig two capsule po daily daily lisinopril mg tablet sig one tablet po daily daily bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation polyethylene glycol gram dose powder sig one po daily daily metformin mg tablet sig one tablet po bid times a day omeprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day discharge disposition extended care discharge diagnosis primary acute blood loss anemia diverticulosis dvt s p ivc filter secondary dmii hypertension schizoaffective disorder discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with acute blood loss anemia from a lower gastrointestinal bleed in the setting of anti coagulation for a dvt you have been transfused with blood and your blood counts have stabilized without any sign of further bleeding you underwent placement of an ivc filter to treat the dvt please note that we have stopped the coumadin you should not take this medication again unless you are instructed by a physician we have restarted your home regimen including metformin mg twice daily and two new medications ferrous sulfate mg daily in place of multivitamin omeprazole mg daily please continue to monitor your blood sugars at home you should not take the metformin if you are not eating regular meals followup instructions name a location address phone appointment thursday am please call the clinic at after discharge to schedule a follow up appointment with them,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""dateOfBirth"": ""2017-03-29"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Patient recorded as having no known allergies to drugs""
],
""admissionDate"": ""2017-04-03"",
""dischargeDate"": ""2017-04-05"",
""dateOfDeath"": ""2017-04-05"",
""chiefComplaint"": ""Bright red blood per rectum"",
""historyOfPresentIllness"": ""Ms. [**Known lastname 1051**] is a year old female with history of left leg DVT on war"
7519,admission date discharge date service history of present illness the patient is an year old female with a past medical history of multiple myeloma status post treatment with chemotherapy and radiotherapy last treated approximately one year prior to admission who presented with shortness of breath and fever lasting the patient was doing well until approximately p m on the afternoon of admission when she returned home from work and noticed that her mother felt clammy had difficulty breathing and was febrile to she reported that her mother has had a dry cough for several days that worsened on the day of admission the cough has never been productive of sputum the patient was brought to the emergency room for cough she denied chills night sweats abdominal pain urinary tract changes swelling of lower extremities musculoskeletal aches and pain headaches constipation diarrhea nausea and vomiting she was hypotensive at in the emergency room and was started on dopamine drip past medical history multiple myeloma type diabetes pneumonia weeks prior to admission medications on admission micronase decadron q month social history the patient lives with her daughter smoking or alcohol use she is ambulatory family history father and brother had history of cancer allergies morphine sulfate codeine oxycontin physical examination vital signs temperature respirations heart rate oxygen saturation on non rebreather general she was a tachypneic elderly white female sitting up in bed in obvious respiratory distress heent normocephalic atraumatic pupils equal round and reactive to light extraocular movements intact dry mucous membranes pulmonary diffuse rhonchus breath sounds expiratory wheezing throughout cardiovascular positive tachycardia normal s and s no murmurs rubs or gallops abdomen soft nontender nondistended no rebound or guarding soft bowel sounds times four extremities there were pulses in lower extremities no no swelling right knee with bandage neurological she was grossly intact laboratory data white count hematocrit platelet count sodium potassium chloride bicarb bun creatinine glucose abg with a ph of carbon dioxide oxygen ck troponin chest x ray showed right middle lobe infiltrate hospital course she was admitted to the micu green team after a long complicated hospital course involving intubation and unsuccessful trials of extubation the patient was made comfort measures only she expired on condition on discharge deceased no postmorbid examination was obtained m d dictated by medquist d t job,"{
""date"": ""2019-12-10"",
""type"": ""Pt Admitted to ICU""
},
{
""date"": ""2019-12-11"",
""type"": ""Pt transferred to [**Hospital Ward Name **]""
},
{
""date"": ""2019-12-12"",
""type"": ""Pt transferred to [**Hospital Ward Name **]""
},
{
""date"": ""2019-12-13"",
""type"": ""Pt transferred to [**Hospital Ward Name **]""
},
{
""date"": ""2019-12-14"",
""type"": ""Pt transferred to [**Hospital Ward Name **]""
}"
17413,admission date discharge date date of birth sex m service micu history of present illness the patient is a year old spanish speaking gentleman with a history quadriparesis following a cervical crush injury approximately years ago history of tracheostomy at time of cervical crush injury history of decannulation of tracheostomy history of interstitial lung disease times to years of unknown etiology and chronic obstructive pulmonary disease who was transferred from hospital on to the the patient was in a good state of health until approximately years ago when he had a crush injury to his neck resulting in quadriparesis at that time he was working underneath a motor vehicle when its support slipped this resulted in quadriparesis with a prolonged hospital course prolonged ventilation dependence necessitating tracheostomy placement shortly after his original injury the patient s tracheostomy was decannulated and he was able to breathe independently in the intervening years he had a history of multiple recurrent pneumonias and bronchial infections he was recently admitted to hospital on with a chief complaint of neck pain and abdominal pain the patient has a history of chronic constipation requiring fleet enemas every other day secondary to his abdominal pain and bloating he is unable to tolerate his oral pain medication for his chronic neck pain during that admission he also developed bronchitis resulting in a chronic obstructive pulmonary disease flare for the bronchitis he was started on clindamycin ciprofloxacin and prednisone a sputum sample from also showed yeast the patient was started on diflucan on the patient had an episode of respiratory distress while at hospital resulting in decreased oxygen saturations on liters nasal cannula oxygen to the low s he was transferred from the medicine floor to the intensive care unit at hospital where he was intubated for hypercapnic respiratory failure prior to intubation the patient s chronic opiate use was attempted to be reversed with narcan with only transient improvement in his respiratory status arterial blood gas at the time of intubation was a ph of pco of po of and bicarbonate of during his intensive care unit admission he completed a day course of ciprofloxacin and clindamycin however at hospital the intensive care unit staff felt it difficult to wean the patient from the ventilator this was felt to be multifactorial in nature secondary to the patient s history of hypercapnia from chronic obstructive pulmonary disease flare neuromuscular weakness from his underlying quadriparesis as well as poor lung reserve from his history of interstitial lung disease therefore he underwent tracheostomy and percutaneous endoscopic gastrostomy tube placement on during the hospital course at hospital the pulmonary staff noted abnormalities on his chest x rays including bilateral pleural effusions a chest computed tomography was performed at hospital with evidence of pleural thickening and loculated pleural effusions bilaterally also noted was calcified lung parenchyma seen in the apices with retraction consistent with chronic lung disease in light of these abnormalities the patient s case was discussed with dr a thoracic surgeon a therefore the patient was transferred to on in order to undergo open lung biopsy the end goal was to establish a diagnosis or etiology for his interstitial lung disease past medical history cervical spine injury at level c resulting in quadriparesis approximately years ago status post cervical crush injury chronic obstructive pulmonary disease interstitial lung disease times to years etiology never characterized chronic pain status post crush injury with intrathecal pump containing morphine baclofen and clonidine hypertension gastritis depression history of recurrent bronchial and pneumoniae infections history of tracheostomy status post initial cervical spine injury sleep apnea on level positive airway pressure at night neurogenic bladder requiring suprapubic foley chronic constipation medications on admission medications prior to admission included elavil mg by mouth at hour of sleep fleet enemas every other day zoloft mg by mouth once per day trazodone mg by mouth once per day oxycontin mg by mouth twice per day as needed for pain oxygen liters via nasal cannula prednisone admits to being tapered albuterol meter dosed inhaler atrovent meter dosed inhaler flovent mcg inhaler puffs inhaled twice per day intrathecal pump containing morphine baclofen and clonidine allergies the patient has a reported allergy history of oral baclofen however please noted that baclofen is a component of his intrathecal pump and he tolerates this without a reaction social history the patient is a former pack year tobacco smoker he quit smoking in his is primarily spanish speaking he is married he is confined to a chair and is dependent in all of his activities of daily living code status the patient is a full code physical examination on presentation physical examination upon admission revealed the patient s temperature was degrees fahrenheit his blood pressure was and his heart rate was ventilator setting on continuous positive airway pressure with pressure support tidal volume was to his respiratory rate was to and his oxygen saturation was to on these settings with a pressure support of positive end expiratory pressure of fio of general appearance revealed the patient was a well developed obese gentleman who was depressed in appearance with a flat affect in no acute distress head eyes ears nose and throat examination revealed left internal jugular central venous line was in place no erythema edema or purulent discharge from the internal jugular site right neck with multiple ecchymotic lesions otherwise normocephalic and atraumatic pupils were equal round and reactive to light and accommodation the oral mucosa were moist the neck was supple no masses or lymphadenopathy lung examination revealed coarse breath sounds anterolaterally with scattered rhonchi cardiovascular examination revealed a regular rate and rhythm normal first heart sounds and second heart sounds were auscultated no murmurs rubs or gallops the abdomen was obese soft nontender and nondistended quiet bowel sounds positive percutaneous gastrostomy tube site no evidence of erythema edema or purulent discharge around percutaneous endoscopic gastrostomy tube site genitourinary examination revealed positive suprapubic foley catheter was in place extremity examination revealed pitting edema to the mid thighs bilaterally pertinent laboratory values on presentation pertinent laboratories revealed complete blood count on admission with a white blood cell count of his hemoglobin was his hematocrit was and his platelets were coagulation profile revealed his prothrombin time was his partial thromboplastin time was and his inr was serum chemistry revealed the patient s sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and blood glucose was calcium was phosphorous was and magnesium was liver function tests revealed his alt was his ast was his alkaline phosphatase was his amylase was his lipase was and his total bilirubin was his total protein was albumin was globulin was urinalysis showed large blood trace ketones and urobilinogen negative leukocyte esterase and nitrites microanalysis revealed to red blood cells to white blood cells and occasional bacteria urine culture grew greater than enterococcus pertinent radiology imaging studies available from hospital included an abdominal x ray from with very few air fluid levels present within nondilated small bowel loops no free air was identified no abnormal masses or abnormal calcification was seen a chest computed tomography without contrast on at hospital showed pleural thickening with loculated pleural fluid present bilaterally calcified lung parenchyma seen in both apices with retraction consistent with chronic lung disease diffuse air space and interstitial changes in both lungs could represent a combination of acute or acute on chronic changes there were multiple enlarged mediastinal lymph node the largest of which pretracheal at cm electrocardiogram from revealed a normal sinus rhythm at beats per minute normal axis and a right bundle branch block there was a q wave noted in lead iii no st t wave changes when compared to study concise summary of hospital course by issue system respiratory failure issues it was felt that the patient s respiratory failure and prolonged ventilator dependence was likely multifactorial in nature namely this was most likely contributed to by his hypercapnia secondary to his chronic obstructive pulmonary disease flare his neuromuscular diminished strength secondary to his cervical spine injury as well as poor lung reserve secondary to his interstitial lung disease his airway mechanics were assessed via upright and supine studies upright his negative inspiratory force was negative and his vital capacity was supine his negative inspiratory force was negative with a vital capacity of the patient was slowly weaned from ventilation primarily via decrease in his level to pressure support he was continued wit aggressive pulmonary toilet and atrovent and albuterol meter dosed inhalers he was admitted on high dose steroids which were initiated at the outside hospital these were tapered during this hospitalization he was able to tolerate weaning to a tracheostomy collar mask on a venous blood gas on tracheostomy collar mask showed adequate oxygenation and ventilation in light of the patient s history of persistent bilateral pleural effusions an echocardiogram was ordered to assess for a possible cardiac component to his pulmonary edema at the time of this dictation the results of this study were still pending interstitial lung disease issues on original admission we were unable to get a full occupation travel and social history on the patient secondary to his depressed state and flat affect and nonparticipation in the history and physical his occupational history was discussed with his wife who reported that the patient had previously worked as a chemical and insecticide sprayer however it was unclear if this contributed to his development of interstitial lung disease although the differential diagnosis for interstitial lung disease is extremely broad the patient s chest imaging was highly suggested of a upper lobe predominant process this is more commonly due to sarcoid silica or coal exposure ideally the patient should undergo high resolution computed tomography scanning when he is stable off the ventilator in light of his underlying quadriparesis it was felt that pulmonary function tests would not be revealing as the patient would likely have evidence of an obstructive process secondary to longstanding quadriparesis in order to rule out a rheumatologic cause of his interstitial lung disease antinuclear antibody and rheumatoid factor laboratory values were evaluated these were both negative the presence of the ground glass in addition to fibrotic and calcified changes on his computed tomography scan were highly suggestive of an acute on chronic process in light of the presence of both ground glass as well as fibrotic and calcified changes on his computed tomography scan it was felt that the patient was most likely suffering from an acute on chronic process in terms of his interstitial lung disease therefore there a possibility that an open lung biopsy particularly a biopsy of an acutely inflamed or active area could contribute much to understanding the etiology of his interstitial lung disease therefore the patient underwent an open lung biopsy on the patient tolerated the procedure quite well he was readmitted to the medical intensive care unit with a chest tube drain in place he was able to have the chest tube removed on he tolerated this well at the time of this dictation the tissue biopsy sample showed a gram stain with polymorphonuclear leukocytes no antineutrophil cytoplasmic antibody organisms tissue culture had no growth anaerobic culture was still pending an acid fast smear was negative for acid fast bacilli acid fast culture was still pending a fungal culture showed no fungus isolated additionally there were no fungal elements on potassium hydroxide smear studies for legionella were negative immunofluorescent staining for pneumocystis carinii pneumonia were also negative further discussion of the patient s laboratory and imaging findings with the pulmonary staff led us to the opinion that the patient s interstitial lung disease was most likely secondary to silicosis however this was a clinical diagnosis and ultimately the final pathology should be followed up on delirium issues status post biopsy the patient had a waxing and mental status a psychiatry consultation was obtained they felt the patient s presentation was consistent with delirium he was evaluated with a head computed tomography which was negative for any acute intracranial bleed or other intracranial process thyroid stimulating hormone levels were checked and were normal the patient s outpatient psychiatric medications including zoloft trazodone and elavil were held these can be reinstituted once his mental status is stable at his baseline at the time of this dictation the patient s mental status was much improved hypertension issues upon admission the patient was on a regimen on clonidine patch hydralazine and captopril due to the effects of rebound hypertension with clonidine and hydralazine the patient s clonidine and hydralazine were discontinued while he was in a monitored intensive care unit setting his captopril dose was increased and should be titrated up further as needed for adequate blood pressure control gastritis issues the patient was continued on his outpatient proton pump inhibitor dose chronic pain issues the patient was continued on his intrathecal pump as well as morphine sulfate for breakthrough pain fluids electrolytes nutrition issues the patient was tolerating tube feeds at goal he was fitted with a passey muir valve by the speech and swallow department in light of previous speech and swallow evaluations at hospital the patient will be undergoing a video swallow examination on the results of that evaluation were still pending infectious disease issues the patient had a low grade temperature on he was pan cultured the results of this culture was pending at the time of this dictation the patient s left internal jugular central venous line was removed intravenous access was reestablished with a right femoral line he was not started on any antibiotic therapy the results of his cultures will be followed up by the accepting medicine team code status issues the patient is a full code communication issues the patient s plan of care was discussed extensively with his wife she serves as his primary health care decision maker when the patient is unable to make decisions for himself the remainder of the patient s discharge summary including his condition on discharge discharge status discharge diagnoses discharge medications as well as follow up plans will be dictated as a separate addendum to this report m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service concise summary of hospital course since previous discharge summary pulmonary on transfer to the general medicine floor from the micu the patient was completely stable from a pulmonary standpoint he was maintained on a trach mask over his trach collar and demonstrated good oxygen saturations with a gradual wean in his fio he was maintained on his nebulizer treatments his lung biopsy results returned with an increased number of intra alveolar macrophages and focal foreign body giant cell reaction to foreign material with mild focal interstitial fibrosis which was considered consistent with silicosis interstitial lung disease the patient s solu medrol was switched to prednisone mg po q day and it is anticipated that the patient will undergo a two week taper of oral steroids infectious disease the patient was noted to have a fever to on the morning following his transfer to the general medicine floor the patient had blood cultures positive for two out of four bottles with gram positive cocci that eventually grew coag negative staph he received a three day course of intravenous vancomycin but given subsequent blood cultures were negative the coag negative staph and two out of four blood culture bottles was considered to be likely contaminate once the patient s vancomycin was stopped the patient s fever curved decreased and he was afebrile for four days prior to discharge in addition to the coag negative staph in his blood cultures the patient was also noted to have enterococcus in his urine culture as well as on his femoral line that was pulled on given that the patient was afebrile off antibiotics and showed no signs of symptoms of infection no antibiotics were started and the patient was monitored throughout the rest of his hospital course neurology on the morning following the transfer to the medicine floor the patient had an episode of unresponsiveness in which he was noted to have roaming eye movements as well as a laceration of his tongue thought suffered secondary to tongue biting given the concern for seizure the patient had an electroencephalogram which was read as negative for seizure focus the patient had no further episodes of unresponsiveness throughout the remainder of his hospital course and reported that this episode was secondary to his typical panic attacks that he suffers when he is left alone cardiovascular the patient was noted to be hypertensive in the micu and had his antihypertensive regimen changed to captopril mg t i d the patient was hemodynamically stable throughout his stay on the general medicine floor he was noted to have somewhat low blood pressures in the s to low s s and his captopril dose was cut in half he was otherwise noted to be stable from a cardiovascular standpoint gastrointestinal the patient was maintained on his proton pump inhibitor throughout his hospital stay he had frequent regular bowel movements fen a speech and swallow evaluation was obtained on transfer to the medicine floor which showed no evidence of aspiration but fatigue with swallowing the patient was therefore started on a thin liquid pureed solid diet in addition to his tube feeds it is hoped that the patient s diet will be gradually increased to regular food though it is likely that the patient s tube feeds will be required for some time discharge condition good discharge status the patient is discharged to a pulmonary rehabilitation center where he will continue all medications as listed discharge diagnoses interstitial lung disease secondary to silicosis quadriplegia status post c spine fracture status post respiratory failure chronic obstructive pulmonary disease chronic pain hypertension depression panic attacks obstructive sleep apnea discharge medications albuterol one to two puffs q hours prn lansoprazole mg po q day captopril mg po t i d polyvinyl alcohol one to two drops prn miconazole powder b i d colace mg per milliliters ml b i d lorazepam mg and to one tablet po q to hours prn anxiety ipratropium micrograms two puffs q i d fluticasone micrograms two puffs b i d heparin units subq q hours acetaminophen one to two tablets q to hours prn morphine sulfate to mg intravenously or im q one hours prn prednisone mg po q day times four days then mg po q day times four days then mg po q day times three days follow up the patient will be followed by physicians at his pulmonary rehabilitation center his wife is encouraged to call his primary care physician at to schedule an outpatient appointment m d dictated by medquist d t job,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Male"",
""service"": ""MICU"",
""historyOfPresentIllness"": ""admission date discharge date date of birth sex m service micu history of present illness the patient is a year old spanish speaking gentleman with a history quadriparesis following a cervical crush injury approximately years ago history of tracheostomy at time of cervical crush injury history of decannulation of tracheostomy history of interstitial lung disease times to years of unknown etiology and chronic obstructive pulmonary disease who was transferred from hospital on to the the patient was in a good state of health until approximately years ago when he had a crush injury to his neck resulting in quadriparesis at that time he was working underneath"
86259,admission date discharge date date of birth sex m service cardiothoracic allergies latex attending chief complaint chest pain major surgical or invasive procedure coronary artery bypass grafting x with left internal mammary artery to left anterior descending coronary artery reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery reverse saphenous vein single graft from the aorta to the distal right coronary artery history of present illness yo m without cardiac history who presented to outside hospital ed with substernal chest pain during the night patient took tums thinking it was his usual gerd but it did not help initially the next day his pcp instructed him to go to the ed where his trop was with ekg showing std in inferior and lateral leads he was transferred to for cardiac catheterization where he was found to have lm and vd we are asked to evaluate for surgical revascularization past medical history gastro esophageal reflux disease benign positional vertigo cervical pinched nerve social history dentist tobacco history none no history etoh none history of social use occasional drink illicit drugs none no history family history no family history of early mi or sudden cardiac death otherwise non contributory physical exam on admission to floor vs t bp hr rr o sat ra general wdwn male in nad oriented x mood affect appropriate heent ncat sclera anicteric perrl conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple no jvd cardiac rr normal s s no r g no s or s sem rusb lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd abd aorta not enlarged by palpation extremities no c c e skin no stasis dermatitis ulcers scars or xanthomas pulses radial dp strong and symmetric pertinent results echocardiography report complete done at pm final referring physician information c status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication coronary artery disease hypertension shortness of breath for cabg icd codes test information date time at interpret md md test type tee complete son md doppler full doppler and color doppler test location anesthesia west or cardiac contrast none tech quality adequate tape aw machine aw echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left ventricle septal wall thickness cm cm left ventricle inferolateral thickness cm cm left ventricle diastolic dimension cm cm left ventricle systolic dimension cm left ventricle fractional shortening left ventricle ejection fraction left ventricle stroke volume ml beat aorta annulus cm cm aorta sinus level cm cm aorta sinotubular ridge cm cm aorta ascending cm cm aorta arch cm cm aortic valve peak velocity m sec m sec aortic valve mean gradient mm hg aortic valve lvot vti aortic valve lvot diam cm aortic valve valve area cm cm mitral valve mva p t cm mitral valve e wave m sec mitral valve a wave m sec mitral valve e a ratio findings left atrium mild la enlargement no mass thrombus in the laa no spontaneous echo contrast is seen in the laa good cm s laa ejection velocity left ventricle normal lv wall thickness normal lv cavity size mildly depressed right ventricle normal rv chamber size and free wall motion aorta normal aortic diameter at the sinus level normal ascending aorta diameter normal aortic arch diameter mildly dilated descending aorta simple atheroma in descending aorta aortic valve three aortic valve leaflets no as trace ar mitral valve no ms physiologic mr within normal limits tricuspid valve physiologic tr pulmonic valve pulmonary artery pulmonic valve not well seen physiologic normal pr general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the patient was under general anesthesia throughout the procedure the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope no tee related complications results were personally reviewed with the md caring for the patient conclusions pre cpb the left atrium is mildly dilated no mass thrombus is seen in the left atrium or left atrial appendage no spontaneous echo contrast is seen in the left atrial appendage left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is mildly depressed right ventricular chamber size and free wall motion are normal the descending thoracic aorta is mildly dilated there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets there is limited excursion of the left coronary cusp there is no aortic valve stenosis trace aortic regurgitation is seen between left and noncoronary cusps physiologic mitral regurgitation is seen within normal limits dr was notified in person of the results post cpb the aortic contours are intact there is no change in the baseline trivial mr is improved to the rvef continues to be within normal limits am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt inr pt am blood glucose urean creat na k cl hco angap brief hospital course mr is a year old male with no significant past medical history who presented with chest pain found to have nstemi was taken for cardiac catheterization which revealed multi vessel coronary disease on he underwent coronary artery bypass grafting times x left internal mammary artery to left anterior descending coronary artery reverse saphenous vein from the aorta to the ramus intermedius coronary artery reverse saphenous from the aorta to the first obtuse marginal coronary artery reverse saphenous vein from the aorta to the distal right coronary artery performed by dr please see the operative note for further details he tolerated this procedure well and was transferred to the surgical intensive care unit in critical but stable condition intubated and sedated he awoke neurologically intact and was extubated without difficulty all drips were weaned off and he was started on beta blocker statin aspirin and diuresis all lines and drains were discontinued in a timely fashion pod he went into postoperative atrial fibrillation it was treated with amio and increased beta blocker he had a few episodes of converting back into nsr but most of his postoperative course he remained in atrial fibrillation flutter overdrive pacing with his epicardial wires was attempted and failed anticoagulation was started with coumadin inr goal pod he was transferred to the step down unit for further monitoring physical therapy was consulted for evaluation of strength and mobility the remainder of his hospital course was essentially uneventful prior to his discharge coumadin dosing inr monitoring was arranged with his pcp he was cleared by dr for discharge to home with vna on pod all follow up appointments were advised medications on admission prilosec mg tums discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily disp capsule delayed release e c s refills warfarin mg tablet sig one tablet po once a day for doses dose to change daily for goal inr dr to manage disp tablet s refills outpatient lab work labs pt inr for coumadin please use hemosence machine for each inr goal inr for afib first draw results to phone fax the office of dr fax plan confirmed with from dr office metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day mg x week then mg daily x week then mg daily until further instructed disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours furosemide mg tablet sig one tablet po once a day for days disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po daily daily for days disp tab sust rel particle crystal s refills discharge disposition home with service facility vna discharge diagnosis primary coronary artery disease secondary hypertension hyperlipidemia gastroesophageal reflux disease benign positional vertical discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesia incisions sternal healing well no erythema or drainage leg right left healing well no erythema or drainage edema discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than pounds for weeks please call with any questions or concerns females please wear bra to reduce pulling on incision avoid rubbing on lower edge please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments surgeon dr on at pm cardiologist dr on at am please call to schedule appointments with your primary care dr w please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours labs pt inr for coumadin goal inr for afib first draw tuesday results to the office of dr fax plan confirmed with from dr office completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Male"",
""service"": ""Cardiothoracic"",
""allergies"": [
""Latex""
],
""chiefComplaint"": ""Chest pain"",
""admissionDate"": ""2014-03-21"",
""dischargeDate"": ""2014-03-24"",
""dateOfDeath"": ""2014-03-24"",
""historyOfPresentIllness"": ""Yo M without cardiac history who presented to outside hospital ED with substernal chest pain during the night. Patient took Tums thinking it was his usual GERD but it did not help initially. The next day his PCP instructed him to go to the"
18644,admission date discharge date date of birth sex f service history of present illness this is a year old woman who presents for a preoperative admission for a cadaveric kidney transplant the patient was started on dialysis in the patient has a longstanding history of polycystic kidney disease physical examination the patient has vitals of temperature blood pressure of heart rate of a respiratory rate of and saturation of on room air the patient was in no acute distress in terms of general exam her cardiac was regular rate and rhythm s and s were appreciated no murmurs rubs or gallops the chest exam was clear to auscultation bilaterally there were no rales there were no rhonchi there was no wheezing there was no egophony or whispered pectoriloquy on abdominal exam the patient was nontender she was nondistended her abdomen was soft bowel sounds were appreciated in the right lower quadrant there was a peritoneal dialysis catheter the patient s extremities were not cyanotic they were not edematous the patient had pulses bilaterally the lower extremities were warm and well perfused capillary refill was within seconds on neurologic examination the patient was alert awake and oriented x on cranial nerve exam cranial nerves ii xii were grossly intact laboratory data the pertinent labs on admission included a white blood cell count of hematocrit and platelet count the serum sodium was the potassium was the chloride was the co was the bun was and the creatinine was the calcium was the phosphorus was the inr was the pt was the ptt was the patient s ekg was normal sinus rhythm the chest x ray showed no cardiopulmonary process hospital course on the patient was admitted for preoperative workup and evaluation for a cadaveric kidney transplant she was made npo after midnight her preoperative workup was complete she was scheduled for a renal transplant in the morning in the morning of the patient went to the operating room for a cadaveric renal transplant the patient was consented her tissue typing was sent off to and she underwent a transplant please the operative report for further details of the operational procedure postoperatively the patient stayed in the pacu area for hours she was doing fine there and was transferred to the regular hospital floor on her postop check later that night the patient was doing well her pain was well controlled she was to be weaned from dopa in the pacu prior to be transferred to the floor which she was and there were no real issues when the patient got to the floor on postop day the patient was doing fine she experienced some episodes of hypotension that required some boluses of normal saline a few times her urine output was somewhere between cubic centimeters and cubic centimeters per hour roughly on postop day in the day the patient was transferred to the sicu for what was routine sort of a dopamine drip so that her blood pressure could be titrated to a systolic pressure of above and her urine output could increase comfortably to cubic centimeters per hour on postoperative day the patient was doing very well she was continued on iv fluids her urine output had been excellent overnight her dopamine iv was titrated down to from and she was doing very well she got a dose of thymoglobulin that day and an echocardiogram was obtained just to check for any kind of cardiac wall motion abnormalities that echocardiogram was negative on postoperative day the patient continued to do well her dopamine was titrated down to her urine output was good we continued to try to wean off dopamine her k lyte was increased to mg b i d the patient was followed throughout the hospital course by renal transplant medicine who helped very diligently in her care on postoperative day the patient again did very well she was making good urine output she was still on a dopamine drip but she was doing very well the plan was to transfer her to the floor and that was to be discussed with the team since she was doing so well the patient in the unit continued to do very well she was tolerating her diet she was up and around walking around on postoperative day and she really had no complaints other than she wanted to get back up to the floor on postoperative day she was transferred to the regular hospital floor and she was doing very well she was comfortable on postoperative day she continued in that same light on the floor with close monitoring of her blood pressure she was out of bed she was walking around her urine output had maintained above cubic centimeters an hour and her prograf level was evaluated with labs daily on postoperative day the patient was deemed ready to go home she was given a followup on the following day for all of her labs to be reassessed by the transplant team she went home on an fk level of and she was given very strict instructions as to some of the diarrhea that she had been having towards her final day and she was started on mg of flagyl prior to leaving she was told that if that tailed off she would be able to stop the flagyl otherwise she could continue that two of her c difficile samples that were sent the final days of her hospital stay were negative but we are awaiting for the third one we just had her continue on her flagyl discharge condition stable discharge status to home discharge diagnosis end stage renal failure secondary to polycystic kidney disease discharge medications protonix mg p o q h nystatin suspension ml p o times daily colace mg p o b i d diphenhydramine mg at bedtime p r n valacyclovir mg p o every other day percocet mg tabs p o q h p r n pain tablets ambien mg p o at bedtime tablets fludrocortisone acetate mg p o t i d mycophenolate mofetil mg p o times daily flagyl mg p o t i d for days tacrolimus mg p o b i d potassium chloride meq p o once a day bisacodyl mg suppository at bedtime p r n followup plans the patient s followup plans are to followup with transplant medicine the following day on for labs she has additional followup with dr on at pm she also has followup with dr on at pm and with dr on at am m d dictated by medquist d t job,"{
""date"": ""2022-10-10"",
""discharge_date"": ""2022-10-13"",
""service"": ""Nephrology"",
""admission_date"": ""2022-10-10"",
""date_of_birth"": ""2002-1-15"",
""sex"": ""Female"",
""service_history"": [
""This is a year old woman who presents for a preoperative admission for a cadaveric kidney transplant. The patient was started on dialysis in the patient has a longstanding history of polycystic kidney disease. Physical examination the patient has vitals of temperature blood pressure of heart rate of a respiratory rate of and saturation of on room air. The patient was in no acute distress in terms of"
46603,admission date discharge date date of birth sex f service medicine allergies levofloxacin lisinopril diphenhydramine attending chief complaint s p arrest in the or during ip stent procedure major surgical or invasive procedure left main stem stent placement endotracheal intubation left femoral tripple lumen catheter placement history of present illness y o f with pmhx of copd and small cell lung cancer diagnosed s p xrt chemo tumor debridement r mainstem bronchus stent placement and recent lue dvt on coumadin who initially presented to hospital on with episodes of hemoptysis increased cough wheezing and shortness of breath she was started on iv solumedrol mg iv q hrs nebs and tessalon pearles she was supratherapeutic with an inr of and coumadin was held cta was negative for pe and revealed right mainstem stent with distal intraluminal narrowing or tumor effusion mediastinal and subcarinal confluent metastatic lymphadenopathy decision was made for transfer to for bronch and ip evaluation pt was admitted to and was continued on steroids nebs and cough suppressants she went for flexible bronchoscopy on which revealed normal trachea extensive tumor at carina obstructing both mainstem bronchi extrinsic mediastinal compression of l mainstem and unable to visualize stent in right mainstem due to intraluminal tumor pt was taken to the or on and had stent placed in the left mainstem with good result there was attempted argon plasma coagulation inside of the right stent to remove intraluminal obstruction during this procedure pt became progressively hypoxic bradycardic and loss of pulse at approx pm cpr was started immediately and pt received a total of mg of epi after approximately minutes of cpr rhythm was checked and there was a palpable pulse with hr and sbp tee was performed and showed bubbles in the right atrium suggestive of apc related air embolism but no rv dilation suggestive of acute pe oxygen sats recovered into the s right femoral a line and left femoral cvl was placed pt was given an additional bolus of midazolam and some neosynephrine for bp support prior to transfer to the icu on arrival to the icu pt was intubated and sedated with hr and bp s sedation was rapidly weaned and pt was clearly responding to commands and moving all extremities past medical history small cell lung cancer diagnosed in and recurred in initially started weeks of xrt followed by multiple regimens of chemo has been off chemo for the last months because ct scans have been stable last bronchoscopy was in small amounts of granulation tissue seen in stent recent lue dvt mid l arm port was changed after which she developed dramatic swelling from shoulder to wrist uenis confirmed lue dvt coumadin mg was started copd longstanding unknown date of diagnosis lupus diagnosed years ago after work up for painful knee and finger joints l finger joints r finger joints treated with pills but not prednisone shingles infection in t dermatome in treated with acyclovir and recovered within week anxiety insomnia past surgical history right eye cataract surgery bronchial stent placement in by dr lung cancer tumor debridement and ablation in by dr social history she lives in with her husband she has children and grandchildren who live within a mile of her house she worked as a homemaker she smoked tobacco for approximately pack years pack per day for years and quit in the she does not know of any asbestos exposure she drinks alcohol only on social occasions and uses no other drugs family history she reports no family history of lung cancer sle or cad her mom died of stomach cancer at yo and her niece has breast cancer her son has physical exam vitals t bp p r o on l general alert oriented not in acute respiratory distress sitting upright in bed watching tv with audible upper airway inspiratory and expiratory stridor heent sclera anicteric pupils equal round reactive to light mucous membranes moist no jugular venous distention mucous membranes moist oropharynx clear without thrush no oropharyngeal source of bleeding seen neck supple jvp not elevated no lymphadenopathy no carotid bruits loud and harsh inspiratory upper airway stridor heard trachea not deviated lungs nasal cannula intact patient sitting upright with audible upper airway inspiratory and expiratory stridor patient appears comfortable and is not using any accessory muscles of inspiration respiratory rate is mildly elevated scattered anterior inspiratory and expiratory wheezes left sided bronchial breath sounds bases apices right sided bronchial breath sounds with fine crackles at bases scattered inspiratory and expiratory wheezes but not consistently cv tachycardic with regular rhythm normal s s no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly ext warm well perfused no clubbing cyanosis or edema skin no skin rash or ecchymoses noted dressing over left anterior pectoral region covering old portacath neuro alert oriented x extraocular movements intact cns ii xii grossly intact and patient moving all four extremities spontaneously on discharge vs l gen ill appearing female appearing older than stated age cv tachycardic no rubs gallops murmurs lungs diffuse rhonchi few wheezes scant basilar rales on the left moderate movement abd soft nd nt abs ext wwp with palpable dp pulses neuro alert and oriented eomi patient moving all extremities spontaneously pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium radiology chest portable ap known treated right upper lobe mass with expected post treatment change and soft tissue density seen in a right paramediastinal location is stable new mild bilateral pleural effusions otherwise no significant interval change with no focal consolidation and pulmonary vascularity within normal limits no new abnormality involving cardiomediastinal contours stable appearance of bilateral bronchial stents and port with tip terminating within the upper svc no evidence of pneumothorax radiology mr head w w o contras there is a linear region of decreased diffusion within the right frontal lobe predominantly involving the cortex and subcortical white matter as well as multiple additional punctate foci of decreased diffusion within the biparieto occipital lobes including extending into the splenium of the corpus callosum on the right there is an additional focus of abnormal slow diffusion within the inferior aspect of the right cerebellar hemisphere measuring cm with associated brisk enhancement there is enhancement over the right frontal lobe signal abnormalities described above all of the regions of decreased diffusion have associated t signal abnormality there are no regions of abnormal marrow replacement despite limitations by motion artifact focus of susceptibility artifact along the posterior focus likely represents a small calcified dural plaque there are multifocal regions of punctate post embolic encephalomalacia within the left cerebellar hemisphere suggesting chronic embolic disease impression multifocal regions of abnormally decreased diffusion most prominent within the right frontal lobe which has an appearance suggestive of watershed infarction the more punctate foci of decreased diffusion posteriorly suggest multiple small emboli well defined mm focus of enhancement and decreased diffusion within the right cerebellar hemisphere may represent a subacute enhancing infarct but is more concerning for a metastatic lesion in this patient with lung cancer consideration could be given to neck mra or cta to evaluate the cervical circulation though the pattern suggests a proximal source radiology bilat lower ext veins p grayscale and color doppler images of bilateral common femoral superficial femoral and popliteal veins were performed there is normal compressibility flow and augmentation cardiology echo the estimated right atrial pressure is mmhg left ventricular systolic function is hyperdynamic ef right ventricular chamber size is normal with mild global free wall hypokinesis there is a small to moderate sized pericardial effusion there are no echocardiographic signs of tamponade cardiology echo no atrial septal defect is seen by d or color doppler right ventricular chamber size is normal with borderline normal free wall function the aortic valve leaflets are mildly thickened the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen mild tr upon initial placement small air bubbles visualized in ascending aorta no air visualized in la lv no lv wall motion abnormalities no thrombus visualized in ra rv pa right pa appears compressed by large mass but still patent arrest possibly secondary to left sided intracardiac air coronary air embolism but unable to determine given time between event and images pe also on the differential but no signs of significant rv failure however inotropes epinephrine were administered pathology tissue bronchus intermedius small cell carcinoma radiology venous dup ext uni map grayscale color and doppler images were obtained of the left subclavian ij axillary brachial basilic and cephalic veins there is normal flow compression and augmentation seen in all of the vessels brief hospital course y o f with pmhx of large mediastinal scc s p right mainstem stenting who presented with recurrent compressive symptoms who underwent or placement of left mainstem stent and right mainstem apc complicated by hypoxia and pea arrest pt thought to have had pea arrest after rigid bronchoscopy was removed subsequent to l main stent placement for sclc and use of argon anticoagulation she underwent cpr immediately for minute the etilogy was thought to be air emboli secondarely to argon coagulation vs hypoxia tee was not done during procedure due to technical difficulties secondarely to the mediastinal mass however tee done after arrest showing air bubbles in l atrium on admission the a a gradient with po was of on fi and lactate was she was moving all extremities and following commands ce were negative x repeat tte was normal anticoagulation was initially held for dvt and patient was extubated succesfuly days after initial intubation her ventilatory support was minimal risbi was with air leak and she was extuabted hours after procedure unfortunately she developped stridor and increase number of secretions in the upper airways with respiratory rate in the s and spo in s she required emergent re intubation high dose steroids methylprednisolone mg q hrs were started and continued for hours and patient was succesfully extubated on day steroids were slowly down tapered due to long standing disease with e o hyperinflation on cxr and report of bronchospasm on presentation she was also treated for copd exacerbation with standing and prn nebulizers after several days on the medical floor patient s respiratory status was not improving interventional pulmonology was reconsulted pt was taken for flexible bronchoscopy which showed significant mucus some of which was removed and on the vocal cords thoracentesis was also performed cc were removed and sent for culture culture was still pending at time of discharge lue dvt per psh report pt had portacath associated upper extremity dvt and has been on coumadin p w supratherapeutic inr however ultrasound on did not show any dvt lenis were negative anticoagulation was held prior to procedure and re started hours afterwards with lovenox given her malignancy and higher bleeding risk during her hospitalization there was concern of a cerebellar metastasis of sclc per radiology pt should undergo a repeat mri in weeks for further characterization due to h o dvt and atrial fibrillation as well as evidence of embolic stroke anticoagulation was continued upon discharge primary oncologist dr was informed of this and he agreed with the plan tachycardia svt pt has remained tachycardic since admission suspect some component of dehydration and underlying malignancy cta neg for pe at osh prior to transfer lenis were negative patient was hydrated and tachycardia did not improve then she had episodes of atrial fibrillation up to bpm with stable bp she was started on metoprolol and it was titrated up to mg tid which maintained a hr of as monitored on telemetry metoprolol was not further uptitrated as sinus tachycardia was thought to be secondary to her illness she was discharged on this regimen would consider uptitration of metoprolol if rate requies better control she was diltiazem prior to this admission but it did not control her heart rate adequately sclc pt with sclc s p chemo radiation and now with l and r main bronchus metal stents given that she has already received max radiation doses plan is to do brachitherapy and chemo as outpatient she will need follow up mri in weeks for further charactization of a potential brain metastasis outpatient providers will also have to reassess whether or not to continue anticoagulation plan for patient to follow up with dr medical center for hdr brachytherapy in the bronchus intermedius in the next week follow up with primary oncologist within wks with a repeat mri head and ct chest and follow up with dr in ip in wks for return visit and flex bronch bacteremia pt grew staphylococcus coagulase negative from a line which was removed after positive blood culture and started on vancomycin day then patient grew mrsa from sputum and plan was to treat with vanc for weeks given endovascular infection uti pts urine was growing gnrs so ciprofloxacin was started speciation showed enterobacter cloacae pan sensitive she was switched to bactrim to continue treatment for days d medications on admission aspirin mg po daily warfarin mg po daily diltiazem mg po daily magnesium oxide mg po daily lorazepam mg po bid benzonoatate mg po tab tid spiriva inhaler tiotropium discharge medications magnesium oxide mg tablet sig one tablet po once a day lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety prednisone mg tablet sig three tablet po daily daily for two days then reduce to mg daily for two days then reduce to mg daily for days enoxaparin mg ml syringe sig one syringe subcutaneous q h every hours tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily benzonatate mg capsule sig one capsule po tid times a day nystatin unit ml suspension sig five ml po qid times a day pt should also gargle with this medication for treatment of her sore throat guaifenesin mg tab multiphasic release hr sig one tab multiphasic release hr po bid times a day albuterol sulfate mg ml solution for nebulization sig one neb neb neb inhalation q h every hours albuterol sulfate mg ml solution for nebulization sig one neb neb inhalation q h every hours as needed for sob ipratropium bromide solution sig one neb inhalation every six hours as needed for sob trazodone mg tablet sig tablet po hs at bedtime as needed for sleep menthol cetylpyridinium mg lozenge sig one lozenge mucous membrane prn as needed as needed for sore throat sulfamethoxazole trimethoprim mg tablet sig one tablet po bid times a day last dose is evening of vancomycin mg recon soln sig one gram intravenous twice a day please resume on after checking vanco trough to ensure level is not supratherapeutic goal last day of treatment is outpatient lab work please check vanco trough every third dose please check on trough on prior to resuming vancomycin administration port a cath please deaccess permanent catheter after antibiotic regimen is complete heparin flush units ml ml iv prn line flush indwelling port e g portacath heparin dependent flush with ml normal saline followed by heparin as above daily and prn per lumen heparin flush units ml ml iv prn de accessing port indwelling port e g portacath heparin dependent when de accessing port instill heparin as above per lumen metoprolol succinate mg tablet sustained release hr sig and half tablet daily tablet sustained release hr po once a day mg daily outpatient lab work please check weekly cbc and chem to ensure no major abnormalities discharge disposition extended care facility discharge diagnosis primary small cell lung cancer pea arrest copd exacerbation pulmonary effusion atrial fibrillation mssa bacteremia enterobacter uti secondary hypertension h o dvt anxiety discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions ms it was pleasure to care for you during your hospitalization you were admitted for hematemesis you were to have one of your stents reopened and have another stent placed in your lungs however shortly after the procedure you developed very low blood pressure and required icu hospitalization you were intubated twice upon extubation you had swelling in your neck impairing your breathing as well as severe wheezing you were treated with steroids and nebulizers unfortunately your breathing did not improve so you underwent another bronchoscopy which showed alot of mucus some of which was removed you had fluid removed from your lungs also your vocal cords show a candidal infection thrush so you should continue to gargle with nystatin swish and swallow you will require oxygen for some time until your lung function improved also during your hospitalization you were found to have staph aureus infection of your blood stream and possibly a staph aureus pneumonia you will complete a day course of vancomycin antibiotic you were also found to have a urinary tract infection for which you are on a second antibiotic called bactrim you were also treated for atrial fibrillation irregular heart rhythm which requires medication to control the heart rate and continuation of blood thinners to prevent strokes you were previously on coumadin and this is being switched to lovenox unfortunately to complicate this matter a small abnormality was found in your brain that may be a metastasis of the lung cancer this is not entirely clear if it is you could potentially have a bleed in the brain on the other hand if you do not continue with the lovenox treatment you could have a stroke from a blood clot formed in the heart which you may have already had in the past the present plan is to continue you on blood thinners until we can obtain a repeat mri to confirm a metastatic brain tumor at that time the matter of continuing blood thinners can be readdressed regarding treatment you should discuss further treatment of your lung cancer with your pulmonologists and your primary oncologist many medications were changed during this hospitalization you will start prednisone taper ipratropium and albuterol for treatment of copd guifenessin has been added to break up mucus bactrim and vancomycin have been added for treatment of urinary tract infection and blood stream infection nystatin swish and swallow for treatment of oral and vocal throat infection yeast please gargle with this medication for most effective treatment metoprolol has been started for better heart rate control stop taking diltiazem lovenox has been started to thin the blood stop taking coumadin aspirin has been discontinued due to increased risk of bleeding lorazepam may be used as frequently as every hrs as needed followup instructions please make the following appointments name address phone appointment thursday am department interventional pulmonary when tuesday at am building de building complex campus west best parking garage department chest disease center when tuesday at pm building building complex campus west best parking garage we are working on a follow up appointment with dr in the pulmonary department at medical center within weeks the office will be contacting you at home with an appointment if you have not heard or have any questions please call completed by,"[
""date"": ""2019-12-10"",
""type"": ""SICU NPN""
]

73 y/o female with PMH of COPD, SCLC, LLLT, ESRD on HD, HTN, DM2, CAD, CVA, and PVD, who initially presented to hospital on [**12-10**] with episodes of hemoptysis, increased cough, wheezing, and shortness of breath. She was started on IV Solumedrol, Mg IV Q Hrs, NeBs, and Tessalon Pears. She was supratherapeutic with an INR of 1.8 and Coumadin was held. CTA was negative for PE and revealed right mainstem stent with distal intraluminal narrowing or tumor effusion, mediastinal and subcar"
8077,admission date discharge date date of birth sex m service neonatology history of present illness baby was born at weeks gestation to a year old gravida para now three woman prenatal screens are blood type a positive antibody negative rubella immune rpr nonreactive hepatitis b surface antigen negative and group b strep unknown this pregnancy was complicated by rupture of membranes four days prior to delivery the mother was treated with ampicillin and a complete course of betamethasone her previous obstetrical history is remarkable for two cesarean births this infant was born by cesarean section for fetal heart rate deceleration the infant emerged vigorous apgars were nine at one minute and nine at five minutes the birth weight was grams the birth length was cm and the birth head circumference is cm the admission physical examination reveals a vigorous nondysmorphic male infant anterior fontanel is open flat and soft ears and eyes normally positioned mild tachypnea with breath sounds clear and equal grade systolic ejection murmur soft abdomen three vessel umbilical cord normal male genitalia testes descended bilaterally femoral pulses present and symmetric tone and reflexes hospital course by systems respiratory status infant has remained on room air through his nicu stay his initial tachypnea resolved by approximately hours of age he has had some apnea and desaturations episodes in a hour period he has never been treated with methylxanthine on examination his respirations are comfortable his lung sounds are clear and equal cardiovascular status he has had a grade systolic ejection murmur at the time of admission he is pink and well perfused after being heard only intermittently murmur has resolved no cardiac evaluation was done he has remained normotensive throughout his nicu stay fluids electrolytes and nutrition status his weight at transfer is grams enteral feeds were begun on day of life and advanced without difficulty to full volume feeding of breast milk or preemie enfamil calories per ounce he is taking most of his feeding orally total fluids are currently at cc kg day his electrolytes last were done on and they were sodium of potassium chloride and bicarbonate he has remained euglycemic throughout his nicu stay gastrointestinal status a bilirubin at hours of age was total of direct bilirubin this morning is which is borderline for phototherapy as he is being transferred the decision re phototherapy is left to the neonatologist at bilirubin levels should be followed hematological status the infant has received no blood product transfusions during his nicu stay his hematocrit at the time of admission was and his platelet count was infectious disease status the infant was started on ampicillin and gentamicin at the time of admission for sepsis risk factors his white count was with a differential of polys and band the antibiotics were discontinued after hours and the blood cultures were negative and the infant was clinically well there are no further infectious disease issues neurology no hus is required as he is greater than weeks he has been clinically appropriate sensory hearing screening has not yet been done but is recommended prior to discharge psychosocial parents have been visiting during his nicu stay and involved with the infant s care infant is being transferred in good condition to for continuing care primary pediatrician dr at telephone number care recommendations feedings breast milk or preemie enfamil calories per ounce po or by gavage if necessary total fluids at cc kg day infant is discharged on no medications the infant has not yet had a car seat position screening test one is recommended prior to discharge his state newborn screen was sent on infant has not yet received any immunizations bilirubin should be followed and decision made regarding phototherapy recommended immunizations synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria born at less than weeks born between and weeks with plans for daycare during rsv season with a smoker in the household or with preschool siblings or with chronic lung disease influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age before this age the family and other caregivers should be considered for immunization against influenza to protect the infant discharge diagnoses prematurity weeks gestation sepsis ruled out status post transient tachypnea as a newborn apnea of prematurity physiologic jaundice m d dictated by medquist d t job,"{
""date"": ""2019-10-10"",
""type"": ""NPN"",
""id"": 217511,
""hl7_id"": 100000000000000000000000000000,
""hospital2"": ""MICU 7A"",
""service"": ""NEUROSURGERY"",
""doctor"": ""JOHNSON [**First Name (Titles) 1011**] M.D. [**Last Name (Titles) 1011**] M.D. [**Last Name (Titles) 1011**] M.D. [**Last Name (Titles) 1011**] M.D. [**Last Name (Tit"
78356,admission date discharge date date of birth sex f service neurology allergies penicillins attending chief complaint headache major surgical or invasive procedure none history of present illness per admitting resident y o rhf with pmh sig for htn presenting with day history of sudden global leaking like ha the ha started suddently on friday pm and she took no ha meds taken at home she went to bed early for her pm on friday night and still awoke with the same ha she tried to lie down and keep still to relieve the pain pt was noted to have nausea this am only dry heaving she was taken to osh in which her bp she was given labetalol mg per written note and diuladid mg and was planned to start on a labetalol drip ivf were rendered the ha subsided to upon arrival to er vs af hr bp rr o on ra pt has a known history of htn since she is complaint on her meds her meds were recently changed she states that her atenolol was mg qday yet decreased to mg due to her low hr then while she was on mg she was noted to have epitaxis on several occasions so her asa mg was decreased to mg her bp was running high so she was increased back to atenolol mg qday per her daughter in law she sometimes does not like to take her lasix due to the increased urination neurology consult was called no bp correction was done yet she was started on a nicardipine gtt due to her known low hr no additional anagelesics were given during the exam she had some additional nausea when standing her up during the physical exam and a stat repeat hct was obtained which showed an increase in size of the l frontal ich cm intraparenchymal hemorrhage and sah without ivh spread or midline shift icu admission was arranged neurosurgery was consulted no surgical intervention at this time pertinent nausea pertinent no head trauma no visual changes no photophobia no phonophobia no weakness no changes in sensation no coumadin usage hx of migraines past medical history htn since knee sx s p mva had to have a spinal tap x to relieve ha pressure epistaxis starting in most recent episode of epistaxis was days ago bradycardia social history lives independently had sons died from htn family history htn son who died in his s mi y o brother physical exam on admission o t af bp hr r on ra o sats gen wd wn comfortable eyes closed in slight distress heent no traumatic insults pupils eoms neck supple lungs cta bilaterally cardiac rrr s s no murmurs no bruits abd soft nt bs extrem warm and well perfused bilateral ue edema neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date with cues recall objects at minutes with cues language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors difficulty with qtrs calc yet she is normally able to handle her own finances pt also was delayed in answering questions cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields are full to confrontation iii iv vi extraocular movements intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric viii hearing intact to voice ix x palatal elevation symmetrical sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout no pronator drift sensation intact to light touch propioception pinprick and vibration bilaterally reflexes b t br pa ac right left difficult to obtain le reflexes due to edema toes downgoing bilaterally coordination normal on finger nose finger rapid alternating movements heel to shin gait steady on feet yet became nauseous with standing and moving around ct noon repeat hrs after the initial osh hct showing cm ich in the l frontal area ind inc nausea results increase in size of the l frontal ich cm intraparenchymal hemorrhage and sah without ivh spread or midline shift labs assessment plan y o rhf with pmh sig for htn pres with day hx of sudden global ha with nausea found to have a ich cm l frontal at an osh with interval inc in ich within hr with sbp on pe she is noted to have slightly diminished mentation and nml neuro exam otherwise she took her meds yet doses were modified recently with and without her pcp her asa which have impaired her platelet fxn she has a hypertensive intraparenchymal hemorrhage with mild increase in size in the setting of continue htn admit to neuroicu attg cont nicardipine gtt goal sbp aim for s repeat hct in hrs at mn to compare ich progression neuro checks q if neuro exam changes obtain a stat hct to eval for herniation neurosurgery consult completed and appreciated plt transfusion rec no neurosurgical intervention at this time will continue to follow platelet transfusion packet x due to asa adm yesterday tylenol prn ha no narcotics for pain due to masking signs of inc icp npo until hct obtain and stable for possible neurosurgical intervention zofran mg prn n v am cbc bmp coags plan d w icu resident rn and family code status dnr only pressors no intubation no cardioversion i have reviewed this case with dr neuro attg who reviewed the above formulated plan md neurology resident addendum by md on at pm patient was seen and examined agree with dr note exam impression and plan on with additions to the plan noted below patient is a year old right handed woman hx of htn and epistaxis who reports onset of severe headache on at pm the correct date was given by her son patient said that the headache started on this headache was diffuse and associated with nausea and dry heaving but not vomiting she was unable to sleep during the night at am on her son took her to hospital sbp was she received labetalol mg iv ct brain showed a left frontal hematoma she was transferred to repeat ct brain showed left frontal hematoma measuring cm in diameter subarachnoid hemorrhage was present in the left cerebral convexity there was no intraventricular extension no midline shift neurosurgery was consulted but there was no neurosurgical intervention indicated she was admitted to sicu additional pmh she has a hx of epistaxis starting in most recent episode of epistaxis was days ago also has bradycardia htn since on exam at pm on neuro ms alert and oriented x intact naming repetition spelling house backwards ir sr no apraxia knows that is president cn vfftc no visual extinction perrla eomi intact lt and facial strength intact t u p motor no pronator drift strength of deltoids biceps triceps we wf right iliopsoas is and left iliopsoas is we and wf sensory intact light touch and pinprick of all four ext intact proprioception of toes reflexes symmetric ue and le right toe upgoing left toe downgoing coord intact fnf bilaterally gait deferred pertinent results wbc rbc hgb hct mcv plt glucose urea n creat sodium potassium chloride total co anion gap pt ptt inr pt ctropnt imaging ct head without contrast stable left inferior frontal lobe hemorrhage with sah and mild mass effect on the left lateral ventricle from the study done hrs earlier this is likely related to trauma given the location to correlate with h o trauma and further work up can be considered if there is no correlating h o trauma early mild hydrocephalus is not excluded ct head without contrast impressions inferior left frontal lobe intraparenchymal hemorrhage with surrounding edema and local mass effect diffuse left cerebral hemisphere subarachnoid hemorrhages and intraventricular extension are not changed from hours prior no new focus of hemorrhage shift of normally midline structures or new enlargement of the ventricles mri mra head areas of intraparenchymal hematoma in the left frontal lobe with mass effect on the frontal is redemonstrated no obvious abnormal enhancement is noted compared to the precontrast images patent major intracranial arteries without focal flow limiting stenosis occlusion or aneurysm more than mm within the resolution of mr angiogram followup assessment can be considered for any residual obscured lesions ct head without contrast no change since left frontal intraparenchymal hematoma with scattered subarachnoid and intraventricular hemorrhage no evidence of new bleeding cxr impression no evidence of pulmonary infectious process on single plain chest examination brief hospital course ms is an year old right handed woman with a history including htn who initially presented to hospital with headache and nausea a non contrast ct of the head demonstrated a left frontal intraparenchymal hemorrhage and she was transferred to the for further evaluation and care at the time of arrival the neurosurgery team was asked to evaluate the patient no intervention was thought to be necessary she was admitted to the stroke service from to neuro to evaluate for evolution of the lesion several head cts were performed over time the neuroimaging documented a stable left inferior lobe intraparenchymal hemorrhage with surrounding edema and local mass effect in addition to diffuse left cerebral hemisphere subarachnoid hemorrhages an mri performed to evaluate for evidence of ischemia confirmed ct findings angiography studies showed that the major intracranial vessels were patent the etiology of the hemorrhage remains unclear the patient denies preceding trauma and the bleed is in a location uncharacteristic for hypertensive events furthermore vessel imaging failed to suggest the presence of an avm and other contributory abnormalities it is possible that amyloid angiopathy is a contributing variable for this reason aspirin has been discontinued keppra mg po bid was started as seizure prophylaxis and should be continued until particularly in the setting of intraparenchymal hemorrhage blood pressure control with a target systolic blood pressure of to was an important focus of care in addition to continuing the patient s pre existing atenolol regimen the lasix was continued in the course of the hospitalization the lisinopril dosing was increased from mg po daily to mg po daily norvasc mg po daily was also initiated prior to discharge id in the course of the hospitalization the patient was found to have a urinary tract infection for which a three day course of bactrim was started on the last day of antibiotic treatment will be rehabilitation following a pt evaluation the patient was discharged to rehabilitation code status dnr dni pressors acceptable medications on admission atenolol mg qday lasix mg qday asa mg qday lisinopril mg qday all pcn unknown discharge medications levetiracetam mg tablet sig one tablet po bid times a day for days disp tablet s refills furosemide mg tablet sig one tablet po daily daily atenolol mg tablet sig one tablet po daily daily trimethoprim sulfamethoxazole mg tablet sig one tablet po bid times a day as needed for uti for days disp tablet s refills lisinopril mg tablet sig two tablet po daily daily disp tablet s refills amlodipine mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition extended care facility rehab for discharge diagnosis left frontal hemorrhage possibly due to amyloid angioathy discharge condition stable the neurological condition is notable for a mild left pronator drift left triceps weakness and left finger extensor weakness in addition to a mild bilateral postural tremor discharge instructions you presented to the hospital with headache a ct scan revealed bleeding in the brain and you were transferred to the for further care repeat imaging demonstrated stability of the hemorrhage and surrounding swelling it is thought that the bleeding could be related to a condition called amyloid angiopathy for this reason aspirin has been discontinued to help better control your blood pressure the anti hypertensive medication norvasc mg by mouth daily was started during the hospitalizations the lisinopril dose was also increased to mg by mouth daily please note that aspirin has been discontinued the antibiotic bactrim was started to treat a urinary tract infection please finish the day course prescribed on please continue the keppra as seziure prevention until please continue all medications as prescribed please attend all follow up appointments please seek medical attention if you develop a severe headache vision changes trouble speaking difficulty walking weakness especially on one side of the body shaking of the limbs chest discomfort shortness of breath or any other symptom you find concerning followup instructions please attend the following appointments primary care physician on at am stroke specialist md phone on at pm an mri of the brain with and without contrast should be repeated in approximately one month to evaluate the frontal hemorrhage,"[
""admission_date"" : ""2022-10-22"",
""discharge_date"" : ""2022-10-24"",
""date_of_birth"" : ""2033-1-1"",
""sex"" : ""Female"",
""service"" : ""Neurology"",
""allergies"" : ""Penicillins"",
""attending_chief_complaint"" : ""Headache"",
""chief_complaint"" : ""Headache"",
""history_of_present_illness"" : ""Per admitting resident: YO with RHF with PMH sig for Htn presenting with day history of sudden global leaking like ha the ha started suddently on Friday PM and she took no ha meds taken at home she went to bed early for her PM on"
70119,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint ventricular fibrillation arrest major surgical or invasive procedure central line placement cardiac cath history of present illness m with a history of mi s p bms to rca years ago is admitted s p witnessed cardiac arrest according to the report he collapsed while at work a bystander found him breathing with a bleeding laceration to his right forehead and initiated cpr x minutes until ems arrived placed an aed which delivered a single shock he received another minutes of compressions and atropine mg epinephrine mg and lidocaine mg while intransit to hospital according to the report on arrival to widdham he was in pea he was treated with epinephrine mg x atropine mg x and amiodarone mg and converted to vf he was cardioverted x and re entered pea he was treated with narcan mg another epinephrine mg x amiodarone mg and re entered vf and was cardioverted x after which return of spontaneous circulation was noted he was started on a amiodarone heparin and dopamine drips in total he received cpr for minutes at widdham with possibly another minutes of cpr in the field cooling protocol was initiated and he was transfered to for evaluation and further management fixed and dialated pupils were noted prior to transfer on transfer his vitals were temp p bp rhythm strip showed afib with rvr on arrival to the ed his vitals were t p bp initial ekg showed atrial fibrillation with ventricular rate of bpm ste in v std ii iii avf q waves in ii iii avf in comparison to the ekg from q waves are unchanged std ste are new he was successfully cardioverted to sinus rhythm repeat ekg showed improvement in ste std with decreased ventricular rate ct head showed no acute process cta chest showed emphysematous blebs and no pe he was admitted to the ccu on admission to the ccu his vitals were bp p on vent settings of peep fio he was taken to the cath lab which showed chronically occluded rca and lad with a patent lcx given chronicity of lesions no intervention was performed ischemic cardiomyopath likely vt vf arrest after cardiac cath patient entered sinus tachycardia and was given metoprolol leading to hypotension and return of atrial fibrillation he was again cardioverted to sinus rhythm given furosemide with appropirate urine output on discussion with the family patient has not sought medical care in the last years following his cardiac cath in patient was compliant with aspirin plavix atenolol lisinopril and lipitor for roughly months after which he discontinued all medications except aspirin mg and nitro prn which he has not taken recently accodording to the wife he has had long standing dyspnea on exertion worse in the winter months she notes that he does not complain of orthopnea pnd palpatations she reports that he has never had loss of consciousness past medical history cardiac risk factors dyslipidemia hypertension cardiac history cabg none percutaneous coronary interventions bms x to rca cath showing stenosis of mid lad pacing icd none other past medical history hypertension hyperlipidemia social history tobacco history ppd x years pack years etoh drinks month illicit drugs none family history mother hypertension hyperlipidemia silent mi on ekg noted early s father first mi at maternal gf cad maternal uncle first mi maternal cousin female first mi paternal gf cad physical exam on admission general middle aged male intubated sedated c collar in place heent cm laceration to right brow sutures in place pupils mm and not reactive to light conjunctiva pink no pallor or cyanosis of the oral mucosa neck c collar in place jvp not assessed cardiac rrr normal s s no m r g lungs ctabl no rales wheezes or rhonchi abdomen soft nd bowelsounds absent extremities cool to the touch motteling and palor of toes bl ashen lower extremities skin no stasis dermatitis ulcers scars or xanthomas pulses right dp not dopperable pt not dopperable left dp dopplerable pt not dopperable access right radial sheath right femoral a v sheaths left femoral vl left radial a line pertinent results on admission pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh ck cpk alkphos totbili pm blood lipase pm blood ctropnt pm blood ck mb mb indx pm blood albumin calcium phos mg pm blood hba c eag pm blood tsh pm blood type art rates tidal v fio po pco ph caltco base xs aado req o assist con intubat intubated pm blood lactate imaging ct chest performed at osh read by the patient is intubated with the et tube terminating within the distal trachea a transesophageal catheter terminates within the stomach with the side port at the ge junction multiple large blebs are seen throughout both lungs predominantly in the upper zones there is neighboring interstitial fibrosis moderate dependent atelectasis is seen with enhancement throughout most of the parenchyma although there are pockets of hypoperfusion which may signify an early infectious process no pneumothorax is seen the great vessels are patent and normal in caliber no pulmonary embolism is detected to the subsegmental levels the heart size is normal there is no pericardial effusion there is no effusion or pulmonary edema included views of the upper abdomen demonstrate a normal appearing liver stomach spleen and left adrenal gland osseous structures there is no acute fracture or dislocation no concerning blastic or lytic lesions are detected impression multiple large blebs in a panlobar pattern raising suspicion for alpha anti trypsin deficiency moderate dependent atelectasis with pockets of hypoperfused lung parenchyma raising the possibility of early infection or aspiration no pe detected to the subsegmental levels ct head performed at osh read by findings there is no evidence of acute intracranial hemorrhage edema mass mass effect or large vascular territorial infarction the ventricles and sulci are normal in configuration no acute fracture is seen a small mucous retention cyst is present within the right maxillary sinus there is mucosal thickening seen within the sphenoid sinuses greater on the right the middle ear cavities and mastoid air cells are clear impression no acute intracranial process mild sinus disease echo left ventricular wall thicknesses are normal the left ventricular cavity size is normal there is an apical left ventricular aneurysm overall left ventricular systolic function is severely depressed lvef secondary to multiple focal wall motion abnormalities including extensive apical akinesis with focal dyskinesis right ventricular chamber size is normal there is focal hypokinesis of the apical free wall of the right ventricle the aortic root is mildly dilated at the sinus level the aortic valve is not well seen there is no aortic valve stenosis the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse the pulmonary artery systolic pressure could not be determined there is no pericardial effusion at time of expiration am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood albumin calcium phos mg am blood phenyto am blood type art po pco ph caltco base xs am blood lactate brief hospital course a yom with pmh smoking htn hl cad s p bms to rcx with poor medical follow up was is transfered s p ventricular fibrillation arrest for cooling protocol neurological prior to arrival at patient was resuscitated with acls for minutes per family patient was seen on security camera after collapse and was down for minutes prior to the initiation of cpr arctic sun protocol was initiated hours post arrest neurologic examination on admission was notible for fixed and dilated pupils and absent corneal reflex ct head is negative for acute process after hours patient was re warmed and sedation was held off sedation patient remained unresponsive and was noted to have clinical signs of seizure eeg showed status epilepticus patient was loaded with keppra followed by dilantin with fair control of seizure activity eeg also showed gpeds pattern which is associated with high mortality after a hour period off sedation seizure activity increased a family meeting was held in which the poor prognosis was discussed and his care was transitioned to comfort measures only with both the patient s wife and son in agreement he expired approximately hours after extubation with family at bedside autopsy was declined by the family and not referred to the cme coronaries patient underwent cardioversion in the field and in pea arrest at hospital where acls was continued he was successfully resuscitated intubated placed on amiodarone drip pressors sedation and anticoagulation and transferred to for further management in the ed he was noted to be in afib with rvr lateral stemi echo performed at bedside showing global hypokinesis with anterior anteroseptal lateral and apical wall motion abnormalities admission ekg showed rate dependent ste elevations likely related to demand ischemia cardiac cath showed old rcx and lad lesions with patent lcx given chronicity of lesions no intervention was performed vf arrest is likely a result of arrythmagenic focus of infarcted myocardium rhythm initially in afib with rvr in the ed dccv in the ed with reuturn to sinus rhythm throughout remainder of hospitalization patient remained in sinus rhythm gi bleed on admission patient was noted to have sanguanous return from ogt hct remained stable throughout hospitalization and transfusion was not necesary stress ulcer is likely etiology head trauma skin laceration on right brow noted by ems at time of arrest likely post traumatic after syncope head ct negative however c collar could not be cleared without mri given neurologic dysfunction chf last echo in showed lvef echo peformed on admission showed severely depressed lvef secondary to multiple focal wall motion abnormalities including extensive apical akinesis with focal dyskinesis according to the family the patient did not experience congestive heart failure symptoms resarch patient consented to participate in corticosteroid in myocardial infarction study he was randomized to receive hydrocortisone mg iv q h or placebo x days comm wife hcp h c medications on admission aspirin mg daily nitro sublingual prn discharge medications expired discharge disposition expired discharge diagnosis anoxic brain injury cardiac arrest discharge condition expired discharge instructions n a followup instructions n a,"[
""admission_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-11"",
""date_of_birth"": ""2047-1-1"",
""sex"": ""M"",
""service"": ""Medicine"",
""allergies"": [
""No Known Allergies""
],
""adverse_drug_reactions"": [
""Attending Chief Complaint Ventricular Fibrillation Arrest""
],
""chief_complaint"": ""Ventricular Fibrillation Arrest"",
""history_of_present_illness"": ""M with a history of MI s/p BMS to RCA years ago is admitted s/p witnessed cardiac arrest according to the report he collapsed while at work a bystander"
13352,admission date discharge date date of birth sex f service nb history baby girl is a week gestation age born to a year old gravida i para mother with type a positive antibody negative rpr nonreactive hepatitis b surface antigen negative and rubella immune female the estimated date of confinement was the prenatal course was significant for cervical shortening at weeks and not a candidate for cerclage the patient remained in the hospital for observation preterm contractions were noted and patient was started on magnesium and received betamethasone the contractions resolved after she was started on magnesium she continued on observation in the hospital until weeks and then was noted to have contractions again magnesium was restarted and the contractions resolved the patient was sent home on bed rest there was a maternal history of fetal bilateral intrarenal dilitation of the collecting systems was noted by ultrasound on the mother on the day of delivery presented with contractions the gbs status was positive but no maternal fever rupture of membranes was hours prior to delivery the patient was started on clindamycin hours prior to the deliver y the infant was delivered on at a m spontaneous vaginal delivery with apgar scores of and at one and five minutes the infant emerged active good respiratory effort pink and was brought to the neonatal intensive care unit for issues of prematurity her birth weight was grams length inches and head circumference cm her weight th percentile head circumference at the th percentile physical examination baby girl appeared pink with a nterior fontanelle open and flat her chest examination showed breath sounds clear and equal on auscultation her heart sounds were normal s and s with no audible murmur she had mild intercostal subcostal retraction her abdomen was soft nontender nondistended the extremities were well perfused and the tone was appropriate for gestational age her facial features include a flat nose with midline indentation most probably due to the position prior to the delivery she had a caput and normal female genitalia summary of hospital course by systems respiratory the patient remained stable and continued to do well on room air she did not require any intubation or oxygen supp ort during this period in the neonatal intensive care unit cardiovascular system the patient remained hemodynamicall y stable her heart sounds were normal and no murmur was heard fluids electrolytes nutrition the patient remained n p o with intravenous fluid d w on day zero she was started on feeds and was gradually advanced on breast milk special care currently she is on total fluids of cc per kg per day breast milk or neosure cals ounce her discharge weight is grams gastrointestinal baby girl had a peak bilirubin of and a direct component of on day of life she did not receive phototherapy hematology her initial cbc showed a hematocrit of an d a platelet count of infectious disease baby girl was started on ampicillin and gentamicin her initial cbc had shown wbc count of with bands her ampicillin and gentamicin were discontinued on day of life at hours her cultures remained no growth to date sensory hearing screen prior to discharge was renal the patient had a renal ultrasound on due to history of prenatal hydronephrosis this showed mild pyelectasis of the right kidney otherwise normal examination immunizations hep b immunization given on psychosocial the soc ial wor is involved with the family the contact social worker can be reached at her newborn screening was sent to the state laboratory on discharge diagnosis prematurity at weeks rule out sepsis discharge plans f u within days of discharge at cop dr to visit home day post discharge m d dictated by medquist d t job,"{
""admission_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-14"",
""date_of_birth"": ""2019-10-10"",
""sex"": ""Female"",
""service"": ""OB/GYN"",
""history"": [
""Baby girl is a week gestation age born to a year old gravida I para mother with type A positive antibody negative RPR nonreactive hepatitis B surface antigen negative and rubella immune female. The estimated date of confinement was the prenatal course was significant for cervical shortening at weeks and not a candidate for cerclage. The patient remained in the hospital for observation preterm contractions were noted and patient was started on magnesium and received betamethasone the contractions"
2526,admission date discharge date date of birth sex m service admitting diagnosis non hodgkin s lymphoma il therapy discharge diagnoses vt cardiac monitoring history of present illness the patient is a year old male with a history of metastatic renal cancer admitted to for il biologic therapy dictation ended m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service biologics history of present illness patient is a year old male with a history of metastatic renal cell carcinoma admitted for cycle one week one of high dose il his oncologic history began in when he developed fatigue and by he had developed anemia ct of his abdomen revealed a large right kidney mass he underwent a right radical nephrectomy on revealing adenocarcinoma with predominant clear cell type with anaplastic spindle cell areas firm and grade there was tumor invasion of the renal vein and metastases to the adrenal staging workup was otherwise negative he was followed closely and developed a cough in chest ct in revealed large lung nodules consistent with renal cell metastases patient was evaluated here for high dose il treatment program and found to meet eligibility criteria past medical history metastatic renal cell carcinoma bilateral inguinal hernia repairs vasectomy allergies no known drug allergies admission medications percocet prn ms contin mg p o b i d multivitamin physical exam on admission reveals a well appearing middle age male in no acute distress performance status vital signs and o saturation on room air head eyes ears nose and throat normocephalic and atraumatic pupils are equal round and reactive to light moist oral mucosa without lesions neck is supple no jvd heart regular rate and rhythm s s lungs clear abdomen is rounded positive bowel sounds soft mild tenderness over the right nephrectomy scar area extremities without edema neurologic is nonfocal admission laboratories wbc hematocrit platelet count bun creatinine sodium potassium chloride co alt ast cpk alkaline phosphatase total bilirubin albumin calcium phosphorus magnesium uric acid hospital course patient was admitted admission weight was noted to be kg and he was dosed with il iu kg equaling miu iv q h for planned doses scheduled doses with dose held due to hypotension and doses and held related to mild neurotoxicity and severe constitutional side effects his course was notable for early hypotension initially responding to fluid boluses later requiring dopamine and neo synephrine vasopressor support he was eventually weaned from his pressors on day but was noted to have a cpk of at that time ck mb and troponin values were also elevated as per protocol he was placed on a cardiac monitor and on at a m he had a run of question of ventricular tachycardia he was transferred to the intensive care unit for closer monitoring cardiology felt his rhythm strip was from artifact rather than true ventricular tachycardia he had no acute ischemic changes on ekg echocardiogram revealed mild aortic regurgitation and mild mitral regurgitation with a left ventricular ejection fraction slightly decreased at cardiac enzymes continued to trend downward and he remained without any arrhythmia on telemetry he was felt to have an il induced myocarditis without myocardial infarction he was planned for an outpatient stress test to further evaluate cardiac function he was discharged to home on with a normal cpk and no cardiac symptoms other side effects during his course included fevers and chills and an erythematous skin rash he also had some nausea and vomiting treated with antiemetic therapy his hemoglobin and hematocrit on were and respectively and he was transfused with units of packed red blood cells to help support his blood pressure he had a mild thrombocytopenia with a minimum platelet count of thought related to il which had improved to on the day of discharge and developed hyperbilirubinemia with a peak bilirubin of on improved to on mild transaminitis with an alt of and an ast of on again improved before discharge he developed a mild metabolic acidosis with a co of on treated with bicarb and his maintenance iv fluids he had a mild renal insufficiency with a peak creatinine of improved to on the day of discharge the side effects included mild diarrhea treated with antidiarrheals by he had recovered from myocarditis and other side effects to allow for discharge to home condition on discharge stable discharge status to home with his wife discharge instructions the patient is to notify us for fever or cardiac symptoms he will have an outpatient thallium stress test performed prior to his next planned week of il therapy discharge medications keflex mg p o b i d x days ranitidine mg p o b i d prn nausea acid stomach or while on nsaids lomotil two tablets p o q h prn diarrhea compazine mg p o q h prn nausea ativan mg q h prn nausea or anxiety or for sleep benadryl mg q h prn pruritus tylenol mg p o q h prn fever or pain motrin mg p o q h prn pain oxycodone mg p o q h prn pain colace mg p o b i d prn constipation diagnosis status post cycle one week one high dose il for metastatic renal cell carcinoma with course complicated by myocarditis m d dictated by medquist d t job cc,"[**2141-1-2**] 12:37 PM
 Pt. admitted from [**Hospital1 10**] for IL therapy.

Pt. is a 53 yo M with a history of metastatic renal cell carcinoma,
admitted for cycle one week one of high dose IL.

Pt. has a history of metastatic renal cell carcinoma, admission for
high dose IL.

Pt. is a 53 yo M with a history of metastatic renal cell carcinoma,
admitted for cycle one week one of high dose IL.

Pt. has a history of metastatic renal cell carcinoma, admission for
high dose IL.

Pt. is a 53 yo M with a history of metastatic renal cell"
31592,admission date discharge date date of birth sex f service medicine allergies darvocet n percocet attending chief complaint chest pain major surgical or invasive procedure right and left heart catheterization at osh history of present illness f with dm htn dyslipidemia cad imi rca stent lcx stents and for instent thrombosis developed acute chest discomfort which is predominantly nausea saturday am lasted several hours remitted for an hour then recurred and so she presented to the ed at hosp her prior ischemic pains were substernal chest tightness ekg there c w inferior stemi and she was taken to the cath lab from osh notes access was difficult body habitus cath showed normal lmca ostial mid and distal lesions in the lad hazy prox lesion in the lcx at the site of prior stents and stenosis and a proximally occluded rca ptca to the lcx required several balloon dilations and after recoil there was residual stenosis she was transferred to for consideration of cabg reopro gtt started at am for planned duration hours rfa and rfv sheaths in place at time of transfer past medical history obesity htn hyperlipidemia cad s p prior imi in nstemi in and in s p rca stents overlapping penta stents to rca in and taxus stents to lcx in at with unsuccessful pci of the rca chf lv diastolic dysfunction dmii poorly controlled c b neuropathy copd respiratory failure requiring tracheostomy months ago s p trach reversal s p cva w residual r sided weakness s p c section h o cocaine use none for years social history social history is significant for the absence of current tobacco use remote history of cigarette smoking h o etoh abuse no etoh x years h o cocaine use none for many years family history h o cad in siblings and mother with renal failure physical exam vs t hr bp rr l gen nad oriented x very anxious appearing heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp of cm cv soft heart sounds given body habitus late peaking crescendo decrescendo murmur at the rusb without radiation to carotids and without pulsus parvus et tardus chest lungs are clear difficult to assess given habitus abd obese soft ntnd no hsm or tenderness ext pitting pedal edema bilaterally symmetrical skin stasis dermatitis ankles wrapped in ace bandages weeping no ulcers scars or xanthomas pulses right carotid dp dop pt dop left carotid dp dop pt dop pertinent results ekg presentation sr ste in ii iii avf with q waves ste in v v as well std with biphasic twaves in i avl post cath no significant change from above arrival still with ste q in inferior and ant precordial leads same std in high lateral leads cardiac cath report from hosp normal lmca ostial mid and distal lesions in the lad hazy prox lesion in the lcx at the site of prior stents and stenosis and a proximally occluded rca ptca to the lcx required several balloon dilations and after recoil there was residual stenosis d echocardiogram performed on report from osh ef diastolic dysfunciton and moderate concentric lvh moderate as with a valve area of cm and peak gradient mean gradient cxr enlarged heart prominent hila with pulmonary vascular congestion no obvious evidence for consolidation or pleural effusion brief hospital course f with dm extensive prior cad including multiple instent thromboses now presents with hrs of nausea found to have inferior wall q wave mi cad ischemia imi due to instent thrombosis of lcx stent with chronically occluded rca attempted ptca at with sub optimal angiographic result and no resolution of st elevations so referred to for further eval however given q wave infarction and pt s co morbid conditions uncontrolled dm h o of lung disease requiring trach in the past pt previously denied for cabg and would be denied on same grounds at this time pt was transferred on heparin and abciximab asa plavix high dose atorvastatin with arterial and venous sheaths still in place decision was made not to recath as imaging from did not show an intervenable lesion pt had an episode of bleeding from around her sheaths and so they were pulled and she had an episode of bleeding from the venous sheath site pressure was held for minutes and the bleeding resolved hct remained essentially stable so there was no concern for major bleeding after leaving the ccu pt had multiple episodes of sharp chest pain worse w palpation of chest associated with shortness of breath and anxiety these episodes were not associated with ekg changes her cardiac enzymes continued to trend downward and her symptoms were resolved with reassurance pump h o diastolic chf with ef echo here showed mild lv systolic function hypokinesis of basal half of inferior and inferiolateral segment and distal half of septum ef of pt did not appear acutely volume overloaded on discharge she had chronic appearing edema of her legs which did not change over the course of her admission her furosemide was held because of concern for hyportension after recieving increased doses of carvedilol we uptitrated her carvedilol from at home to mg on d c her lisinopril was decreased to mg daily because of carvedilol induced hypotension rhythm sr st monitored on telemetry little ectopy pvc s pt had warfarin listed in her admission medications but her inr was on presentation valves murmur suggests as consistent with prior report of moderate as will check echo as above htn pt was actually hypotensive through most of this admission most likely secondary to her partial right ventricular infarct dm a c was so poorly controlled she was maintained on her home dose of insulin as we did not have time to uptitrate her basal insulin depression continued escitalopram code full communication with patient medications on admission aspirin mg daily plavix mg daily coreg mg daily lipitor mg daily lasix mg lisinopril mg daily imdur mg daily insulin levemir units daily and humalog units sliding scale prior to meals nexium mg daily lexapro mg daily neurontin mg tid potassium chloride discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily nitroglycerin mg tablet sublingual sig one tablet sublingual sublingual prn as needed as needed for chest pain for doses call if first dose is not effective tablet sublingual s atorvastatin mg tablet sig one tablet po daily daily gabapentin mg capsule sig one capsule po tid times a day clopidogrel mg tablet sig two tablet po daily daily carvedilol mg tablet sig two tablet po bid times a day insulin regular human unit ml solution injection ferrous sulfate mg mg iron tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily insulin detemir unit ml solution subcutaneous nexium mg capsule delayed release e c sig one capsule delayed release e c po once a day lexapro mg tablet sig one tablet po once a day discharge disposition home with service facility rehab discharge diagnosis primary diagnosis inferior mi secondary diagnoses hypertension hypercholesterolemia dm diastolic chf copd respiratory failure in required tracheostomy which has subsequently been reversed h o cva with residual r sided weakness s p c section discharge condition good pain free discharge instructions you were transferred here from your outside hospital because you had had a heart attack they looked at your coronary vessels to try and help your blood flow to your heart and improved it as much as they could they thought you still should be evaluted for cardiac bypass and sent you here to accomplish this unfortunately because of your very difficult to control diabetes the surgeons felt the surgery would present more danger than benefit to you thus we managed your pain and maximized your medications your medications have been changed your plavix clopidogrel was doubled to mg daily because of your history of clotting in your stents your lasix furosemide was held temporarily because of low blood pressure your doctor may want to restart this once you have adjusted to the carvedilol your carvedilol was changed to mg twice daily for added protection of your heart this caused your blood pressure to be low your lisinopril was decreased to mg daily because your blood pressure was low your doctor may want to increase this again after you adjust to the carvedilol your daily potassium chloride was held while you were not recieving furosemide please keep all scheduled follow up appointments as these are important to manage your health please go to the emergency room or call your doctor if you have fever chest pain shortness of breath inability to tolerate food by mouth or any other distressing changes in your health completed by,"[
""admission_date"": ""2019-12-28"",
""discharge_date"": ""2019-12-30"",
""date_of_birth"": ""2043-12-28"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Darvocet N""
,""Percocet""
],
""attending_chief_complaint"": ""Chest pain"",
""chief_complaint"": ""Chest pain"",
""history_of_present_illness"": ""F with DM, HTN, dyslipidemia, cad, imi, rca stent, LCX stents and for instent thrombosis developed acute chest discomfort which is predominantly nause"
1103,admission date discharge date date of birth sex m service history of the present illness this is a year old male involved in a high speed motorcycle accident where he became airborne after a motorcycle accident landed upon a guardrail and came to rest underneath a patch of poison he was awake and alert there was no loss of consciousness he was ambulating and conversing bilateral chest wound his helmet was intact he suffered a large bilateral open chest wound per the ambulance after intubation he had a gcs of and at the scene was awake alert oriented and talking when he was evacuate by the air ambulance where he was intubated for airway protection with succinylcholine and prior to being transported to emergency department past medical history none admission medications none allergies the patient has no known drug allergies physical examination on admission vital signs heart rate blood pressure palpable mechanically ventilated with saturations of gcs of heent the pupils were mm equal and reactive bilaterally to light the tms were clear and the midface was stable there was a hard c collar in place on the neck and the trachea was midline he has a regular rate and rhythm without any murmurs there was a large avulsion injury to the chest with an open right pneumothorax the abdomen was soft and there were bowel sounds the pelvis was stable to in the ap and lateral direction rectal was heme negative with decreased tone noted the extremities were warm without any deformities or obvious dislocations with pulses in all distal extremities laboratory radiologic data hematocrit white count inr negative serum tox for alcohol and other drugs the urine was positive for opiates which he had been stated prior to intubation hospital course the patient became hypotensive in the emergency department fast scan was positive for blood in the abdomen a cordis was placed in the right femoral vein the patient received liters of crystalloid and units of blood a right chest tube was inserted the patient was taken to the operating room for emergent surgery exploratory laparotomy revealed a large liver laceration which was patched and packed several short mesenteric bleeders were also ligated a large avulsion to the right and left chest wall were repaired by thoracic surgery after irrigation and debridement a left chest tube was also inserted the right sided chest was explored without any evidence of foreign body or obvious vascular injury an intraoperative tee was performed that showed normal cardiovascular function and no injury to the aorta the abdominal wound was left open and the patient was transferred to the surgical intensive care unit the following day he returned to the operating room for the removal of the packs and an abdominal washout and the abdominal wound was closed at this point he had several radiological studies revealing a t compression fracture on his t films that was confirmed by ct a ct of the head c spine and ls were normal with the exception of an arachnoid cyst noted on the head ct plastic surgery was consulted regarding the patient s extensive thoracic wounds the patient was started on oral prednisone for an extensive outbreak of poison he also received wet to dry dressings for a cm deep avulsion injury to the left buttock not initially noticed upon his presentation his condition continued to improve and he was extubated uneventfully and transferred to the floor where upon his chest tubes and drains slowed in output when these were removed he was fitted with a tlso brace and subsequently evaluated by physical therapy for the need of rehabilitation versus discharge to home it was felt that the patient would be able to be transferred home without difficulty and would be able to care for his wounds final diagnosis status post motorcycle accident right chest wall avulsion degloving right open pneumothorax liver laceration left buttock avulsion t compression fracture contact dermatitis recommended follow up the patient should follow up with thoracic surgery either dr or dr in one week after discharge he also needs to see dr regarding the t fracture within two weeks the patient should follow up in the trauma clinic in two weeks and also with his primary care doctor as needed discharge medications ibuprofen mg p o t i d oxycodone sr mg q hours with a two week supply dispensed oxycodone acetaminophen mg p o q six hours p r n with dispensed and one refill docusate mg p o b i d benadryl mg p o p r n lactulose mg p o b i d p r n constipation keflex mg p o q i d for three days prednisone taper for four days m d dictated by medquist d t job,"[
""admission_date"" : ""2019-10-12"",
""discharge_date"" : ""2019-10-14"",
""date_of_birth"" : ""2099-10-12"",
""sex"" : ""M"",
""service"" : ""HOSPITAL"",
""service_history"" : ""This is a year old male involved in a high speed motorcycle accident where he became airborne after a motorcycle accident landed upon a guardrail and came to rest underneath a patch of poison he was awake and alert there was no loss of consciousness he was ambulating and conversing bilateral chest wound his helmet was intact he suffered a large bilateral open chest wound per the ambulance after intubation he had a gcs of and at the scene"
83673,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint atrial septal defect major surgical or invasive procedure minimally invasive closure of atrial septal defect history of present illness this year old caucasian female had several episodes of visual defects earlier this year which fully resolved a mri detected embolic deficits and further workup led to the finding of an asd she was referred for surgical repair as she was not a candidate for transvascular closure this was deferred until she completed her schooling this year past medical history migraines embolic strokes social history physical therapy student non smoker social alcohol use family history non contributory physical exam admission vss afebrile lungs clear cor sr no murmur extremeties no edema abdomen benign neuro intact pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood urean creat cl hco am blood mg f radiology report chest pa lat study date of am r csurg fa a am chest pa lat clip reason evaluate for effusion medical condition year old woman with s p minimally invasive asd closure reason for this examination evaluate for effusion preliminary report preliminary reports are not available for viewing dr dr f radiology report femoral vascular us right study date of am r csurg fa a am femoral vascular us right clip reason evaluate for hematoma or fluid collection potantially compre medical condition year old woman with minimally invasive asd closure reason for this examination evaluate for hematoma or fluid collection potantially compressing on nerve c o sharp pain final report indication status post minimally invasive asd closure with pain in the groin to assess for possible hematoma or fluid collection grayscale color flow and pulse doppler assessment of the right groin was performed the femoral arteries and veins are fully patent and normal in appearance there is no evidence of pseudoaneurysm or av fistula no fluid collections or hematoma are identified there is a normal lymph node seen in the right groin conclusion normal study no hematoma or fluid collection dr approved wed pm echocardiography report complete done at am final referring physician information r division of cardiothorac status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m indication hx of reported asd and tias planned intraop closure of asd icd codes test information date time at interpret md md test type tee complete son md doppler full doppler and color doppler test location anesthesia west or cardiac contrast none tech quality adequate tape aw machine echocardiographic measurements results measurements normal range findings left atrium no mass thrombus in the laa right atrium interatrial septum pfo is present left to right shunt across the interatrial septum at rest left ventricle normal lv wall thickness cavity size and global systolic function lvef overall normal lvef right ventricle normal rv chamber size and free wall motion aorta normal ascending transverse and descending thoracic aorta with no atherosclerotic plaque aortic valve normal aortic valve leaflets no as no ar mitral valve normal mitral valve leaflets with trivial mr tricuspid valve normal tricuspid valve leaflets with trivial tr pericardium no pericardial effusion general comments the patient was under general anesthesia throughout the procedure the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope no tee related complications the patient appears to be in sinus rhythm see conclusions for post bypass data conclusions pre cpb no mass thrombus is seen in the left atrium or left atrial appendage a small left to right shunt across the interatrial septum near interatrial cushion is seen at rest given minimal size of shunt a patent foramen ovale more likely left ventricular wall thickness cavity size and global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation there is no pericardial effusion post bypass the atrial septum appears intact s p surgical closure with no residual interatrial flow by doppler preserved biventricular systolic fxn other parameters as pre bypass electronically signed by md interpreting physician brief hospital course following admission she went to the operating room and underwent atrial septal defect closure see operative note for further details postoperatively she was taken to the intensive care unit for monitoring she weaned from the ventilator easily and was extubated she was started on non steriodal anti inflammatory medications for minimally invasive incision she continued to progress except complaint of pain in right groin sharp right leg normal sensation warm pulses palpable ultrasound of femoral artery which ruled out hematoma or fluid collection she was started on gabapentin with improvement in pain physical therapy worked with her for mobility and strength she was ready for discharge home with services on pod with plan for follow up wound check in week for evaluation right groin incision right underbreast thoracotomy no erythema no drainage right groin with steri strips no erythema no drainage small amount swelling medications on admission mvi discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours for days disp tablet s refills ranitidine hcl mg tablet sig one tablet po daily daily for days disp tablet s refills gabapentin mg capsule sig one capsule po bid times a day disp capsule s refills outpatient physical therapy evaluate and treat right hip s p saphenous nerve manipulation discharge disposition home with service facility vna discharge diagnosis atrial septal defect discharge condition good discharge instructions shower daily no baths or swimming until follow up with dr no lotions creams or powders to incisions no driving for weeks and off all narcotics report any redness of or drainage from incisions report any fever greater than take all medications as directed please continue with physical therapy if pain in right leg does not continue to improve or gets worse please call please call with any questions or concerns followup instructions please call to schedule appointments dr in weeks wound clinic in week scheduled appointments provider md phone date time completed by,"[
""date"": ""2019-10-10"",
""service"": ""Cardiothoracic"",
""sex"": ""Female"",
""allergies"": [
""Patient recorded as having no known allergies to drugs""
],
""chief_complaint"": ""Atrial septal defect"",
""history_of_present_illness"": ""This year old caucasian female had several episodes of visual defects earlier this year which fully resolved a MRI detected embolic deficits and further workup led to the finding of an ASD she was referred for surgical repair as she was not a candidate for transvascular closure this was deferred until she completed her schooling this year past medical history migraines embolic strokes social history physical therapy student non smoker social alcohol use family history non contributory physical exam admission V"
99098,admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics attending chief complaint delirium major surgical or invasive procedure removal of left tibial hardware left tibial washout with wound vac placement history of present illness history limited by patient s decreased mental status with collateral obtained from orthopedic floor team and chart this is a yo male with a history of dm osa seizure disorder bipolar disorder who was admitted to orthopedics on for removal of external fixator and orif of his left tibial plateau fracture this am pod he was found to be somnolent and oriented times one from a baseline of full orientation his chem revealed an am glucose of with fs of he was given juice with added sugar briefly increased to but then fs decreased to he then received amp of d and repeat fingerstick was merit was called for medicine consultation given hypoglycemia and altered mental status in addition to new renal failure in the setting of oliguria at the time of merit resident assessment the patient was somnolent and would arouse to voice able to state his name and that he was in a hospital date was friday but would fall asleep quickly he was noted to have occasional jerks of his extremities suggestive of asterixis also he was on l of o by nc given hypoxia to on ra which is new his most recent vs were l an abg was obtained and only showed mild co retention the micu resident was notified of his issues and it was agreed to transfer to the icu for closer monitoring regarding his recent hospitalization he was admitted to from after a motorcycle accident and underwent external fixation of a left tibial plateau fracture left proximal fibula fracture with fasciotomies for compartment syndrome on the left lower extremity this was notable for development of post op agitated delirium which was comanaged with psychiatry upon arrival to the icu the patient was minimally responsive and quite sleepy however was following commands past medical history htn dm seizure disorder ptsd and bipolar disorder osa reportedly noncompliant with cpap in hospital social history denies etoh or substance use to me per omr h o incarceration for shooting his wife in the context of a drinking binge family history nc physical exam micu admission physical vs temp bp hr rr o sat l gen pleasant comfortable nad heent pupils constricted and minimally responsive anicteric mmm op without lesions no supraclavicular or cervical lymphadenopathy no jvd no carotid bruits no thyromegaly or thyroid nodules resp cta b l with good air movement throughout cv rr s and s wnl soft systolic murmur heard throughout precordium no gallops rubs abd nd b s soft nt no masses or hepatosplenomegaly ext warm well perfused no cyanosis no edema bandage on left leg is c d i skin no rashes no jaundice no splinters neuro aaox moving extremities and following commands no sensory deficits to light touch appreciated pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt am blood ck cpk am blood asa negative ethanol negative acetmnp bnzodzp negative barbitr negative tricycl negative am blood lithium am blood tsh am urine color amber appear clear sp am urine blood neg nitrite pos protein glucose neg ketone tr bilirub sm urobiln ph leuks sm am urine rbc wbc bacteri many yeast none epi pm urine osmolal pm urine hours random urean creat na k cl cxr there are low lung volumes mild cardiomegaly is accentuated by the low lung volumes the lungs are grossly clear there is no pneumothorax or pleural effusion other labs am blood ck cpk am blood lithium discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood calcium phos mg brief hospital course yo m with bipolar d o type ii dm and osa originally admitted to orthopedics for hardware removal who was transferred to the micu for hypoglycemia and delerium when sugars and metal status had improved he was tranfered to the medical floor left tibial fracture s p orif initially admitted to the hospital from rehab for removal of external fixator on postoperative pain was managed with tylenol atc and low dose oxycodone prn he went back to the or for a washout on pt saw patient and recommended home with home pt altered mental status likely multifactorial including hypoglycemia infection and medication build up from arf causing decreased elimination notably seroquel ativan lithium duloxetine dilaudid and gabapentin build up in setting of arf psych was consulted who recommended putting patient on a bzd taper which he finished on the day of discharge he was also started on haloperidol mg tid over time the patient s delirium improved and haloperidol was d c prior to discharge his qtc was monitored while on haloperidol and did not prolong he was found to have a urinary tract infection see below hypoglycemia patient transferred to micu in setting of ams with hypoglycemia in s etiology of hypoglycemia likely caused by medication error as patient was started on glyburide mg following surgery furthermore clearance of glyburide was reduced given acute kidney injury see below hypoglycemia was corrected with d and d gtt which were weaned off once blood sugar had normalized and patient was called out to the medical floor he was maintained on sliding scale humalog on the floor and will be discharged home with his outpatient dose of metformin uti urine culture from grew pseudomonas patient was initially treated with zosyn and when the organism was found to be fairly pan sensitive he was switched to po ciprofloxacin to complete a day course for a complicated uti as patient had a foley in the micu which was d c upon transfer to the floor low grade fever leukocytosis improved with initiation of treatment for uti but source was unclear initially lateral leg incision was draining serosanguinous fluid and orthopedics took pt back to or for a washout he was put on ancef initially then switched to vanco for gram coverage wound gram stain showed pmns but no organisms and cultures were negative per ortho recs pt will be d c with a week course of keflex acute renal failure oliguric on admission fena that was consistent with pre renal etiology and resolved with fluids his home enalapril was initially held but re started when arf resolved pt was prophylaxed with sq heparin initially then switched back to lovenox when arf resolved he should continue lovenox as an outpatient as laid out by ortho hypoxia on admission to micu abg c w hypercapnia likely hypoventilation given patient s ams resolved with resolution of delirium anemia hct down to low s from baseline of high s had cc of ebl in or anemia most likely from or blood loss received units rbc s and hct bumped appropriately and was stable throughout the rest of the admission bipolar disorder ptsd initially held home seroquel clonazepam ativan trazodone duloxetine lithium in setting of arf and ams slowly restarted meds and renal doses which were changed back to home doses once renal function returns however pt was tapered of bzds as noted above and will be discharged without any lorezapam or clonazepam osa reportedly noncompliant with cpap in micu but did not showing evidence of apnea on monitor however on the medical floor pt was using his cpap and tolerating it well seizure disorder held gabapentin bzds in setting of arf and slowly restarted and titrated back to home dose when arf resolved htn given low dose of diltiazem in preparation for discharge dilz was d c and enalapril was increased to mg daily pt will follow up with pcp upon c hyperlipidemia held gemfibrozil in setting of arf and elevated ck continued pravastatin upon discharge medications on admission home medications acetaminophen mg tablet sig two tablet po q h every hours docusate sodium mg capsule sig one capsule po bid times a day enoxaparin mg ml syringe sig one syringe subcutaneous daily daily for weeks lithium carbonate mg tablet sustained release sig two tablet sustained release po bid times a day clonazepam mg tablet sig four tablet po daily daily as needed for prn anxiety gabapentin mg capsule sig three capsule po q h every hours hydromorphone mg tablet sig tablets po q h prn as needed for pain quetiapine mg tablet sustained release hr sig one tablet sustained release hr po daily daily enalapril maleate mg tablet sig one tablet po daily daily glucophage mg tablet sig one tablet po twice a day pravastatin mg tablet sig one tablet po once a day cymbalta mg capsule delayed release e c sig two capsule delayed release e c po once a day diltiazem hcl mg tablet sig one tablet po once a day trazodone mg tablet sig two tablet po at bedtime ativan mg tablet sig tablets po tid prn discharge medications lithium carbonate mg tablet sustained release sig two tablet sustained release po bid times a day enoxaparin mg ml syringe sig one injection subcutaneous daily daily enalapril maleate mg tablet sig two tablet po daily daily disp tablet s refills gabapentin mg capsule sig three capsule po tid times a day quetiapine mg tablet sustained release hr sig one tablet sustained release hr po qhs once a day at bedtime trazodone mg tablet sig two tablet po hs at bedtime as needed for sleep acetaminophen mg tablet sig two tablet po q h every hours disp tablet s refills oxycodone mg tablet sig one tablet po q h every hours as needed for pain not relieved by tyenol disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metformin mg tablet sig one tablet po twice a day pravastatin mg tablet sig one tablet po once a day docusate sodium mg capsule sig one capsule po once a day hold for loose stools or more than bowels movements per day senna mg tablet sig two tablet po at bedtime hold for loose stools or more than bowels movements per day disp tablet s refills keflex mg capsule sig one capsule po twice a day for weeks disp capsule s refills duloxetine mg capsule delayed release e c sig two capsule delayed release e c po once a day discharge disposition home with service facility all care vna of greater discharge diagnosis primary s p hardware removal and washout left tibia urinary tract infection secondary diabetes sleep apnea discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions mr thank you for coming to for your medical care you were admitted to the hopital so the orthopedic surgeons could remove the hardware from your left leg your blood sugar got low so you were transfered to the medical intensive care unit micu you were also confused in the micu when your sugars were stable you came to the regular medical floor the surgeons took you back to the or to clean the operation site you were started on antibiotics for a urinary tract infection you should continue to take ciprofloxacin for more days to finish your course we made the following changes to your medications please stop taking ativan lorezapam and klonapin clonazepam the psychiatrists thought these medicines contributed to your confusion please stop taking glyburide we think this is responsible for your low sugars please start taking ciprofloxacin mg twice a day for the next days please start taking keflex cephalexin mg twice a day please stop taking diltiazem please increase your enalapril to mg daily you may take tylenol acetaminophen mg every hours for pain you may take mg of oxycodone every hours for pain not relieved by tylenol we have given you a small supply of pain medicine you should discuss the amount of pain you are having when you see your primary care doctor later this week while on the oxycodone please take docusate and senna regularly to prevent constipation stop taking these medications if you have loose stools or more than bowel movements in one day please continue taking enoxaparin injections twice a day for at least more weeks you should discuss the need for this medication when you see the orthopedic surgeons followup instructions you should call your psychiatrist to make an appointment name thavaseelan s location internists address phone appointment thursday am department orthopedics when thursday at pm with ortho xray scc building sc clinical ctr campus east best parking garage department orthopedics when thursday at pm with np building campus east best parking garage,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2013-03-20"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Sulfa"",
""Sulfonamide"",
""Antibiotics""
],
""attendingChiefComplaint"": ""Delirium"",
""chiefComplaintHistory"": ""Delirium"",
""historyOfPresentIllness"": ""This is a yo male with a history of DM, OSA, seizure disorder, bipolar disorder who was admitted to orthopedics on for removal of external fixator and orif of his left tibial plateau fracture this am pod he was found to be somnolent and oriented times one from a baseline of full orientation his chem revealed an am glucose of"
26928,admission date discharge date date of birth sex m service micu history of present illness the patient is a year old gentleman with a history of hypertension who presented to the emergency room complaining of left sided tongue swelling the patient noticed that his tongue felt full at pm on the day of admission he denied any shortness of breath or stridor but did comment that he experienced some dysphagia with trouble swallowing a hamburger at dinner he also complained of a new lisp he had a questionable history of trauma to the tongue the patient visited the dentist about one week ago and remembered the hygienist telling him that it looked as if he had bit his tongue the patient also felt that he had a canker sore on that side of his tongue for approximately one week on the day of admission the patient had eaten cereal with blackberries for breakfast a bagel with sardines for lunch and a hamburger for dinner there were no new foods and the patient did not give any history of any environmental exposures or insect bites he also denied fevers or recent upper respiratory infections the patient had been given diovan for hypertension for many years and he had been taking vioxx for six months in the emergency room the patient was evaluated by the surgery and ent services he was breathing without difficulty a laryngoscopy indicated a normal cough with no laryngeal edema and the vallecula and epiglottis were within normal limits he was given benadryl and solu medrol and sent to the floor review of systems on review of systems it was noted that the patient had been experiencing several episodes of substernal chest pain with exertion over the last several months with the last episode several days prior to admission the chest pain lasted for four to five minutes at a time it was brought on by walking and was relieved by rest and was associated with cold clammy sweats shortness of breath and pain radiating to the center of the shoulder blades past medical history the past medical history was significant for hypertension hypotriglyceridemia back surgery years ago arthroscopic surgery on the right knee in sigmoid polyps and non steroidal anti inflammatory drugs gastropathy with an upper gastrointestinal bleed in allergies there were no known drug allergies there also were no known environmental allergies medications on admission the patient came in on diovan hydrochlorothiazide gemfibrozil vioxx and aspirin social history the patient was married and worked at home in sales and marketing he quit smoking years ago he had smoked one half pack per day times years he drank an occasional glass of wine he denied street drugs family history the family history was noncontributory physical examination on examination the patient had a temperature of f a pulse of a respiratory rate of a blood pressure of and an oxygen saturation of on room air in general the patient was an alert pleasant gentleman sitting up on the gurney in no acute distress on head eyes ears nose and throat examination the pupils were equal round and reactive to light the oropharyngeal examination indicated swelling of the left side of the tongue minimal point tenderness of the posterior third of the tongue from the left minimal erythema and no apparent lesions there was no stridor or vocal change the neck was supple with a cm rubbery soft submandibular lymph node on pulmonary examination the chest had a couple of dry crackles at the left base but otherwise was clear to auscultation bilaterally the cardiovascular examination revealed a regular rhythm with a normal s and s the patient did have an s gallop there was a i vi systolic murmur the abdominal examination was benign as was examination of the extremities laboratory data the patient s laboratory studies in the emergency department indicated an unremarkable cbc with a white blood cells of and a normal chem and coagulation studies the patient s last cholesterol panel which was in indicated a low cholesterol of hdl of ldl of and triglycerides of hospital course the patient was admitted to the medical intensive care unit and continued on decadron and benadryl intravenously over the evening that he was in the medical intensive care unit the tongue swelling was noted to become significantly diminished with a patient airway and no difficulty respirating on the morning of discharge after consulting with the patient s primary care provider it was decided that the patient should receive an inpatient echocardiogram as part of a workup for angina pectoris the echocardiogram revealed a ejection fraction mild left ventricular hypertrophy aortic regurgitation mitral regurgitation tricuspid regurgitation and no evidence of aortic stenosis disposition the patient was discharged from the medical intensive care unit to home on hospital day he is to follow up with his primary care physician next week he is also scheduled for a stress thallium test on friday he is also to follow up with an allergist discharge medications benadryl mg p o times one decadron mg p o times one cardizem cd mg p o q d hydrochlorothiazide mg p o q d gemfibrozil mg p o b i d discharge diagnoses laryngeal edema probably secondary to allergy stable angina m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint acute stemi major surgical or invasive procedure cardiac catetherization history of present illness m with cad s p lad cypher p w chest pain he was in his usoh free of anginal symptoms until today at roughly am when he developed the acute onset of substernal chest pain radiating to the l shoulder after vacuuming in his house he states that he became diaphoretic noting perspiration on his forehead and mildly dyspneic and lightheaded no palpitations he took a ntg sl without any change in his sx he has never before needed a ntg his wife called for an ambulance and he arrived to the ed within hour of the onset of symptoms initial vitals in the ed t p ra he was found to have st elevations v on the ecg was started on heparin integrilin given asa plavix mg po x he was sent to the cath lab where he was found to have a to lad within the stent and unable to be crossed lcx was to mid vessel and rca had no signifant disease poba was used to treat diag and first septal the pt tolerated the cath without complications and was admitted to the ccu service for monitoring overnight in the setting of stemi on review of symptoms he denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools he denies recent fevers chills or rigors he denies exertional buttock or calf pain all of the other review of systems were negative cardiac review of systems is notable for cp dyspnea and sob as per hpi no orthopnea ankle edema palpitations syncope or presyncope past medical history cad s p lad cypher hypertension hypotriglyceridemia back surgery years ago arthroscopic surgery on the right knee in sigmoid polyps and ugib nsaids in b l hip replacement social history the patient is married lives with his wife and works in sales and marketing he quit smoking years ago and smoked one half pack per day times years occasional etoh no illicits walks without need of cane or walker family history mother died at of chf and diabetes father died at of mi brother died of mi in s physical exam vs t bp hr rr o on l gen wdwn middle aged male in nad resp or otherwise oriented x mood affect appropriate pleasant heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa neck supple with jvp of cm cv pmi located in th intercostal space midclavicular line rr normal s s no s no s chest basilar crackles no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use abd soft ntnd no hsm or tenderness no abdominial bruits ext no c c e r groin small hematoma no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid without bruit femoral without bruit dp left carotid without bruit femoral without bruit dp pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb mb indx ctropnt pm calcium phosphate magnesium cholest pm triglycer hdl chol chol hdl ldl calc pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am ctropnt am ck mb am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt cardiac cath brief hospital course yo male with cad s p cypher stent lad htn hypercholesterolemia presents with substernal chest pain while vacuuming hospital course presented by problem nstemi patient initially presented to the ed w stemi he was given asa plavix heparin gtts integrillin and morphine patient urgently underwent cardiac catheterization an in stent thrombosis in the lad was found but unable to be crossed the diagonal and first septal arteries were opened with angioplasty but not stented afterwards the patient remained chest pain free and hemodynamically stable toprol xl was titrated up and he was put on his home dose valsartan since he gets a cough to ace i an echocardiogram showed anterior lv dysfunction and he was started on anticoagulation for this initially w heparin and coumadin and then bridged to a therapeutic inr w lovenox mg his peak ck was he will see his cardiologist dr tomorrow in he will take toprol valsartan atorvastatin aspirin and plavix he was also evaluated by cardiothoracic surgery given his three vessel disease he will call to schedule an appointment with them for a planned cabg in early pump systolic dysfunction ef as above he remained compensated rhythm post mi hrs patient had several episodes of nsvt however these resolved over time and with beta blockade titration as well as electrolyte repletion hyperlipidemia atorvastatin mg was provided and should be continued as an outpatient patient remained hemodynamically stable and afebrile during admission he should follow up with dr cardiology his pcp and ct surgery he should continue to take coumadin and have his inr followed by either his pcp or cardiologist he should no longer take norvasc or hydrochlorothiazide aspirin was increased to mg daily beta blockade was increased to toprol xl mg daily atorvastatin was increased to mg from mg daily medications on admission diovan hctz atenolol lipitor norvasc aspirin discharge medications atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills valsartan mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po qhs once a day at bedtime disp tablet s refills metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills enoxaparin mg ml syringe sig one subcutaneous times a day for days disp refills discharge disposition home with service facility homecare discharge diagnosis primary myocardial infarction cad three vessel disease htn hypercholesterolemia discharge condition good discharge instructions you were admitted to the hospital with a heart attack st elevation myocardial infarction you had a heart catheterization which showed blockage of the lad left anterior descending artery as well as the other arteries of the left coronary artery you should continue to take your medications as prescribed you will need to follow up the cardiothoracic surgeon as well as your pcp and cardiologist if you have recurrent chest pain shortness of breath excessive bleeding you feel light headed or dizzy with standing or bloody dark black foul smelling stolls please return to the emergency room or call your pcp followup instructions provider lab phone date time provider md phone date time cardiothoracic surgery you must call to make an appointment primary care doctor cardiology in pm cardiology [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint angina major surgical or invasive procedure cabgx lima lad svg om svg diag svg pda history of present illness mr is a yo male with known coronary disease he had recent worsening of angina experiencing chest discomfort associated with diaphoresis and lightheadedness after vacuuming had ekg changes in er and was taken for urgent cath which showed severe vd with lad in stent restenosis he was therefore referred for elective surgical revascularization past medical history cad s p lad cypher hypertension hypotriglyceridemia back surgery years ago arthroscopic surgery on the right knee in sigmoid polyps and ugib nsaids in b l hip replacement social history the patient is married lives with his wife and works in sales and marketing he quit smoking years ago and smoked one half pack per day times years occasional etoh no illicits walks without need of cane or walker family history mother died at of chf and diabetes father died at of mi brother died of mi in s physical exam nad hr bp lungs ctab cv rrr no m r g abdomen soft nt nd trace le edema pp pertinent results tee pre bypass no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal there is mild to moderate regional left ventricular systolic dysfunction of the anterior anterolateral and apical segments overall left ventricular systolic function is mildly depressed lvef right ventricular chamber size and free wall motion are normal the descending thoracic aorta is mildly dilated there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened there is no aortic valve stenosis mild to moderate aortic regurgitation is seen the mitral valve leaflets are structurally normal mild mitral regurgitation is seen brief hospital course mr was admitted and underwent coronary artery bypass grafting surgery with dr for surgical details please see seperate dictated operative note intraoperative echocardiogram was notable for systolic congestive heart failure with an lvef of following the operation he was brought to the cvicu for invasive monitoring within hours he awoke neurologically intact and was extubated without incident he maintained stable hemodynamics and transferred to the sdu on postoperative day one chest tubes and pacing wires were removed without complication he remained in a normal sinus rhythm as beta blockade was advanced as tolerated due to steady clinical improvement with diuresis he was medically cleared for discharge to home on postoperative day three at discharge his bp was with a hr of his room air saturations were medications on admission diovan hctz qd lipitor qd plavix stopped coumadin stopped metoprolol prilosec discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills hydromorphone mg tablet sig one tablet po q h every hours as needed disp tablet s refills furosemide mg tablet sig one tablet po bid times a day for days disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po bid times a day for days disp capsule sustained release s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills prilosec mg capsule delayed release e c sig one capsule delayed release e c po once a day disp capsule delayed release e c s refills discharge disposition home with service facility homecare discharge diagnosis coronary artery disease s p nstemi s p cabg mild systolic congestive heart failure ef history of lad stent cypher hypertension history of ugi bleed discharge condition good discharge instructions please shower daily no baths pat dry incisions do not rub avoid creams and lotions to surgical incisions call cardiac surgeon if there is concern for wound infection no lifting more than lbs for at least weeks from surgical date no driving for at least one month followup instructions dr in weeks call for appt dr weeks call for appt dr weeks call for appt already scheduled appointments provider orthopedic private practice date time completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2013-01-01"",
""sex"": ""Male"",
""service"": ""MICU"",
""historyOfPresentIllness"": ""admission date discharge date date of birth sex m service micu history of present illness the patient is a year old gentleman with a history of hypertension who presented to the emergency room complaining of left sided tongue swelling the patient noticed that his tongue felt full at pm on the day of admission he denied any shortness of breath or stridor but did comment that he experienced some dysphagia with trouble swallowing a hamburger at dinner he also complained of a new lisp he had a questionable history of trauma to the tongue the patient visited the dentist about one week ago and remembered the hygienist telling him that it looked as if he"
15198,admission date discharge date date of birth sex f service ct chief complaint the patient is a year old woman with a history of mi in the past now referred for outpatient cardiac cath due to a positive stress test history of present illness the patient reports that she had an inferior mi in she was treated at hospital and did not have cardiac catheterization at that time she has done well since that time and reports that she is very active occasionally still dances with her husband and performs all activities of daily living independently denies any symptoms of chest pain or dyspnea also denies claudication orthopnea edema lightheadedness primary care provider is who she sees on a regular basis she was recently at his office for an annual stress echo which was done on patient exercised for three minutes on protocol ekg revealed inferolateral changes echo revealed exercise induced ischemia in the lad distribution evidence of an old inferior mi resting ejection fraction was to she has been referred for outpatient cardiac cath past medical history significant for hypertension hypercholesterolemia cad status post mi past surgical history significant for thyroid nodule removal and cataract surgery with lens implantation allergies no known drug allergies medications prior to admission aspirin mg q d zestril mg q d lopressor mg b i d pravachol mg q d triamterene hydrochlorothiazide mg three times per week synthroid mg q d laboratory data white count hematocrit platelet count sodium potassium chloride co bun creatinine inr social history married lives in with her husband she does not have any children denies cigarette use denies alcohol use family history she has a brother and sister who have both had coronary artery bypass grafting in the past physical examination on the day of catheterization heart rate was in the s sinus rhythm blood pressure respiratory rate o sat neck had no bruits lungs were clear bilaterally heart s s no murmurs regular rate and rhythm abdomen soft nondistended nontender right groin with a hematoma oozing no bruit dorsalis pedis on the right and trace on the left lower extremities were warm and without edema hospital course on the day of admission patient underwent cardiac catheterization please see the cath report for full details in summary the cath showed left main lad after d left circumflex rca with proximal occlusion distal vessels filled via collaterals from the acute marginal ef was approximately mr cardiothoracic surgery was consulted following catheterization patient was accepted for coronary artery bypass grafting on the following day she was brought to the operating room at which time she underwent coronary artery bypass grafting times three please see o r report for full details in summary patient had cabg times three with lima to the diagonal saphenous vein graft to the lad and saphenous vein graft to the om patient tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit at the time of transfer patient had nitroglycerin and nipride infusions running as well as an insulin drip she did well in the immediate postoperative period but remained intubated throughout the night of her surgery she was slow to awaken from anesthesia in the morning of postoperative day one patient had already been weaned from the ventilator and was successfully extubated following extubated patient was weaned from nitroglycerin as well as nipride on the morning of postoperative day two patient s chest tubes were discontinued and she was scheduled to transfer to the floor for continued postoperative care and cardiac rehabilitation she ended up staying in the intensive care unit for an additional day as there were no floor beds available on postoperative day three patient was actually transferred to the floor and with the assistance of the nursing staff and physical therapy patient s activity level was gradually increased over the next several days of note on postoperative day three patient did have one episode of rapid atrial fibrillation which was treated with iv lopressor after which patient converted back to normal sinus rhythm by postoperative day six it was decided that patient was stable and ready for discharge to home at the time of discharge patient s physical exam was as follows vital signs were temperature heart rate sinus rhythm blood pressure respiratory rate o sat in room air weight preoperatively kg at discharge kg neuro alert and oriented times three moved all extremities respiratory clear to auscultation bilaterally cardiac regular rate and rhythm s s no murmur incision with staples with staple reaction noted along the length of the incision sternum was stable abdomen was soft nondistended nontender normoactive bowel sounds extremities were warm and well perfused with no edema right leg incision with steri strips and dermabond open to the air clear and dry no erythema lab data included white count of hematocrit platelets sodium potassium chloride co bun creatinine glucose discharge medications aspirin mg q d pravastatin mg q d lasix mg q d times days potassium chloride meq q d times days captopril mg t i d levothyroxine mcg q d lopressor mg b i d tylenol mg q six hours p r n percocet one to two tabs q four hours p r n colace mg b i d p r n discharge diagnoses cad status post coronary artery bypass grafting times three with lima to the diag saphenous vein graft to the lad and saphenous vein graft to the om hypertension hypercholesterolemia status post thyroid nodule excision status post cataract surgery and lens implantation condition on discharge stable discharge status she is to be discharged to home with visiting nurse followup services followup follow up with dr in three to four weeks follow up with her primary care provider in three to four weeks follow up in wound clinic in two weeks m d dictated by medquist d t job [NEW_RECORD] name t unit no admission date discharge date date of birth sex f service addendum discharge medications aspirin mg p o q d pravastatin mg p o q d lasix mg p o q d times days k dur meq p o q d times days captopril mg p o t i d levothyroxine mcg p o q d lopressor micrograms p o b i d percocet one to two tablets p o q p r n colace mg p o b i d as long as the patient is on percocet amiodarone mg p o b i d times one week and then mg p o q d times one week and then mg p o q d times one week and then to stop as the patient did have two bursts of paroxysmal atrial fibrillation that were treated with iv amiodarone during this hospitalization she immediately converted and in sinus at the time of discharge there was no need for anticoagulation as determined by dr the patient will be sent home on the appropriate amiodarone lopressor and amiodarone taper follow up the patient should be seen by dr who is the patient s pcp patient will follow up with the pcp in approximately one to two weeks from the time of discharge to review the patient s medications and also to assess her volume status given the fact that she will be on a two week diuresis postoperatively the patient will follow up with dr as described by nurse practitioner s dictation in the primary discharge summary m d dictated by medquist d t job,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-11"",
""date_of_birth"" : ""2019-10-10"",
""sex"" : ""F"",
""service"" : ""CARDIAC"",
""chief_complaint"" : ""CHEST PAIN"",
""allergies"" : ""None"",
""pt_full_name"" : ""Susan [**Last Name (un) 1056**]"",
""service_name"" : ""CARDIAC"",
""doctor_last_name"" : ""Santos"",
""MD_last_name"" : ""Santos"",
""HPI"" : ""admission date discharge date date of birth sex f service"
61594,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint stemi major surgical or invasive procedure cardiac catheterization with drug eluting stent to left circumflex artery history of present illness this is a yom with history of htn hep c who presented today with sudden onset of l chest pain associated with sob sweating and radiation to the left neck and lue this pain has been progressively becoming worse over the last weeks initially it was exertional in nature but this afternoon he noticed pain that occurred at rest the pain is located in his left side and radiated to his left arm jaw pain was constant for hours prior to presentation reported to be ibuprofen did not relieve cp denies any recent injury or changes in vision or change in gait no n v f c he denies palpitations lh or changes in vision denies recent bleeding he intially presented to ed where initial vitals were on l he received peripheral ivs ivf bolus of l ns morphine mg then mg x asa nitro mg x ativan mg nitropaste heparin units bolus heparin gtt u hr plavix mg po integrilin bolus and gtt laboratory work up there showed wbc of hct of plt of na k co crt ck and trop associated ekg showed nsr no ectopy ste in ii iii avf v v std and twi avr avl v v no q waves he was transfered at where he underwent a uncomplicated cardiac catheterization showing occlusion in circumflex with des placed post cath he is on asa clopidrogel and eptifibatide he is curretnly symptom free on review of systems he denies chest pain paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools he denies recent fevers chills or rigors s he denies exertional buttock or calf pain all of the other review of systems were negative past medical history htn hepatitis c chronic pain in right knee social history tobacco history quit smoking yrs ago mj use etoh denies illicit drugs mj use on the day of presentation no cocaine family history father with early onset cvd and cabg physical exam general nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple without jvd cardiac pmi located in th intercostal space midclavicular line rr normal s s no m r g no thrills lifts no s or s lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities no c c e no femoral bruits no groin strikethrough skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt am blood triglyc hdl chol hd ldlcalc pm blood asa neg acetmnp neg bnzodzp neg barbitr neg pm blood hba c pm blood totprot albumin globuln calcium phos mg pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct cardiac cath study date of coronary angiography in this right dominant system revealed single vessel coronary artery disease the lmca had minor irregularities the lad had minor irregularities the lcx had a thrombus with total occlusion in the distal portion just after the origin of the om branch there was a stenosis in the origin of the om branch the rca had a stenosis in the proximal portion and did not supply a large distribution of the myocardium resting hemodynamics revealed normal blood pressure of left ventriculography revealed very mild hypokinesis of the posterior segment of the heart with a normal lvef estimated at there was no evidence of mitral regurgitation successful ptca manual aspiration thrombectomy and placement of a x mm endeavor stent were performed final angiography showed normal flow no apparent dissection and no residual stenosis see ptca comments the right common femoral arteriotomy was successfully closed using a fr angioseal sts device final diagnosis one vessel coronary artery disease normal ventricular function placement of a drug eluting stent in the distal lcx portable tte complete done the left atrium is normal in size no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is mild regional left ventricular systolic dysfunction with inferior and lateral hypokinesis lvef the remaining segments are dynamic no masses or thrombi are seen in the left ventricle there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic arch is mildly dilated the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild to moderate mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion ecg study date of sinus rhythm low limb lead qrs voltage is non specific st t wave changes raise the consideration of possible ischemia injury or possible early repolarization pattern clinical correlation is suggested since the previous tracing of further st t wave changes are present brief hospital course in brief this is a year old man with history of htn hep c low grade cirrhosis and chronic leg pain on ibuprofen who presents with unstable angina over the last two weeks and found to have stemi in the circumflex territory with des placed during uncomplicated c catheterization stemi patient first arrived to osh with angina and was found to have stemi he was transferred to for emergent pci with revascularization using des to his left circumflex his cardiac enzymes were falling after revascularization he has had some mile chest soreness since cath waxing and mostly on the day of discharge he was chest pain free on asa clopidrogel bb and ace hga c was wnl and lipid panel with inc tg heart rate increased to ambulation and caffeine which resolved prior to his discharge htn controlled goal bp increased bb on the day of discharge he will followup with outpatient cardiologist for his care hep c cirrhosis compensated clinically he should not take more than grams of tylenol in hours he was instructed to follow up outpatient chronic leg pain he was told to avoid nsaids while on concurrent asa for secondary prevention he will start tylenol on an as needed bases and was told to not take more than grams of tylenol in hours he was instructed to follow up with his pcp medications on admission motrin mg held omerprazole mg qd mvi tab qd was on hctz till monthes ago stopped by pcp discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills nitroglycerin mg tablet sublingual sig one tablet sublingual sublingual prn as needed as needed for chest pain tightness take mintues apart for a total of tablets if you still have chest pain call disp tablet sublingual s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills acetaminophen mg tablet sig two tablet po bid times a day do not take more than twice daily simvastatin mg tablet sig one tablet po once a day disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day centrum silver tablet sig one tablet po once a day discharge disposition home discharge diagnosis st elevation myocardial infarction hypertention hepatitis c discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you had a heart attack and one stent was placed in your left circumflex artery to fix a blockage you will need to take new medicines to keep the stent open and prevent another heart attack you will need to avoid strenuous activity until after you see your new cardiologist a physical therapist has reviewed these restrictions with you the most important medicine you take is the plavix or clopodigrel you must take this every day for at least one year do not miss or stop taking plavix unless dr tells you to if you stop taking this you run the risk of the stent clotting off and having another heart attack new medicines aspirin take mg every day to prevent blood clots metoprolol a beta blocker to slow your heart rate and help your heart recover lisinopril a medicine to lower your blood pressure simvastatin a medicine to lower your cholesterol and help your heart recover clopodigrel a medicine to keep the stent open stop taking ibuprofen this can harm your heart you can take mg of tylenol twice daily for your knee pain do not take more than twice daily because of your hepatitis nitroglycerin to take if you have chest pain again take tablet under your tongue minutes apart for a total of if you still have chest pain call please call your cardiologist if you have any reoccurance of chest pain you have been set up with new doctors please keep all appts followup instructions cardiology md phone ext date time tues at am primary care md suite phone date time office will call you at home with an appt,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Patient recorded as having no known allergies to drugs""
],
""admissionDate"": ""2014-03-20"",
""dischargeDate"": ""2014-03-21"",
""dateOfDeath"": ""2014-03-21"",
""chiefComplaint"": ""STEMI"",
""historyOfPresentIllness"": ""This is a YOM with history of Htn hep c who presented today with sudden onset of L chest pain associated with sob sweating and radiation to the left neck and lue this pain has been progressively becoming worse over the"
7704,admission date discharge date date of birth sex m service cardiothoracic allergies reserpine attending chief complaint palpitations w vt major surgical or invasive procedure cabg x lima to lad svg to diag om om pda on aicd placement history of present illness y o male w h o cad s p mi s x who on was sitting in a chair when he started having palpitations sensation of rapid hr a few minutes later he developed mild chest discomfort took asa ibuprofen then nitro a few minutes later called ems found to be in vt at shocked x w j w conversion to afib cp resolved immediately pt taken to mwmc had cath that showed vd and was then transferred to for cabg past medical history cad s p mi x h o pericarditis htn chol dm claudication chronic rbbb peripheral neuropathy s p chole s p appy social history denies tobacco or etoh use family history non contributory physical exam vs p sr w pvcs bp neuro aao x strength equal ue le cv s s sem resp decreased bs at bases bilat w r r gi soft nt nd bs well healed surgical scars pulses bilat fem bilat r dp pt l dp dop r pt bilat rad carotid bruits pertinent results pre op ekg sinus rhythm right bundle branch block left atrial abnormality inferior infarct age indeterminate may be old lateral st t wave changes may be in part primary pre op cxr cardiomegaly healing fractures of the ribs cardiac cath lad d to d to rca ef by ech pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood plt ct am blood plt ct am blood pt inr pt pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood k pm blood alt ast alkphos amylase totbili am blood calcium phos mg pm urine color straw appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg brief hospital course after transfer pt was evaluated by cardiology and stated it was reasonable to do cabg pt was started on amiodarone at mg tid also recommended eps consult and will likely need icd pt was monitored in csru and was stable for days and then brought to the or on after general anesthesia pt underwent coronary artery bypass graft surgery x lima to lad svg to diag om om pda please refere to op summary for full surgical details total cpb time was min and xct was min pt tolerated the procedure well with no complications and was transferred to csru in stable condition with map cvp pad hr nsr and on neo propofol and nitro drips later that day propofol was weaned and pt was extubated he was breathing well on his own alert awake and neurologically intact pod pt hemodynam stable currently on amio and ntg drips which were both weaned off today pt was started on po amio at tid he was transferred to telemetry floor later that day pod pt doing well w unremarkable pe besides trace edema mg was and replaced pt encourage to ambulate and use is later this day pt had run of serial tachycardia svt w rate of s broke to s then returned to rate of s pt was asymptomatic resolved w mg of iv lopressor ep added lopressor foley d c d pod chest tubes and foley removed central line inserted in l ij secondary to no iv access pod muilt episodes of a fib ep recommended to hold amio cont lopressor and start heparin pod hr sr pt hemodynam stable eps study tomorrow pod heparin stopped and pt brought to ep lab see eps results for full details aicd placed amio d c d and sotalol started pacing wires d c d after eps pod d c epicardial pacing wire v wire coumadin started pod sotalol held last pm lopressor d c d pt was hemodynam stable had complicated post op course w recurrent arrythmia s and needed aicd which was thought to be needed prior to cabg pt was ambulating well and at level d c pe vs p sr bp rr neuro alert oriented non focal pulm ctab cardiac rrr chest stable w sm amount serosang drng at distal aspect erythema abd soft nt nd bs ext warm inc c d i medications on admission meds at transfer procardia xl mg qd asa mg qd pravachol mg qd heparin neurontin mg tid ativan prn tylenol prn riss ntg iv gtt discharge medications potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for days disp capsule sustained release s refills pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours disp tablet delayed release e c s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills pravastatin sodium mg tablet sig two tablet po daily daily disp tablet s refills sotalol hcl mg tablet sig one tablet po bid times a day disp tablet s refills gabapentin mg capsule sig one capsule po hs at bedtime disp capsule s refills gabapentin mg capsule sig one capsule po tid times a day disp capsule s refills warfarin sodium mg tablet sig one tablet po once a day for days mg on then check with dr office for continued dosing disp tablet s refills lasix mg tablet sig one tablet po twice a day for days disp tablet s refills discharge disposition home with service facility vna discharge diagnosis cad s p mi x s p cabg x lima to lad svg to diag om om pda on vt afib s p aicd h o pericarditis htn chol dm diet controlled claudication chronic rbbb peripheral neuropathy s p chole s p appy discharge condition good discharge instructions no lifting or driving for month no creams or lotions to incisions may shower in days no bathing for month p instructions schedule appt with device clinic in week with dr in weeks with dr in weeks with dr in weeks completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-13"",
""date_of_birth"" : ""2043-1-15"",
""sex"" : ""Male"",
""service"" : ""Cardiothoracic"",
""allergies"" : ""Reserpine"",
""attending_chief_complaint"" : ""Palpitations with VT"",
""chief_complaint"" : ""Palpitations with VT"",
""history_of_present_illness"" : ""This is a 76 yo male with h/o CAD, s/p MI, s/p PCI, s/p CABG, s/p PDA, s/p AVR, s/p C"
95694,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint back chest pain major surgical or invasive procedure cardiac catheterization promus drug eluting stent placed to left circumflex artery history of present illness y o gentleman with type dm dyslipidemia presented with back pain radiating to chest patient stated feeling unwell yesterday afternoon with diffuse myalgia last night at around pm he started having back pain radiating to his chest he has had similar pain in the last two years but not as severe as last night he felt nauseous diaphoretic and short of breath he came to ed in the ed initial vitals were t hr bp rr in ra he recieved asa mg plavix mg heparin bolus gtt integrillin bolus gtt he also recieved nitro sl x morphine dilaudid zofran mg iv x he was eventually started on nitro gtt given his chest pain has not resolved and he had concerning ecg changes he was taken to cardiac catheterization he recieved x promus to occluded proximal lcx he had angiosesal in right groin on review of systems he denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery joint pains cough hemoptysis black stools or red stools he denies recent fevers chills or rigors he denies exertional buttock or calf pain all of the other review of systems were negative cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope past medical history past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history n a other past medical history type dm approx years concussion some years ago after a mechanical fall short episode of loc seizures but patient think they were hypoglycemic episodes social history works as a consultant in financial services lives at home with his wife and twins tobacco history denies etoh denies illicit drugs denies family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam vs t bp hr rr o sat general pleasant gentleman in nad oriented x mood affect appropriate heent ncat sclera anicteric eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp of cm cardiac rr normal s s no m r g no thrills lifts no s or s lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses right dp pt left dp pt pertinent results labs on admission pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood ck cpk pm blood ck mb am blood cholest pm blood hba c am blood triglyc hdl chol hd ldlcalc on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood calcium phos mg am blood triglyc hdl chol hd ldlcalc brief hospital course coronaries stemi s p drug eluting stent promus to prox lcx pt was cp free after intervention no complications ck peak was with mbi of and trop of started on metoprolol lisinopril aspirin and plavix his atorvastatin was increased to mg ldl goal will be hgb a c his groin was stable with no significant ecchymosis bruit or hematoma angioseal device was used pt understands that he needs to take plavix every day for one year without missing any doses he should not stop taking plavix unless dr tells him to he received discharge activity instructions and will follow up with dr for a repeat echo and stress test cardiac rehabilitation was suggested to him and dr will refer regional left ventricular systolic dysfunction tte with inferior lateral wall hypokinesis with ef no symptoms of congestive heart failure during hospital stay filling pressures in the cath lab were normal daily weights were discussed with pt prior to dischage started on lisinopril and metoprolol succinate at discharge rhythm currently in nsr no history of rhythm abnormalities few episodes of nsvt seen on telemetry type dm patient has an insulin pump a c currently followed by endocrinologist at but requesting new endocrinologist at appt made after discharge continuing care pt has requested that his care be changed to he will f u with dr for cardiology dr for primary care and dr for endocrinology medications on admission insulin pump with humalog atorvastatin mg daily discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily clopidogrel mg tablet sig one tablet po daily daily take every day for one year do not stop taking unless dr tells you to disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills metoprolol succinate mg tablet sustained release hr sig tablet sustained release hrs po daily daily disp tablet sustained release hr s refills discharge disposition home discharge diagnosis st elevation myocardial infarction diabetes mellitus type dyslipidemia discharge condition stable discharge instructions you had a heart attack and a cardiac catheterization showed a blockage in your left circumflex artery you received a drug eluting stent promus in your left circumflex no lifting more than pounds for one week no pools or bathing for one week you may shower and cover the cath site with a band aid you were started on the following new medicines plavix a platelet inhibitor that prevents the stent from clotting off and causing another heart attack don t miss s or stop taking plavix for one year unless dr tells you to aspirin a platelet inhibitor that works with the plavix to prevent the stent from clotting off lisinopril a blood pressure medicine that helps your heart recover from the heart attack metoprolol a medicine that slows your heart rate and helps your heart recover from the heart attack increase your atorvastatin to mg this help with inflammation and will lower your bad cholesterol further you should follow the activity instructions given to you by the physical therapist dr will refer you to cardiac rehabilitation after he sees you in one month please call dr if you have a reoccurance of your back pain trouble breathing sweating nausea fevers bleeding or swelling at the cathterization site or any other concerning symptoms followup instructions cardiology dr phone date time at pm clinical center endocrinology provider phone date time at am for registration you have a opthamology appt scheduled after this appt provider phone date time office will call you with an appt primary care dr phone date time office will call you with an appt completed by,"[
""admission_date"": ""2019-12-10"",
""discharge_date"": ""2019-12-12"",
""date_of_birth"": ""2043-12-10"",
""sex"": ""M"",
""service"": ""Medicine"",
""allergies"": [
""Patient recorded as having no known allergies to drugs.""
],
""attending_chief_complaint"": ""Back chest pain"",
""chief_complaint"": ""Back chest pain"",
""history_of_present_illness"": ""y/o gentleman with type dm dyslipidemia presented with back pain radiating to chest patient stated feeling unwell yesterday afternoon with diffuse myalgia last night at around pm he started having back pain radiating to his chest"
92764,admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint orthopnea major surgical or invasive procedure urgent coronary artery bypass graft x left internal mammary artery to left anterior descending artery saphenous vein graft to diagonal obtuse marginal saphenous vein sequential graft to posterior descending artery and posterior left ventricular branch endoscopic harvesting of the long saphenous vein history of present illness mr presented to hospital in with respiratory distress on was intubated had an nstemi was diagnosed with vessel disease and declined surgical revascularization in preferring to come to where he has family son and daughter newly diagnosed with copd and started on prednisone mg daily which was stopped prior to transfer and spiriva and albuterol was discharged from hospital in flew commercial air liner to and went directly to er where he was admitted and remained pain free he was seen by nephrology for stage chronic kidney disease creat believed to be due to htn and diabetes found to have eblr enterococcus betalactame resistant to quinolones uti on nitrofurantoin also sensitive to bactrim and zosyn he was transferred to for consideration of surgical revascularizationwith for known vessel coronary disease past medical history coronary artery disease pmh hypertension diabetes copd diastolic heart failure ef past surgical history penile implant social history race hispanic born in republic last dental exam edentulous lives with unknown has family in he is a resident of contact son and daughter living in occupation retired factory worker cigarettes smoked no yes x last cigarette hx packs x years of smoking other tobacco use marijuana occasional etoh drink week drinks week x drinks week illicit drug use cocaine use weekly and just prior to nstemi family history unknown physical exam pulse resp o sat ra b p right general skin dry x intact open blisters on bilateral lower extremities heent perrla x eomi x neck supple x full rom x neck veins distended chest lungs clear bilaterally x heart rrr x irregular murmur grade abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema x pitting edema to knees varicosities none x neuro grossly intact x pulses femoral right left dp right doppler left doppler pt doppler left doppler radial right doppler left doppler carotid bruit right bruit left none pertinent results echocardiography report portable tte complete done at pm final referring physician information division of cardiothoracic status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m m indication pericardial effusion icd codes test information date time at interpret md md test type portable tte complete son rdcs doppler full doppler and color doppler test location west sicu ctic vicu contrast none tech quality adequate tape w machine q vivid echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left ventricle septal wall thickness cm cm left ventricle inferolateral thickness cm cm left ventricle diastolic dimension cm cm left ventricle systolic dimension cm left ventricle fractional shortening left ventricle ejection fraction aorta sinus level cm cm aortic valve lvot diam cm mitral valve e wave m sec mitral valve e wave deceleration time ms ms tr gradient ra pasp mm hg mm hg findings left atrium mild la enlargement left ventricle mild symmetric lvh normal lv cavity size overall normal lvef no resting lvot gradient right ventricle normal rv chamber size and free wall motion aorta normal aortic diameter at the sinus level focal calcifications in aortic root mitral valve mildly thickened mitral valve leaflets no mvp mild mitral annular calcification mild thickening of mitral valve chordae calcified tips of papillary muscles no ms mild to moderate mr tricuspid valve normal tricuspid valve leaflets normal tricuspid valve supporting structures no ts mild to moderate tr normal pa systolic pressure pericardium moderate pericardial effusion effusion echo dense c w blood inflammation or other cellular elements conclusions the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild to moderate mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is a moderate sized pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements this most likely represents a postoperative hematoma and is located posterior to the heart no definite tamponade but the usual signs may be absent in the presence of a consolidating effusion brief hospital course mr was admitted for further pre operative evaluation carotid ultrasound showed stenosis bilaterally he is asymptomatic and will follow up with vascular surgery as an outpatient an echo revealed ef without significant valvular disease surgery was post poned for several days due to a rise in creatinine this stabilized and the patient was brought to the operating room on where the patient underwent coronary artery bypass graft x left internal mammary artery to left anterior descending artery saphenous vein graft to diagonal obtuse marginal saphenous vein sequential graft to posterior descending artery and posterior left ventricular branch with dr see operative note for full details overall the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring pod found the patient extubated alert and oriented and breathing comfortably the patient was neurologically intact and hemodynamically stable weaned from inotropic and vasopressor support beta blocker was initiated and the patient was gently diuresed toward the preoperative weight he did have an elevated creatinine post operatively with a peak of lasix was decreased and kidney function was monitored closely his creatinine was decreasing at the time of discharge the foley catheter had to be reinserted due to failure to void and to closer monitor urine output he did have two episodes of rapid atrial fibrillation on pod which resolved with increased lopressor dose he was placed on coumadin for the atrial fibrillation the patient was transferred to the telemetry floor for further recovery pleural chest tubes left in several days with high amounts of serous drainage the patient had preop pleural effusions chest tubes and pacing wires were discontinued without complication once they met criteria the patient was evaluated by the physical therapy service for assistance with strength and mobility by the time of discharge on pod the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged to ne in good condition with appropriate follow up instructions medications on admission preadmissions medications listed are incomplete and require futher investigation information was obtained from records from osh pt only knows insulin dose does not know any other medications isosorbide dinitrate mg po tid labetalol mg po tid rosuvastatin calcium mg po daily furosemide mg po daily aspirin mg po daily tiotropium bromide cap ih daily albuterol inhaler puff ih q h units breakfast units bedtime humalog units breakfast humalog units lunch humalog units dinner discharge medications units breakfast units bedtime humalog units breakfast humalog units lunch humalog units dinner aspirin mg po daily albuterol neb soln neb ih q h prn sob wheezing atorvastatin mg po daily cepacol menthol loz po prn sore throat diltiazem mg po qid ipratropium bromide neb neb ih q h prn sob wheezing metoprolol tartrate mg po bid hold for sbp metronidazole flagyl mg iv q h stop ondansetron mg po q h prn nausea pantoprazole mg po q h vancomycin oral liquid mg po q h end date warfarin md to order daily dose po daily for atrial fibrillation warfarin mg po once duration doses daily coumadin dosing for goal inr for atrial fibrillation furosemide mg po prn edema resume once renal function improves discharge disposition extended care facility discharge diagnosis coronary artery disease pmh hypertension diabetes copd diastolic heart failure ef past surgical history penile implant discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with oral analgesics sternal incision healing well no erythema or drainage right lower extremity saph site clean dry intact discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments surgeon dr cardiologist dr office will call you with an appointment please call to schedule the following primary care dr in weeks please follow up with dr call to schedule an appointment dialysis schedule hemodialysis unit date time renal dr diabetes if patient requires endocrine follow up after discharge from rehab please contact at please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours inr draw on goal inr indication atrial fibrillation md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending addendum on mr presented with acute left sided weakness facial droop and slurred speech neurology was consulted a head ct was negative for intracranial hemorrhage these symptoms resolved by the time of discharge no follow up with neurology is necessary major surgical or invasive procedure urgent coronary artery bypass graft x left internal mammary artery to left anterior descending artery saphenous vein graft to diagonal obtuse marginal saphenous vein sequential graft to posterior descending artery and posterior left ventricular branch endoscopic harvesting of the long saphenous vein past medical history coronary artery disease pmh hypertension diabetes copd diastolic heart failure ef past surgical history penile implant social history race hispanic born in republic last dental exam edentulous lives with unknown has family in he is a resident of contact son and daughter living in occupation retired factory worker cigarettes smoked no yes x last cigarette hx packs x years of smoking other tobacco use marijuana occasional etoh drink week drinks week x drinks week illicit drug use cocaine use weekly and just prior to nstemi family history unknown medications on admission preadmissions medications listed are incomplete and require futher investigation information was obtained from records from osh pt only knows insulin dose does not know any other medications isosorbide dinitrate mg po tid labetalol mg po tid rosuvastatin calcium mg po daily furosemide mg po daily aspirin mg po daily tiotropium bromide cap ih daily albuterol inhaler puff ih q h units breakfast units bedtime humalog units breakfast humalog units lunch humalog units dinner discharge medications units breakfast units bedtime humalog units breakfast humalog units lunch humalog units dinner aspirin mg po daily albuterol neb soln neb ih q h prn sob wheezing atorvastatin mg po daily cepacol menthol loz po prn sore throat diltiazem mg po qid ipratropium bromide neb neb ih q h prn sob wheezing metoprolol tartrate mg po bid hold for sbp metronidazole flagyl mg iv q h stop ondansetron mg po q h prn nausea pantoprazole mg po q h vancomycin oral liquid mg po q h end date warfarin md to order daily dose po daily for atrial fibrillation warfarin mg po once duration doses daily coumadin dosing for goal inr for atrial fibrillation furosemide mg po prn edema resume once renal function improves discharge disposition extended care facility discharge diagnosis coronary artery disease pmh hypertension diabetes copd diastolic heart failure ef past surgical history penile implant discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with oral analgesics sternal incision healing well no erythema or drainage right lower extremity saph site clean dry intact discharge instructions please draw bun cre inr at least every other day until they stabilize please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments surgeon dr cardiologist dr office will call you with an appointment please call to schedule the following primary care dr in weeks please follow up with dr call to schedule an appointment dialysis schedule hemodialysis unit date time renal dr diabetes if patient requires endocrine follow up after discharge from rehab please contact at please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours inr draw on goal inr indication atrial fibrillation md completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2014-03-25"",
""sex"": ""Male"",
""service"": ""Cardiothoracic"",
""allergies"": [
""Penicillins""
],
""adverseDrugReactions"": [
""Nausea/vomiting""
],
""chiefComplaint"": ""Orthopnea"",
""historyOfPresentIllness"": ""Mr. [**Known lastname 1088**] is a 64 yo male with h/o HTN, DM, CKD, CAD, and COPD who presented to the ED with respiratory distress on [**2139-11-1**] and was intubated. He was diagnosed with vessel disease and declined surgical revascular"
31189,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint recent endocarditis major surgical or invasive procedure redo sternotomy avr mosaic history of present illness yo m s p avr in with recent endocarditis in treated with weeks of antibiotics now returns for surgical repair of partially dehisced prosthetic valve past medical history as s p avr gout htn endocarditis now w severe ai social history works as project manager drinks week ppd tobacco family history cousins grandmother and aunt with bicuspid aortic valve physical exam nad lungs ctab heart rrr murmur abdomen benign extrem warm no edema pp pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood glucose urean creat na k cl hco angap am urine color yellow appear clear sp urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg chest pa lat pm findings cardiac silhouette is unchanged there has been previous sternotomy the right hemidiaphragm remains to be slightly elevated there is a linear oblique opacity within the right lung base mostly representing atelectasis there is no pleural effusion or pneumothorax mediastinum and hila are clear impression no evidence for hemothorax basilar atelectasis on the right no significant change from previous brief hospital course he was admitted to cardiac surgery he was cleared by dental tee showed partial dehiscence of bioprosthatic aortic valve ai he was taken to the operating room on where he underwent a redosternotomy and avr he was transferred to the icu in stable condition he was given hours of vancomycin perioperatively as he was in the hospital for hours peroperatively on the morning of pod just prior to extubated he drained liter into his chest tubes his hct remained stable he did not have any further bleeding and was extubated he was transfused unit he was given vanco and cipro while awaiting final or cultures he initially had a junctional rhythm which recovered to sinus with a first degree blcok and he was started on low dose beta blockade he was transferred to the floor on pod pt consult foley dc d with out sequele pod pw dc d with out sequele pod id thinks not endocarditis iv ab stopped pt stable for dc medications on admission asa toprol xl procardia xl allopurinol lozol simvastatin discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills ranitidine hcl mg tablet sig one tablet po daily daily disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills zocor mg tablet sig one tablet po once a day disp tablet s refills allopurinol mg tablet sig three tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills simvastatin mg tablet sig one tablet po once a day disp tablet s refills captopril mg tablet sig one tablet po tid times a day disp tablet s refills furosemide mg tablet sig one tablet po q h every hours for days disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po q h every hours for days disp tab sust rel particle crystal s refills discharge disposition home with service facility home health and hospice discharge diagnosis dehisced avr secondary to prostetic valve endocarditis now s p redo avr as s p avr gout htn endocarditis now w severe ai discharge condition good discharge instructions call with fever redness or drainage from incision or weight gain more than pounds in one day or five in one week shower no baths no lotions creams or powders to incisions no lifting more than pounds for weeks no driving until follow up with surgeon followup instructions dr weeks dr weeks dr weeks completed by,"[
""date"": ""2022-10-10"",
""service"": ""Cardiothoracic Surgery"",
""admission_date"": ""2022-10-10"",
""discharge_date"": ""2022-10-13"",
""date_of_birth"": ""2047-10-10"",
""sex"": ""Male"",
""service_code"": ""SICU"",
""allergies"": [
""Patient recorded as having no known allergies to drugs""
],
""attending_chief_complaint"": ""Recent endocarditis"",
""chief_complaint"": ""Recent endocarditis"",
""history_of_present_illness"": ""Yo Ms P AVR in with recent endocarditis"
41546,admission date discharge date service medicine allergies codeine demerol attending chief complaint altered mental status major surgical or invasive procedure intubation central venous cathaterization history of present illness f female with complicated medical hx including dementia gerd spinal stenosis chronic pain htn oa h o dvt recurrent utis with recent visits for uti and possible pna c difficile colitis s p treatment presenting with altered mental status the patient was difficulty to arouse this morning per her daughter over last few days has not been herself had heart rates in s this am pt was not responsing dtr initially waited thinking she was sleeping then called pcp who suggested that she come to ed dtr then called ems per daughter patient has not had cough uri symtpoms chest pain fever chills abdominal pain vomiting or diarrhea endorsed shortness of breath daughter also states that pt has been weak and unable to walk for last week in the ed initial vs were ra exam was uncooperative with exam lab significant for lactate of wbc negative ces and bnp of ekg nsr at lad twf laterally cxr showed lll consolidation head ct was negative ua was negative received today ceftriaxone g today azithromycin mg today acetaminophen mg pr initially had bed on general medicine floors however then became hypotensive to s conversative with fluids initially then bolused with l with s became hypoxic to s on l then went to nrb then back down to l nc also was initially altered however was more conversant after receiving fluid also becamwse febrile to and cultures were taken on arrival to the micu pt was moaning and yelling upon translation via daughter pt denied pain however stated that the nasal canula was uncomfortable she also complained of headache without photophobia neck stiffness or nausea past medical history recurrent utis gerd gastroesophageal reflux disease ventral hernia dementia recurrent urinary tract infection pulmonary nodules lesions multiple diverticulosis fatty liver inguinal hernia unilateral lumbar spinal stenosis chronic pain cardiovasc disease unspec spinal stenosis cervical osteoarthritis localized secondary shoulder osteoarthritis localized primary knee thrombophlebitis deep lower extrem anemia vitamin b defic anemia iron defic unspec hypertension essential unspec goiter nontoxic multinodular social history lives with daughter dependent on most adls family history unknown physical exam general uncooperative with exam moaning and yelling heent would not open eyes or mouth neck supple jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs on right lateral cubitus positioning decreased breath sounds on left base crackles throughout right lung fields abdomen soft non tender obese bowel sounds present no organomegaly gu foley in place ext cool pulses no clubbing cyanosis trace to pitting edema to mid shins feet skin appeared slightly mottled neuro uncooperative with exam pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili pm blood ck mb ctropnt probnp am blood calcium phos mg pm blood calcium phos mg am blood digoxin am blood phenoba pm blood asa neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs am blood type art po pco ph caltco base xs pm blood type art temp po pco ph caltco base xs intubat intubated pm urine bnzodzp neg barbitr pos opiates pos cocaine neg amphetm neg mthdone neg stool clostridium difficile toxin a b test final clostridium difficile brief hospital course yof with history of vascular dementia gerd recurrent utis recently pna and c diff infection who presented with altered mental status and hypotension and transferred to the micu due to respiratory distress micu course in the micu the pt was treated with broad spectrum antibiotics for pna however when cta failed to demonstrate e o infiltrate antibiotics were discontinued leukocytosis worsened and c diff toxin returned positive on patient was started flagyl with plan to treat for days from end of broad spectrum antibiotics end date on the patient developed hypercarbic respiratory failure requiring intubation just prior to the event the patient was given small amount of iv ativan for agitation and for concern of barbituate withdrawal as a source for her tachycardia the patient had urine tox positive for barbituates the family noted that patient was taking many sedating russian medications with phenobarbital digitalis and belladonna her respiratory failure was believed to be secondary to sedating medications she was extubated on on without issue the patient was transferred to the floor on after stabilization several hours after reaching the floor the patient developed respiratory distress while being shifted in bed she was placed on a nrb and sats dipped to low s she was given lasix iv mg x a respiratory code was called and she was transferred to the micu after intubation on arrival to the micu she was hypotensive to sbp mid s and was given fluid boluses and started on pressors she was restarted on vancomycin zosyn due to concern for possible aspiration event on she passed sbt and was extubated however she continued to be somnolent despite discontinuing all sedative meds not following commands and opening eyes only to sternal rub she had o desaturations to the high s and was placed on nrb with improvement in oxygenation her bp decreased to s s and she was started on phenylephrine over the following days her cxr continued to show increased pulmonary edema and she had decreased urine output her mental status continued to decline and she lost corneal reflexes repeat cxr on showed left lung collapse family expressed that they did not want her to be re intubated and her code status was changed to dnr dni and then ultimately changed goals of care to cmo pressors were discontinued she passed away on with family present family declined autopsy medications on admission hydrochlorothiazide mg oral capsule take capsule daily gabapentin mg oral capsule take daily desoximetasone topical cream apply twice daily to groin rash stop medication as soon as possible after rash clears omeprazole mg oral capsule delayed release e c capsule twice daily ketoconazole nizoral topical cream apply to affected area twice daily until infection resolves tramadol mg oral tablet take tablets times daily as needed for pain diclofenac sodium solaraze topical gel apply three times daily miconazole nitrate zeasorb af topical powder twice a day cyanocobalamin vitamin b vitamin b mcg ml injection solution inject mcg im monthly metoprolol succinate mg oral tablet extended release hr take tablets daily amlodipine mg oral tablet take tablet daily ribose bulk misc ribose d ribose dose unknown powder three times daily prochlorperazine maleate compazine mg oral tablet take tablet up to every hours as needed for nausea vitamin d unit tab cholecalciferol take tablet daily calcium oral take tablet daily l carnitine oral levocarnitine take three times daily coenzyme q mg cap ubidecarenone take three times daily vitamin b oral cyanocobalamin none entered fergon mg mg iron tab ferrous gluconate take tablet qd sedalgin for pain codeine caffeine phenacetin asa phenobarbitol sodium pumpan for palpitations crataegus arnica kalium carbonleum convallaria digitalis persen valetiana menthol melatonin valocordin phenobarbitoal ethylbromizovalerianate peppermint oil just started days ago insomnia for insomnia hyoscyamus ignatia phos discharge disposition expired discharge diagnosis respiratory failure discharge condition expired discharge instructions n a followup instructions n a,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""1947-10-15"",
""sex"": ""Female"",
""service"": ""Medicine"",
""admission date"": ""2019-10-17"",
""discharge date"": ""2019-10-21"",
""service date"": ""2019-10-17"",
""chief complaint"": ""Altered Mental Status"",
""history of present illness"": ""Female with complicated medical hx including dementia, GERD, spinal stenosis, chronic pain, HTN, OA, H.O. DVT, recurrent UTIs with recent visits for UTI and possible PNA, C. difficile col"
95292,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint change in mental status memory impairment confusion major surgical or invasive procedure biopsy of right parietal lobe lesion biopsy of right iliac lymph node bronchoscopy bal history of present illness m with hx of cad s p cabg dmii hba c bil carotid stenosis ventral hernia repair who presents with weeks of mental status changes including impaired memory confusion and one week of ha two weeks pta pt s friend boss noticed his demeanor was slightly different and that he was losing his train of thought while speaking and was just not acting himself five days pta pt returned to his grocery store job he was on medical leave s p surgery and was noted to have difficulty performing tasks that previously were second nature he could not remember how to operate the register or lottery machine and had coordination problems when trying to wrap a during this time he developed a waxing and frontal headache pain at times over the next two days these symptoms persisted and were very noticeable to the other employees he consistently would forget what he was doing and at one point started speaking french for ten minutes to his english speaking boss pt also reports that over this two week time period he has felt unstable on his feet although this has been occurring to some extent since abd surgery boss sent him to pcp on wed pcp noted pt was having difficulty with tandem gait and remembering what he had had for breakfast neuro exam was otherwise unremarkable pcp sent him for contrast mri which revealed ring enhancing lesions in cerebrum cerebellum brainstem he was sent directly from mri to for further work up but on arrival could not remember why he was there he left the ed walked back to mri facility they subsequently sent him back to the ed by ambulance patient denies vision changes including blurring and scotoma lightheadedness tinnitus hearing changes numbness or tingling or changes in strength his boss friend reports no slurring of speech but does report pt giggles quite often per pt and friend there are lucid periods when he behaves normally with intact memory the pt denies having a hx of serious infections or stds he never uses protection during intercourse and only had two different female partners in his life he denies ever having hematuria he has never been tested for hiv denies fevers chills cough n v d notably his bp have been well controlled for several years at s s and his last few hba cs have been in the s he has had a lb weight loss since surgery in patient does not travel outside of denies sick contacts in the ed his vitals were t hr rr sao ra pt unable to state time gave as year initially but then noted to be aox forty minutes later rest of exam unremarkable piv in r arm cbc chem unrevealing urine and serum tox screen negative urine sent blood culturesx drawn vitals prior to transfer ra past medical history diabetes mellitus type ii hba c cad s p cabg old anterior mi ef in carotid stenosis bil social history as per hpi additionally haitian came her years ago has never been back has no connections with family in does not want like to talk about it lives alone in works at grocery store strong support from boss smoked ppd quit in minimal alcohol no drugs family history unknown physical exam exam on admission vs tc bp hr rr ra general well appearing thin haitian man in nad comfortable pleasant heent nc at sclerae anicteric no conjunctival injection mmm op clear adentulous neck supple no thyromegaly no jvd carotid bruits bil no cervical lad heart rrr no mrg nl s s systolic ejection murmur lungs cta bilat no r rh wh good air movement resp unlabored abdomen soft nt nd no masses or hsm no rebound guarding extremities wwp no c c e peripheral pulses skin no rashes or lesions mental status gen alert interactive expanded affect difficult to follow train of thought flight of ideas and at times nonsensical speech and circumstantiality orientation to person place and time attention has difficulty naming days of the week forwards and backwards speech fluent w o paraphasic errors follows simple and complex commands without l r confusion repetition naming intact memory at registration at minutes normal fund of knowledge calculations intact quarters cn i not tested ii vffc right pupil oval mm to mm left pupil round mm to mm no rapd iii iv vi eomi w o nystagmus or diplopia mild ptosis v sensation intact to lt vii face symmetric without weakness viii hears finger rub equally and bilaterally ix x voice normal palate elevates symmetrically scm and trapezii full xii equivocal tongue protrusion motor normal bulk and tone no tremor rigidity or bradykinesia no pronator drift strength upper and lower extremities coordination dysmetria with finger to nose finger movements no truncal ataxia reflex bicep brachial patellar and ankle jerk sensory lt intact joint position intact no evidence of extinction gait posture stance stride and arm swing normal mild imbalance with tandem gait able to walk on heels and toes romberg negative exam on discharge avss comfortable nad neuro memory objects at registration two hours later able to name months forwards and backwards cn ii xii intact except for impaired l sided palate raise anisocoria r pupil l pupil both responsive strength in ue and le minimal dysmetria with finger nose finger heel to shin intact lt intact in ue and le gait stable pertinent results wbc hct mcv plt na k cl co bun cr glu alt ast alkphos tbili pt ptt inr tibc ferritin transferrin tsh afp urine and serum tox negative lymph node bx flow cytometry negative microbiology multiple bacterial blood cultures done no growth rapid plasma reagin test final nonreactive csf cryptococcal antigen negative csf culture gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final no growth fungal culture preliminary no fungus isolated acid fast culture preliminary the sensitivity of an afb smear on csf is very low if present afb may take weeks to grow no mycobacteria isolated induced sputum concentrate smear for afb negative afb cultures pending hiv antibody negative hiv viral load ultrasensitive final negative toxoplasma igg antibody final positive for toxoplasma igg antibody by eia iu ml bal acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary no mycobacteria isolated gen probe amplified m tuberculosis direct test mtd preliminary sent to state lab for further identification test requested by dr gowri am tissue right iliac node gram stain final no polymorphonuclear leukocytes seen no microorganisms seen tissue final no growth anaerobic culture final no growth acid fast culture preliminary no mycobacteria isolated acid fast smear final no acid fast bacilli seen on direct smear fungal culture preliminary no fungus isolated potassium hydroxide preparation final no fungal elements seen hbv viral load final iu ml pm swab site brain right brain mass gram stain final no polymorphonuclear leukocytes seen no microorganisms seen wound culture final no growth anaerobic culture final no growth acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary no mycobacteria isolated fungal culture preliminary no fungus isolated hcv antibody negative htlv i and ii western blot negative quantiferon gold positive strongyloides antibody negative brucella antibody negative histoplasma antibody negative histoplama urine antigen negative csf wbc rbc polys lymphs monos totprot glucose cmv pcr negative ebv pcr negative toxoplasma pcr negative cysticercus antibodies igg csf negative csf gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final no growth fungal culture preliminary no fungus isolated acid fast culture preliminary the sensitivity of an afb smear on csf is very low if present afb may take weeks to grow no mycobacteria isolated tissue culture data no positive culture data universal pcr for tuberculosis pending on paraffin embedded brain tissue brain tissue pathology showed granuloma with focal areas of necrosis special stains for afb were negative unfortunately brain tissue was not sent to microbiology external iliac node sent to microbiology and pathology no growth of afb at current time in this tissue pathology showed lymphoid tissue with necrotizing granulomas csf cytology negative for malignant cells other studies ct torso solitary right apical lung lesion soft tissue in attenuation with a few foci of peripheral calcification and spiculated margins no associated hilar mediastinal or supraclavicular adenopathy is identified extensive retroperitoneal and pelvic adenopathy with multiple nodes demonstrating central hypoattenuation suggesting necrosis and extensive adjacent inflammatory change and edema throughout the retroperitoneum in the setting of peripherally enhancing brain lesions seen on outside hospital mri both neoplastic and infectious etiologies for these findings must be considered the right apical lung lesion could represent a primary lung neoplasm less likely metastasis though infectious etiologies including tuberculosis could cause a similar appearance the retroperitoneal lymphadenopathy would be unusual secondary to a primary lung neoplasm and the extent of inflammatory change would be atypical of lymphoma infectious or inflammatory processes including possible abdominal tuberculosis or aids related opportunistic infections such as are thus alternate considerations tissue sampling is recommended and a right external iliac node measuring up to cm would represent a reasonable site for initial biopsy tte regional lv systolic dysfunction c w cad prior mi no valve vegetations seen torn calcified mitral chordae seen bil leni impression no evidence of deep vein thrombosis in either leg mri impression multiple infra and supratentorial ring enhancing lesions relatively unchanged since the most recent examination dated differential diagnosis is broad and includes but is not limited to metastatic disease and infectious processes there is no evidence of new lesions in this short interval fiducial markers are in place and biopsy of superficial nodes brain biopsy ct head non con ndication multiple brain lesions now presenting for post operative follow up findings the patient is status post right parietal craniotomy a small amount of gas is seen overlying and subjacent to the craniotomy site a tiny hyperdense focus in the parietal lobe on the right is consistent with a small amount of blood in the surgical bed otherwise there is no intracranial hemorrhage vascular territorial infarction numerous ring enhancing lesions are better assessed on the concurrent mri however note is made of areas of parenchymal hypodensity such as in the thalamus on the left and in the left cerebellar peduncle which correspond to lesions seen on mri ventricles are normal in size and in configuration there is expected effacement of the sulci of the parietal lobe on the right and elsewhere sulcation appears normal extracranial soft tissue structures are normal impression expected post surgical changes immediately following a right parietal craniotomy ct head non con indication hypertension and altered mental status in a patient recently status post brain biopsy findings as before the patient is status post right parietal craniotomy and the small amount of adjacent subcutaneous gas and pneumocephalus is unchanged there has been no interval intracranial hemorrhage there is no vascular territorial infarction the extent of ring enhancing intracranial lesions was characterized to better effect on an mr from though areas of parenchymal hypodensity are noted in the left cerebellar peduncle and the thalamus on the left aside from mild expected effacement of the sulci over the right parietal lobe ventricles and sulci are normal in size and in configuration there is interval increase in subcutaneous soft tissue swelling subjacent to the craniotomy site with a new x cm pocket of fluid likely a developing postoperative seroma impression interval increase in subcutaneous soft tissue swelling and development of a x cm pocket of fluid subjacent to the right craniotomy site likely a developing seroma no interval intracranial hemorrhage or change cxr ap findings there is a status post sternotomy and aortocoronary bypass surgery borderline size of the cardiac silhouette no evidence of pulmonary edema no pneumonia no pleural effusions on the chest radiograph no miliary pattern or opacities are seen cxr pa lat impression no acute cardiopulmonary abnormality eeg impression this is an abnormal routine eeg in the awake and drowsy states due to the presence of a disorganized hz theta rhythm background and frequent bursts of generalized and bifrontal synchronous and independent delta frequency slowing seen during the most awake portions of the recording this pattern is consistent with a mild diffuse encephalopathy there were no focal abnormalities or epileptiform features noted of note the presence of lead artifact over the p o electrodes throughout the tracing may obscure any underlying abnormalities mri spine a degenerative changes of the spine with no evidence of spinal or vertebral tuberculous involvement b numerous findings are only partially visualized including the known intracranial lesions right apical pulmonary lesion ascites mesenteric and paraaortic lymphadenopathy and left vocal cord paralysis brief hospital course haitian male presents with weeks of mental status changes found to have ring enchancing cns lesions by outside mri he is found to additionally have rul nodule pelvic lad with ln and brain biopsy suggestive of disseminated tb he was started on anti tb therapy with steroids on his delirium encephalopathy markedly improved since starting anti tb therapy hospital course neuro deficits seen anisocoria r pupil l pupil both responsive gait instability memory impairment expanded affect and confusion torso ct revealed a x x cm mass in rul no mediastinal or hilar lad and retroperitoneal lad hiv ab negative lumbar puncture unremarkable in terms of rbcs wbcs glucose mild protein elevation csf ncc ab cmv pcr ebv pcr toxoplasma pcr sent and found negative echo performed regional lv systolic dysfunction c w cad prior mi no valve vegetations seen torn calcified mitral chordae seen ruled out for pulmonary tb by is afb negativex patient taken out of isolation bal performed washings negative for malignant cells and otherwise unremarkable rt iliac ln biopsy performed pathology positive for necrotizing granuloma consistent with tb no malignant cells stains negative for organisms afb fungal bacterial cultures pending immunophenotyping negative for lymphoma pt with calf pain bilateral leni performed and negative for dvt pre op imaging followed by brain biopsy of right parietal lesion performed post op imaging showed expected post operative changes pathology notable for granulomas composed of immune cells and focal areas of necrosis no eosinophils gram afb and gms stains negative for organisms afb fungal and bacterial gram stains from tissue swabs and paraffin embedded tissue negative cultures pending universal pcr for afb pending after brain biopsy pt developed hypertensive emergency fevers to with rigors acute change in mental status and with incomprehensible speech and was uncommunicative and transferred to icu icu course year old male with history of type diabetes hypertension hepatitis b and recent ventral hernia repair who was admitted for altered mental status felt possibly due to miliary tb with cns involvement who is transferred to the icu for acute worsening of mental status hypertensive emergency vs urgency and fevers with rigors patient s episode resolved with initiation of vanc cefepime flagyl and with time it is possible he had a seizure eeg was discussed but not initiated because techs not available overnight but symptoms had resolved by am his bp was elevated to s and in setting of recent brain biopsy was goal his lisinopril was increased to mg daily and he was given iv and po hydral the morning after admission the patient was aaox and appropriate and back to baseline per primary team pt started on four drug anti tb regimen with steroids ethambutol mg po qd pyrazinamide mg po qd rifampin mg po qd inh mg po qd mg prednisone qd additionally because of chronic hbc infection see below entecavir mg po qd was also started to prevent viral replication in the setting of steroid treatment pt tolerating treatment lfts since starting treatment have been wnl pt underwent spinal mri to rule out tuberculoma involvement of spine which was negative problem list presumed disseminated tuberculosis with granulomas in the brain necrotizing granulomas on right iliac lymph node biopsy positive quantiferon gold extensive workup also pursued for fungal parasites and malignancy pulmonary tb ruled out with sputum afb smears negative x four drug tb regimen started on encephalopathy relating to brain lesions pt initially noted to have anisocoria r pupil l pupil both responsive gait instability memory impairment expanded affect and confusion this began to all improve once tuberculosis treatment initiated htn pts bps were reasonably well controlled on his home regimen until brain biopsy after procedure patient required uptitrations of his blood pressure medications including the addition of a clonidine patch on his blood pressure was still high on discharge but clonidine patch typically takes days for efficacy he is discharged on the following regimen lisinopril mg po ng daily amlodipine mg po ng daily hydralazine mg po ng q h clonidine patch mg qwed hepatitis b elevated lfts patient was found to have mildly elevated lfts on admission and chronic hepatitis b by blood tests as above hepatology was consulted they recommended entecavir mg po qd when starting steroid treatment as part of anti tb regimen to prevent reactivation entecavir was subsequently started with anti tb treatment lfts have been within normal limits on subsequent testing diabetes mellitus type ii did not require insulin until after starting steroid treatment on subsquently put on lantus u qam on and continues to be on sliding scale continue sliding scale but will likely need adjustment of lantus goal fasting blood glucose is cad stable patient was off aspirin in setting of procedures this was restarted on right upper lung lesion seen on ct torso recommend follow up ct to assess for interval change in size transitional issues pending studies tissue cultures for afb fungus bacteria brain tissue universal pcr other issues weekly cbc chem and lfts in setting starting anti tb treatment with steroids transportation to and from appointments detailed in other sections prednisone taper starting as detailed in opat note blood pressures running high recently started clonidine patch will need follow up will need f u of diabetes and fixed insulin dosing repeat ct chest to assess rul lesion for interval change medications on admission metolazone mg po qam ibuprofen mg po prn pain oxycodone mg po prn pain not taking carvedilol mg po bid furosemide mg po qod simvastatin mg daily lisinopril mg daily glyburide mg po bid asa mg po daily omeprazole mg po before first meal of day discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily simvastatin mg tablet sig two tablet po daily daily furosemide mg tablet sig one tablet po daily daily carvedilol mg tablet sig two tablet po tid times a day lisinopril mg tablet sig two tablet po daily daily entecavir mg tablet sig one tablet po daily daily rifampin mg capsule sig two capsule po q h every hours pyrazinamide mg tablet sig two tablet po daily daily ethambutol mg tablet sig tablets po daily daily prednisone mg tablet sig three tablet po daily daily pyridoxine mg tablet sig two tablet po daily daily isoniazid mg tablet sig one tablet po daily daily amlodipine mg tablet sig two tablet po daily daily polyethylene glycol gram dose powder sig one po bid times a day as needed for constipation acetaminophen mg tablet sig two tablet po q h every hours as needed for fevers pain aspirin mg tablet chewable sig one tablet chewable po daily daily sulfamethoxazole trimethoprim mg tablet sig one tablet po daily daily clonidine mg hr patch weekly sig one patch weekly transdermal qwed every wednesday hydralazine mg tablet sig one tablet po q h every hours docusate sodium mg capsule sig one capsule po bid times a day hold for diarrhea senna mg tablet sig one tablet po bid times a day hold for diarrhea latanoprost drops sig one drop ophthalmic hs at bedtime drop to each eye insulin glargine unit ml solution sig eight units subcutaneous once a day insulin lispro unit ml solution sig one sliding scale subcutaneous four times a day please see attached sliding scale discharge disposition extended care facility discharge diagnosis primary diagnosis disseminated miliary tuberculosis secondary diagnoses hepatitis b coronary artery disease diabetes mellitus type ii carotid stenosis hypertension discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital with confusion memory impairment and instability with walking an mri image of your head taken before you were admitted showed multiple masses scattered through your brain while you were in the hospital you were extensively worked up for your symptoms and findings while you were in the hospital many blood and urine tests were sent a procedure called a lumbar puncture was performed to examine fluid in your spinal cord a different procedure called a bronchoscopy was performed to examine your lungs tissue from your brain and a pelvic lymph node was obtained and examined in a procedure called a biopsy you underwent multiple radiographic imaging tests including cat scans and mri based on our findings we think you have tuberculosis in your brain and other parts of your body we did not find anything to suggest cancer additionally we found that at some point you were infected with hepatitis b you were subsequently started on a multi drug regimen to treat tuberculosis and hepatitis b you have been tolerating this treatment in the hospital this treatment is very detailed and will require frequent blood tests to make sure your body continues to tolerate the medicine additionally it will make your blood sugars more difficult to control to help with all of this we have placed you in a tuberculosis treatment center at the hospital in the director of this infectious disease while we are quite confident that tuberculosis is the cause of your illness we cannot be sure if after a period of time you are not improving or getting worse additional tests will be required to determine the best treatment we have made many appointments for you with several different doctors detailed below it is extremely important that you make all these appointments the hospital will help you make these appointments and find transportation for you we have made many changes to your medications these are detailed in the attached documentation followup instructions we have scheduled the following appointments for you transportation to and from these appointments must be provided by rehabilitation center p md division of infectious disease medical office building phone fax pm provider function lab phone date time pm pm provider dr phone date time pm division of pulmonology critical care and sleep medicine department of medicine p provider md department of neurosurgery medical office building a provider department of ophthalmology sc clinical ctr hmfp eye ma completed by,"[
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31895,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint tylenol overdose major surgical or invasive procedure none history of present illness is a year old male with a history of angry and impulsive behavior who is transferred from an outside hospital s p tylenol overdose reports that he and his girlfriend broke up last wednesday and that he subsequently went on an alcohol and cocaine binge lasting from thursday to saturday during this day binge he estimates that he drank drinks beer and hard liquor sniffed cocaine every few hours and did not sleep he has used alcohol and cocaine regularly in the past but he denies having had a binge of this quantity or duration before on saturday night told his father that he had tried to hang himself at a nearby park but the rope had broken claims that his story was an attempt to seek attention and that he never actually attempted to end his life he does admit to having a very brief thought of dying on saturday night but he says that he could never do it and that he has never had any suicidal ideations in the past at midnight on saturday night ingested tablets of tylenol extra strength in an effort to come down off his cocaine high and fall asleep previously would usually take tablets of tylenol extra strength to come down off his cocaine highs he says that this time he took tablets at once because he was really out of it and was not fully aware of how much tylenol he was taking he said that he did intend to take more tylenol than usual because his binge had lasted so long and because he was so tired but denies any knowledge that the tylenol could kill him he acquired the tylenol from his family s medicine cabinet in the house s bathroom he denies recent use of any other drugs including narcotics mushrooms or sniffing solvents he did not have a substantial meal during his day binge as he only ate a slice of pizza some potato chips and other junk food snacks on sunday morning he awoke at am with sharp stabbing pain in the lower quadrants of his abdomen the pain was in severity was alleviated by eating jello and did not radiate elsewhere he threw up times with the emesis being non bloody non bilious and consisting of the recently consumed jello he then requested his father to take him to the emergency room at the outside hospital received iv fluids zofran phengren and acetylcysteine his peak serum acetaminophen level was approximately hours after ingestion and his initial labs included an inr of ast and alt his labs increased to an inr of ast and alt and he was transferred to on monday for further management and possible liver transplant workup at denied suicidal ideation and expressed desire for a liver transplant if it would help him live he was admitted to the micu where he received acetylcysteine and cxr and abdominal u s studies were unremarkable his labs peaked at an inr of ast and alt before trending downward and on wednesday he was was transferred to the medicine service denies any gross blood loss bruising or jaundice he has not suffered any ruq pain and denies any severe headaches he has been urinating without pain or change in urine color and he denies any flank pain he denies any history of withdrawal symptoms and he has not experienced any tremors or palpitations he denies nausea vomiting chills or diarrhea but he reports sweating and fevers on tuesday night he has been eating and drinking without discomfort and has had well formed stools with no gross blood past medical history angry and impulsive behavior no h o hospitalizations social history finished high school but had problems in college because he did not go to class and struggled with some coursework he got into trouble for fighting and damaging property which he attributes to being in the wrong place at the wrong time and hanging out with bad company he grew up playing hockey and is a big fan of the bruins although he stopped playing a few months ago because he started working in the evenings he currently works for papa as a pizza delivery person and enjoys it because he gets a lot of freedom and makes good money he previously worked in construction first got drunk at his high school senior prom he drinks times a week and he will consume beers in a sitting or beers if he is at a party he has felt the need to cut down his drinking but denies feeling annoyance guilt or requiring an eye opener he has driven short distances after drinking alcohol but will not drive if he feels that he is too drunk he denies smoking cigarettes but he has smoked marijuana although he is not a regular user started using cocaine years ago when he was in college and has used it times a week since then he only uses by sniffing and has never smoked or injected it he has also experimented with lsd mushrooms percocets and vicodins but denies any history of iv drug use he doesn t think that he needs to attend a drug rehabilitation program although he expresses some desire to talk to a counsellor about his substance abuse he has been attending anger management counseling on and off for a few months he denies that the sessions were court ordered but says that he started these sessions at his family s request he currently lives with his father step mother and sister in and reports that he is happy and gets along well with his family he is only rarely in touch with his biological mother who lives in after discharge from hospital hopes to move in with his maternal grandmother in that he can try and get his life back in order family history mother with bipolar disease and impulsive behavior no family history of hepatitis or liver disease physical exam vitals t bp p rr o sat ra general comfortably lying flat in bed nad well nourished and well appearing heent sclera anicteric oral mucosa pink perrl eom intact oropharynx clear no cervical lymphadenopathy respiratory ctab no wheezes or rales cvs rrr normal s s no murmurs abdomen non tender to deep palpation in all quadrants soft non distended normoactive bowel sounds no palpable masses or organomegaly genitalia deferred extremities warm well perfused no edema clubbing or cyanosis skin no rashes no needle track marks no bruising except at iv sites neuro ao x no asterixis no clonus psych listens and responds to questions appropriately pleasant and thankful to be alive pertinent results admission labs ca mg p alt ap tbili alb ast ldh n band l m e bas pt ptt inr albumin peak inr peak ast peak alt peak t bili findings the liver shows no focal or textural abnormalities there is no biliary dilatation and the common duct measures cm the gallbladder is normal without evidence of stones the pancreas is unremarkable the spleen is enlarged measuring cm both right and left kidneys are echogenic but neither shows hydronephrosis or stones or solid masses the right kidney measures cm and the left kidney measures cm the aorta is of normal caliber throughout there is no evidence of ascites doppler examination color doppler imaging and pulse doppler waveforms were obtained the main portal vein right portal vein and left portal vein are patent with hepatopetal flow arterial waveforms of the main hepatic artery the right hepatic artery and the left hepatic arteries show good upstrokes with ris ranging from to cm sec there is appropriate flow in the ivc the hepatic veins and the splenic veins impression patent hepatic vasculature with no liver abnormalities identified splenomegaly cxr the hemidiaphragms are in normal position structure and transparency of the lung parenchyma are unremarkable no signs of overhydration no pulmonary opacities the size and configuration of the cardiac silhouette are normal impression normal chest radiograph u a negative micro urine cx ngtd blood cx ngtd brief hospital course year old male with a history of angry and impulsive behavior presents with unintentional tylenol od during cocaine and etoh binge hospital course by problem list tylenol o d and acute liver failure the patient ingested pills of tylenol extra strength at midnight on the night of he was brought to an osh in the morning of where he had a peak serum tylenol level of approximately hours after ingestion upon presentation at osh his initial labs included an inr of ast and alt and he was started on n acetylcysteine his labs increased to an inr of ast and alt and the patient was transferred to for further management and possible liver transplant workup in the micu the patient s labs peaked at inr of ast and alt before steadily trending downward hepatitis and hiv serologies were negative and ruq u s showed mild splenomegaly but no other abnormalities he was transferred to the medicine service where his labs have continued to decline and after consultation with hepatology and toxicology his n acetylcysteine was discontinued on during his stay he did not show any signs of encephalopathy jaundice or renal failure his most recent labs on showed an inr of ast alt there is no need to continue following liver function tests he can follow up with his pcp etoh substance abuse the patient reports a history of alcohol abuse drinking times a week and consuming beers in a sitting or beers if he is at a party he has felt the need to cut down his drinking but denies feeling annoyance guilt or requiring an eye opener he denies smoking cigarettes but he has smoked marijuana although he is not a regular user he started using cocaine years ago when he was in college and has used it times a week since then he only uses by sniffing and has never smoked or injected it he has also experimented with lsd mushrooms percocets and vicodins but denies any history of iv drug use he presented to the hospital after a day alcohol and cocaine binge he denies having had a binge of this quantity or duration before during this hospital stay he has no experienced no signs of alcohol or other drug withdrawal he had a serum tox screen that was negative for amphetamines on he denies need for social work support or enhanced professional support for substance abuse he plans to discuss overdose as an outpatient he expresses strong determination to maintain sobriety for months to moderate his alcohol use in the future and to quit using cocaine he received a multivitamin folate and thiamine during his stay suicide attempt and h o suicidal ideation patient denies knowledge that tylenol overdose could be fatal and upon arrival at he expressed desire for a liver transplant if it would help him live the patient has consistently and adamantly denied that the tylenol overdose was a suicide attempt he had taken tylenol extra strength tablets in the past to come down off his cocaine highs and to help him sleep just prior to the overdose the patient had told his father that he had tried to hang himself at a nearby park but the rope had broken the patient claims that his story was an attempt to seek attention and that he never actually attempted to end his life he does admit to having a very brief thought of dying on that night but he says that he could never do it and that he has never had any suicidal ideations in the past on exam there was no evidence of bruising on his neck fever the pateint was febrile in the micu to and woke up with drenching sweats at that time on he again spiked a fever to but denied feeling ill or waking up with sweats these fevers are likely due to liver necrosis secondary to tylenol overdose urine culture showed no growth and blood cultures are pending his lungs were clear to auscultation bilaterally the patient was observed for hours from and remained afebrile throughout this time patient may have occasional persistent fevers but these should resolve medications on admission outpatient medications none medications on transfer from micu n acetylcysteine mg iv q h pantoprazole mg daily folic acid multivitamin thiamine discharge medications none discharge disposition extended care facility discharge diagnosis primary acute hepatic failure secondary to tylenol overdose secondary suicide attempt suicidal ideation discharge condition good alt ast inr temp discharge instructions you were admitted with acute hepatic failure after overdosing on tylenol you were tested for other liver diseases and found to be negative for hiv hepatitis a and hepatitis b your peak blood tylenol level was approximately hours after ingestion tests of your liver enzymes peaked at an inr of ast and alt you were given intravenous n acetylcysteine mucomyst for days and the levels of your liver enzymes steadily trended downward after consulting with your liver doctors and the we stopped the n acetylcysteine on your most recent lab values on were an inr of ast alt during your hospital stay you did not show any other signs of liver failure but you were initially evaluated for possible liver transplant you had a temperature of on and woke up with drenching sweats at that time on you again spiked a fever to but you did not feel ill or wake up with sweats these fevers were likely due to the liver damage you experienced because of your tylenol overdose we tested your urine and blood for infection your urine test was negative and your blood tests are pending your lungs were clear with no evidence of pneumonia we observed you for hours from and you remained afebrile throughout this time if you develop any new fevers or experience night sweats or chills please see your primary care doctor there was concern over your emotional stability and impulsive actions in the days leading up to your tylenol overdose there was also concern about your brief suicidal thoughts prior to your overdose given your family history of bipolar disease and after consulting with your anger management counsellor the psychiatrists decided that it would be useful to do an evaluation of you as an inpatient please call your physician if you develop any concerning symptoms such as bleeding jaundice severe abdominal pain nausea vomiting or suicidal thoughts followup instructions inpatient psychiatry md,"[
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""21"
51490,admission date discharge date date of birth sex m service neurology allergies no known allergies adverse drug reactions attending chief complaint seizures major surgical or invasive procedure intubation extubation atraumatic uncomplicated history of present illness the pt is a year old man with a history of a prior left occiptal avm s p embolization with a history of a seizure disorder who presents following a witnessed seizure per discussion with his girlfriend he got home from work around pm and they were in the bedroom getting ready to do laundry he suddenly stopped speaking slumped to the side and began having a seizure she reports that this consisted of flexion of the bilateral arms with rhythmic shaking stiffening and shaking of the legs and gaze deviation to the right with a significant amount of salivary secretions this entire episode lasted minute after which he seemed very confused and out of it she called ems and as they were loading him into the ambulance he began to have another seizure they reportedly were unable to give him anything en route and the second seizure lasted a total of minutes stopping on arrival to the ed he was still quite post ictal on arrival and was given mg of ativan given concerns for inability to protect his airway at that point he was then intubated per discussion with his girlfriend his last seizure prior to today was in this weekend she reports that he did have a friend from out of town visiting so was out late several nights had beers every night and also smoked a lot of marijuana which is not usual for him unable to answer ros past medical history avm s p hemorrhage resection at osh in ny one prior seizure rx dilantin last year by outside neurologist social history lives with his girlfriend of years works in it for a financial company moving to in for graduate school smokes packs week just started recently drinks occasionally socially had night the past two nights per his girlfriend used a significant amount of marijuana over the weekend family history no family hx of avms or seizures mother with diabetes physical exam on admission in ed vitals p r bp sao intubated general somnolant heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s no m r g noted abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities no c c e bilaterally radial dp pulses bilaterally skin no rashes or lesions noted neurologic mental status somnolant flicker of an attempt to open eyes in response to commands but otherwise not following commands does make purposeful movements in response to painful stimuli cranial nerves pupils on the left on the right roving eye movements at rest with intact oculocephalics and corneals does not consistently blink to threat intact gag motor sensory spontaneous anti gravity movements noted in all extremities and withdraws purposefully from painful stimuli dtrs tri pat ach l r plantar response was extensor bilaterally pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood urean creat am blood alt ast ck cpk alkphos totbili pm blood alt ast ck cpk alkphos totbili am blood albumin calcium phos mg am blood phenyto pm blood phenyto pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type art rates tidal v fio po pco ph caltco base xs assist con intubat intubated pm blood ph comment green top pm blood glucose lactate na k cl pm blood glucose lactate na k cl calhco pm blood hgb calchct o sat cohgb methgb pm blood freeca pm blood freeca nchct in ed technique non contrast mdct acquired axial images through the head coronal and sagittal reformats were obtained for evaluation findings no acute intracranial hemorrhage edema mass effect or major vascular territorial infarct encephalomalacia in the left occipital lobe is noted with adjacent left occipital craniotomy ventricles and sulci are normal in size and symmetric in configuration aside from minimal ex vaco dilatation of the left lateral ventricle occipital no shift from normally midline structures white matter differentiation is well preserved a mucus retention cyst is seen in the left maxillary sinus the remainder of the visualized paranasal sinuses and mastoid air cells are clear fluid in the nasopharynx is likely related to intubated status an oral tube is in place no fracture impression no acute intracranial process encephalomalacia in the left occipital lobe cxr in ed supine ap view of the chest endotracheal tube tip terminates approximately cm from the carina nasogastric tube tip is seen within the stomach the cardiac mediastinal and hilar contours are within normal limits there is minimal left basilar atelectasis no focal consolidation pleural effusion or pneumothorax is identified no acute osseous findings are present impression endotracheal tube and nasogastric tube are in standard positions minimal retrocardiac atelectasis brief hospital course the patient did well on the ventilator cpap overnight and was extubated without incident the following morning his only complaint was a scratchy throat he was a little tachycardic s sinus but this resolved to the s after ivf hydration his foley was removed and he urinated cc he felt fine to go home and his neurologic exam was normal non focal he endorsed the etoh and mj and recent sleep deprivation as described above see hpi and said that he rarely if ever misses a dose of dilantin and not recently as far as he can recall there were very good reasons for him to have a seizure and a slightly low dilantin level on presentation etoh heavy mj use dehydration sleep deprivation the former of which can alter dilantin metabolism so we did not feel it was necessary to pursue further workup or change his drug regimen at this time he has an obvious risk factor for seizure the previous surgical resection of a large region of his left precuneus medial parietal cortex as confirmed on nchct here he needs to follow up with his outpatient neurologist to have his dilantin level re checked while back on his home regimen of mg alternating qod we discussed the potential benefits of switching to a more benign and easier to manage medication such as levetiracitam but deferred this decision to his neurologist who should feel free to contact us with any questions we also encouraged him to establish care with a neurologist in where he plans to move in for grad school medications on admission dilantin mg even days mg odd days alternating qod discharge medications phenytoin sodium extended mg capsule sig three capsule po qod even days mg on even days take as prescribed directed by your outpatient neurologist disp refills phenytoin sodium extended mg capsule sig four capsule po qod odd days mg on odd days take as prescribed directed by your outpatient neurologist disp refills discharge disposition home discharge diagnosis primary seizures generalized ictal post ictal respiratory failure secondary arterial venous malformation s p operative resection at osh seizure disorder avm resection on phenytoin discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were brought to the hospital after you had seizures your seizures were stopped but the emergency physicians had to place a breathing tube in your throat and temporarily use a breathing machine because your spontaneous breathing was poor and your blood was became dangerously acidotic from this and from the muscle convulsions your dilantin level was a little low goal range so you were given intravenous dilantin mg and your level increased to in the icu please continue taking dilantin phenytoin at the dose prescribed by your pcp abstain completely from alcohol and cannabis stay well hydrated and get a healthy amount of sleep every night hours these drugs and sleep deprivation make it far more likely that you will have more seizures both by their direct effects on the brain and in the case of alcohol cannabis by altering the metabolism of dilantin by your body liver followup instructions follow up with your primary neurologist as soon as possible he will need to re measure your dilantin phenytoin level as an outpatient and use that number to decide whether or not to change your dose do not drink alcohol in the meantime as this will adversely affect your dilantin level due to altered metabolism in the liver please discuss with him the possibility of changing from dilantin to another drug that is easier to manage such as keppra levetiracitam please establish follow up care with a neurologist in i would recommend anyone at the upenn dept of neurology md completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Neurology"",
""allergies"": [
""None""
],
""adverseDrugReactions"": [
""None""
],
""attendingChiefComplaint"": ""Seizures"",
""chiefComplaintDetails"": ""Witnessed seizure"",
""historyOfPresentIllness"": ""The pt is a year old man with a history of a prior left occiptal avm s p embolization with a history of a seizure disorder who presents following a witnessed seizure per discussion with his girlfriend he got home from work around pm and they were in the bedroom getting ready to do laundry he suddenly stopped speaking slumped to the side"
21870,admission date discharge date date of birth sex f service admitting diagnosis cardiac arrest discharge diagnosis cardiac arrest history of present illness year old woman with no past cardiac history nonsmoker nondrinker with no known family history of coronary artery disease nondiabetic found down in her home found to be in vf arrest by emts transferred to an outside hospital intubated respiratory failure transferred unit to unit to under dr the attending physician the coronary care unit patient had cardiac catheterization but remained neurologically unresponsive neurology was consulted patient also required multiple pressors to maintain her blood pressure when no neurological responses were was found during patient s hospitalization including absence of coronary blink reflexes minimum pupillary reflexes and decorticate posturing she was kept for observation for a hour period as per the recommendation of neurology consult an eeg was performed evaluation of neurology team felt that hope of meaningful improvement was negligible and therefore discussion with the family present as well as social work the attending physician the house staff team decision was made to withdraw care patient expired within five minutes after withdrawal of ventilatory support time of death was p m on the family was present the family declined autopsy m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f service addendum the patient s family requested contact with the tissue bank and organ bank system the patient was evaluated for donor status after her expiration and was deemed unsuitable for organ donation but suitable for tissue transplant m d dictated by medquist d t job,"{
""date"": ""2019-12-10"",
""service"": ""MICU"",
""admission_date"": ""2019-12-10"",
""discharge_date"": ""2019-12-11"",
""date_of_birth"": ""2049-12-10"",
""sex"": ""Female"",
""service_name"": ""MICU"",
""admitting_diagnosis"": ""CARDIAC ARREST"",
""discharge_diagnosis"": ""CARDIAC ARREST"",
""history_of_present_illness"": ""81 year old woman with no past cardiac history nonsmoker nondrinker with no known family history of coronary artery disease nondiabetic found down in her home found"
66016,admission date discharge date date of birth sex m service neurosurgery allergies latex attending chief complaint metastatic melanoma at l major surgical or invasive procedure l s posterior fusion anterior l vertebrectomy w bma history of present illness elective admit for resection of metastatic melanoma at l past medical history metastatic melanoma social history he denies tobacco drinks a few beers essentially only on the weekends he has a year old son from a prior marriage who is now in fourth grade he has a great deal of contact with his son married his current wife only three months ago in family history there is no family history of melanoma or sarcoma or any other cancers there is no history of early heart disease physical exam on discharge mae with full motor strength posterior incision is macerated but sutures remain intact anterior incision is c d i with staples pertinent results mri mra brain impression stable cavernoma in the left frontal lobe no evidence of metastatic disease brief hospital course y o m with history of metastatic melanoma at l presents for elective resection of tumor patient was taken to the or on where a l s posterior fusion was performed post operatively patient remained intubated but was following commands and moving all extremities on patient was extubated and strength throughout his incision was c d i he was transferred to the floor drain was discontinued he remained on bed rest until his anterior approach his incision had moderate drainage but otherwise intact dressing was changed and monitored subcutaneous heparin was started and he was transitioned from pca to oral pain medication on over the evening he was found to have work finding difficulty a head ct was performed which was negative for bleed but did show a mm hyperdensity in the left frontal lobe which was consistent with a cavernoma that had been noted in a previous mri a mri mra was done on he underwent the anterior approach on on pod pain was an issue and oxycontin was initiated physical therapy was initiated on and patient c o nausea and reglan was started lspine xrays were done which showed good hardware placement and alignment patient had a bm on nausea improved and physical therapy signed off his oxycontin was increased on with good effect the incision was macerated but sutures remained intact and in place anterior incision was c d i a repeat wbc was done which was stable pt remained afebrile patient was discharged home on medications on admission ativan percocet discharge medications oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours for days disp tablet sustained release hr s refills lorazepam mg tablet sig one tablet po hs at bedtime as needed for anxiety bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily senna mg tablet sig two tablet po bid times a day docusate sodium mg capsule sig one capsule po tid times a day hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours diazepam mg tablet sig one tablet po q h every hours as needed for muscle spasm stiffness disp tablet s refills ranitidine hcl mg tablet sig one tablet po daily daily metoclopramide mg tablet sig one tablet po qidachs times a day before meals and at bedtime as needed for nausea gi motility disp tablet s refills zofran mg tablet sig one tablet po every eight hours as needed for nausea disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis lumbar stenosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions discharge instructions for spine cases do not smoke keep wound clean no tub baths or pools until seen in follow up ok for daily showers please keep your incision open to air you may apply a dressing if going out and need to protect clothing from any drainage no pulling up lifting lbs excessive bending or twisting for two weeks limit your use of stairs to times per day have a family member check your incision daily for signs of infection take pain medication as instructed you may find it best if taken in the a m when you wake if you experience muscle stiffness and before bed for sleeping discomfort do not take any anti inflammatory medications such as motrin advil aspirin ibuprofen etc for months to promote bony fusion increase your intake of fluids and fiber as pain medicine narcotics can cause constipation followup instructions please return to clinic on for a wound check and suture staple removal this should be done with dr pa or np only please call to make this appointment please call to schedule an appointment with dr to be seen in weeks you will need xrays prior to your appointment completed by,"{
""date"": ""2019-10-10"",
""discharge_date"": ""2019-10-13"",
""service"": ""Neurosurgery"",
""allergies"": ""Latex"",
""attending_chief_complaint"": ""Metastatic melanoma at l major surgical or invasive procedure"",
""chief_complaint"": ""Metastatic melanoma at l major surgical or invasive procedure"",
""history_of_present_illness"": ""Elective admit for resection of metastatic melanoma at l past medical history metastatic melanoma social history he denies tobacco drinks a few beers essentially only on the weekends he has a year old son from a prior marriage who is now in fourth grade he has a great deal of contact with his son married his"
4757,admission date discharge date date of birth sex m service tra history of present illness the patient is a year old man status post fall from a twelve to fourteen foot ladder while hanging lights the patient had been drinking alcohol at the time the fall was witnessed by the family the patient had no loss of consciousness his gcs was the patient was hemodynamically stable he was noted at to be in atrial fibrillation at the time and was placed on a diltiazem drip he was also noted to have a right parietal contusion on ct scan and his only complaint was lower back pain he was transferred to for further care past medical history none medications at home none allergies no known drug allergies social history the patient is married he does smoke and he does drink alcohol physical examination the patient had a temperature of heart rate blood pressure respiratory rate of oxygen saturation percent on room air the patient was alert and oriented x in no acute distress he was conversational and appropriate he had a right posterior head hematoma with staples already in place cranial nerves ii xii were intact tympanic membranes and oropharynx were clear trachea was midline chest was clear to auscultation bilaterally heart had a regular rate and rhythm the sternum was stable abdomen was soft nontender nondistended the patient had normal rectal tone and was guaiac negative the patient had no extremity deformities he had a palpable dorsalis pedis and radial pulse bilaterally he did have positive lumbar tenderness but no spinal step off his pelvis was stable the patient had an admission hematocrit of his coagulation profile was normal electrolytes were normal he had a serum ethanol level of his electrocardiogram was in normal sinus rhythm repeat ct scan of the head revealed a stable punctate right parietal contusion ct scan of the chest was negative ct of the neck was negative ct of the abdomen was negative thoracic and lumbosacral spine films showed a t wedge deformity and l s anterolisthesis and a sacral fracture the patient was admitted to the hospital on and was sent to the intensive care unit for q hourly neurologic checks neurosurgery was involved in his care immediately and indicated that the anterolisthesis was likely a chronic problem whereas the wedge deformity and sacral fractures were likely new however these did not require any intervention while in house he was also on continuous telemetry and was never noted to be in atrial fibrillation again it was assumed that this was caused by drinking alcohol otherwise the patient remained stable while in house and it is now and the patient is being discharged in good condition he will not require any followup with neurosurgery or trauma but should visit his primary care physician for post hospitalization evaluation he should not drive while on narcotic pain medication he may bathe and observe a regular diet final diagnoses cerebral contusion t vertebral fracture sacral vertebral fracture l s vertebral anterolisthesis hypomagnesemia dictated by medquist d t job,"{
""admission_date"": ""2019-10-12"",
""discharge_date"": ""2019-10-14"",
""date_of_birth"": ""2007-1-1"",
""sex"": ""M"",
""service"": ""TRAUMA"",
""history_of_present_illness"": ""admission date discharge date date of birth sex m service tra history of present illness the patient is a year old man status post fall from a twelve to fourteen foot ladder while hanging lights the patient had been drinking alcohol at the time the fall was witnessed by the family the patient had no loss of consciousness his gcs was the patient was hemodynamically stable he was noted at to be in atrial fibrillation at the time and was placed on a diltiazem drip he was also noted"
59420,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal pain x days major surgical or invasive procedure percutaneous cholecystostomy tube placement stent exchanged history of present illness f had and biliary stent placement for mirizzi s syndrome she was pregnant at the time she has not had her gallbladder out and she failed to make the appointment to have the stent taken out today she presents with sharp non radiating ruq pain x days pain has been consistent associated with fevers chills rigors severe nausea and episode of bilious vomiting denies diarrhea last bm and flatus days ago but pt notes that is normal transferred from this evening where she was treated with flagyl past medical history pmh none psh biliary stent placement c sections last in social history lives in ma with her boyfriend and kids no a t d family history nc physical exam on admission pe nad rrr ctab abd soft non distended ttp in the ruq positive sign normoactive bs in all quadrants ext warm well perfused with no c c e on discharge afvss gen nad aox cvs reg pulm no resp distress abd s at nd perc drain in place pertinent results osh labs wbc hct plt na k cl bicarb bun cr admission labs pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm neuts lymphs monos eos basos pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos tot bili pm albumin pm urine ucg negative pm urine color yellow appear clear sp pm urine blood lg nitrite pos protein glucose neg ketone tr bilirubin neg urobilngn neg ph leuk sm liver gallbladder u s impression findings suggestive of acute cholecystitis with mucosal sloughing and necrosis cholelithiasis without evidence of choledocholithiasis distal cbd not visualized due to bowel gas findings esophagus limited exam of the esophagus was normal stomach limited exam of the stomach was normal duodenum limited exam of the duodenum was normal major papilla a plastic stent placed in the biliary duct was found in the major papilla the plastic stent was removed using a snare evidence of a previous sphincterotomy was noted in the major papilla biliary tree an occlusion cholangiogram was performed to define the biliary tree a limited amount of contrast was used due to concern for cholangitis however no pus no thick bile no biliary stones were extracted from the common bile duct evidence of extrinsic compression was noted at the middle third of the common bile duct this was compatible with a stone in the cystic duct as seen previously due to these findings a cm by fr cotton biliary stent was placed successfully impression a plastic stent placed in the biliary duct was found in the major papilla the plastic stent was removed using a snare evidence of a previous sphincterotomy was noted in the major papilla an occlusion cholangiogram was performed to define the biliary tree a limited amount of contrast was used due to concern for cholangitis however no pus no thick bile no biliary stones were extracted from the common bile duct evidence of extrinsic compression was noted at the middle third of the common bile duct this was compatible with a stone in the cystic duct as seen previously due to these findings due to these findings a cm by fr cotton biliary stent was placed successfully otherwise normal to third part of the duodenum recommendations npo today diet orders as per the primary team the patient s clinical picture is not explained by these findings cholecystitis is the most likely cause further management per dr service continue iv antibiotics follow up with dr and dr brief hospital course year old female with biliary stent placed for mirizzi syndrome now with acute cholecystitis and concern regarding infected stent patient had and stent replacement she also had a percutaneous cholecystotomy tube placed and she was treated with iv antibiotics by the time of discharge she was tolerating regular diet afebrile and adequate pain control she will follow up as an outpatient with for stent removal and with dr her drain will remain in place until follow up and she will be placed on po antibiotics acute cholecystitis the patient was treated with unasyn for her acute cholecysistis she underwent due to concern for acute cholangitis given the fact that she has had a previous stent showed that the patient s bile duct stent was working properly and there was no pus in the bile duct again noted was the stone in the cystic duct which was felt to be intermittently compressing the common bile duct for this reason a stent was again placed in the common bile duct it was felt that the patient s symptoms were primarily related to acute cholecystitis rather than cholangitis drain to be left in place until follow up with antibiotics anemia microcytic likely blood loss either gi or gu or hemolysis dic unclear at least partially acute hct at osh pt did report lightheadedness prior to this event guaiac negative denies blood in vomit report mentrual cycles not particularly heavy no prior baseline blood smear fibrinogin hapto inr fdp d bili q h hct the patient s kidney fuction improved from the presentation to osh to the time of admission to it improved with fluid resuscitation non gap metabolic acidosis most likely related to fluid resuscitation and gastric losses from vomiting the patient was given lactated ringers for further volume resusciation and her acidosis resolved urinary tract infection treated with unasyn as above left black eye the patient was noted to have a black eye on admission the patient reported it occurred as an injury related to falling down the stairs the was concern about physical abuse social work was consulted medications on admission none discharge medications augmentin mg tablet sig one tablet po every twelve hours for days disp tablet s refills discharge disposition home discharge diagnosis cholecystitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital for an infected gall bladder you were admitted to the icu for a short peroid of time because you were very sick we treated your symptoms with the placement of a percutaneous cholecystostomy tube and antibiotics this tube will stay in place you are ready to return home until your surgery to remove your gallbladder which will be with dr at the end of six weeks however you must follow up with dr in her office in weeks you will be taking the antibiotic augmentin twice daily for the next days please take this prescription as written and be sure to finish the entire prescription the tube in your abdomen will remain in place until your surgery please monitor the output and empty the drain twice daily the fluid in this drain should have green brown drainage if this turns into frank red blood please seek medical attention or if severe go to the emergency room if this drain begins to put out more than millileters daily please call the office follow drain care instructions as ordered your nurse should provide you with a container to measure the drainage if you return home and you have increased abdominal pain nausea vomiting fever constipation or you are unable to tolerate food please seek medical attention or come to the emergency room if it is severe please keep yourself well hydrated and take it easy for the next week please follow a low fat diet the gall bladder secretes bile which is important for fat absorption and its secretion is stimulate when you eat food and foods especially high in fat that is why you have pain when you eat so it is best to avoid these foods for now while you were in the hospital your heart rate was elevated and your blood pressure at times was elevated we gave you medication to help with this it is important that you have your blood pressure and heart rate checked by your pcp within the next weeks please call them to make an appointment followup instructions please follow up with dr call to make an appointment call pcp to make an appointment for a blood pressure and heart rate check provider st gi rooms date time provider md phone date time md,"{
""name"": ""Jane Doe"",
""dateOfBirth"": ""2014-03-20"",
""sex"": ""Female"",
""service"": ""Surgery"",
""admissionDate"": ""2014-03-21"",
""dischargeDate"": ""2014-03-24"",
""dateOfDeath"": ""2014-03-24"",
""allergies"": [
""Percocet""
],
""attendingChiefComplaint"": ""abdominal pain x days"",
""chiefComplaintHistory"": [
""abdominal pain x days""
],
""historyOfPresentIllness"": ""This is a 24 year old female with a history of MIrizzi syndrome who was pregnant at the time and failed to"
16947,admission date discharge date date of birth sex m service neurology allergies bactrim attending chief complaint altered metnal status major surgical or invasive procedure bronchoscopy history of present illness year old m recently diagnosed by biopsy with gliomatosis cerebri grade ii astrocytoma in being treated with xrt timidar she is currently on a decadron taper after it was increased several months ago secondary to increasing ocular symptoms seen by pmd on w symptoms of cough productive of yellow sputum which wife also had prescribed zpak w o improvement pt was brought to the ed for increasing somnolence over past several days weeks over the past two weeks pt has declined in status he is confused has had hallucinations family believed pt was becoming dehydrated also pt s strength has been declining over the past weeks he used to be able to walk with a walker and the past few days has required a wheelchair incontinence over the past weeks non bloody diarrhea x on doa in the ed vs on arrival were t bp hr rr on ra cxr shows diffuse b l infiltrates r l and pt was found to have a bandemia ldh was pt received bactrim mg x for possible pcp hypoxic respiratory distress during admission became steadily more sob increasing lethargy satting initially on face mask abg he was switched to a nrb mask and abg was on floor on day of transfer on nrb during evaluation pt responsive to sternal rub but could not follow commands intubated for failure to protect airway transferred to icu past medical history pmhx coronary artery disease s p mi years ago hypertension hyperlipidemia djd in the c spine depression h o dvt shingles recently finished treatment social history landfill worker retired pky h o smoking quit yrs ago denies etoh drugs family history non contributory physical exam t bp on neo p ac fi vt peep breathing at w volumes of s intubated minimally responsive localized pain perrl op clear mmm jvd not appreciated to deep inspiratory breaths bs distended soft nt no le edema pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso atyps metas myelos pm blood pt ptt inr pt chem pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili pm blood type art po pco ph calhco base xs am blood lactate brief hospital course impression yo m w astrocytoma on xrt and chemotx who p w wk h o productive cough sick contact hypoxic now intubated w increasing infiltrates b l resp failure pt admitted w primarily hypoxic respiratory failure following admission to the floor the pt developed increasing hypoxia and somnolence requiring intubation on hd pulm had previously been consulted and felt that presentation was c w pcp started on bactrim previously treated for cap as outpt but hypoxia continued to progress similar lack of improvement w additional broad spectrum coverage following admission pt underwent bronchoscopy on following transfer to the icu for hypoxic respiratory failure and intubation on nrb on admission to the icu the pt steroid dose was increased to mg to a dead space measurement of pt did well in the icu w his respiratory status steadily improving and was extubated on he was subsequently tranferred to the floor where he continued to have a stable oxygen requirement repeat cxr was unchanged from previously in the icu official read noted mild chf but pt was continuing to autodiurese and has remained net negative everyday while on the floor on discharge the patient has stable o req on ra astrocytoma grade ii as per d w pmd dr pt has poor prognosis but reasonable for ongoing treatment pt has had two recent neg head cts so unlikely the etiology of the patient s ms change pt was continued on keppra during admission for sz px initially he had been on lamotrigine but the was stopped in when the pt was noted to be developing a new rash decadron has been steadily tapered since arrival on the floor now continued on mg to complete a day course which will be tapered to mg qday on and subsequently to mg qday x days then to be discontinued the patient s keppra should be continued for sz prophylaxis ms change on admission pt was agitated requiring restraints and antipsychotics however as he became increasingly hypoxic he became somnolent in the icu the pt remained stuporous responsive to painful stimuli on the floor the patient intially was imporved but has plateaued responding to simple commands and verbalizing groans but no real speech improvement has correlated w tapering of steroids one of the causes in the differential pt had multiple head cts which ruled out progression of astrocytoma mri has been deferred given that the pt currently would not tolerate the procedure eeg was w o evidence of epileptiform activity and c w toxic encephalopathy plan to continue to follow ms expect improvement as steroids are continued to be tapered h o dvt cont heparin previously on enoxaparin x days at treatment dose followed by prophylactic dose on admission the pt was started on treatment doses of enoxaparin upon transfer to the intensive care unit the pt was started on heparin gtt course was c b one episode of gross hematochezia on w concomitant hct drop of pts b l lower ext duplex us and a cta were performed both of which were negative given that the pt was w o evidence of dvt it was felt that the risks of anticoagulation in the setting of gross gib outweigh the risks of undetected deep vv thrombosis pe pt was continued on prophylactic heparin hypersensitivity reaction on pt was noted to have developing rash of abdomen and anterior thighs derm initially reviewed and thought that it was not c w hypersensitivity rxn over the next the rash progressed and the patient subsequently began spiking fevers to approx f c b hypotension requiring aggressive fluid repletion and pressors and tachycardia to the s the patient also developed elevated transaminases and pancreatic enzymes during this time on the second day that the rash had been noted derm was asked to see again felt c w hypersensitivity bactrim was switched to pentamidine and lamictal was held pt continued to have elev pancreatic enzymes and pentamidine was switched to clinda primaquine following discontinuation of the bactrim the patient defervesced and remained normotensive he received one dose of furosemide in the icu and was transferred to the floor the next day on arrival to the floor the patient was noted to have reticular rash of upper arms which resolved over the next h felt likely the sulfa moiety of the furosemide plan for pt to complete total of day course of therapy for pcp will be completed on anemia previous w u c w acd elev ferritin low transferrin saturation transfuse threshold arf cr mildly elevated on tx to icu u lytes c w prerenal azotemia which resolved w ivf hyponatremia also hyponatremic on transfer resolved w ivf cad w abnl ef however pt tolerated aggressive fluid resusciation w o significant hypoxia continued on valsartan bb continued statin pt was maintained on tfs via post pyloric px heparin full dose iv ppi comm family very involved at bedside evaluating rehab today dnr but may intubate for reversible causes restraint medications on admission meds on transfer acyclovir bactrim zoloft valsartan metoprolol keppra lovenox levofloxacin ambisone atrovent nebs albuterol nebs lasix mg qd lipitor haldol prn discharge medications miconazole nitrate powder sig one appl topical qid times a day sertraline hcl mg tablet sig one tablet po daily daily albuterol sulfate solution sig one inhalation q h every hours ipratropium bromide solution sig one inhalation q h every hours senna mg tablet sig one tablet po bid times a day as needed bisacodyl mg suppository sig one suppository rectal times a day as needed for constipation levetiracetam mg tablet sig three tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day heparin sodium porcine unit ml solution sig one injection tid times a day acetaminophen mg tablet sig tablets po q h every to hours as needed primaquine phosphate mg tablet sig two tablet po daily daily for days metoprolol tartrate mg tablet sig one tablet po bid times a day dexamethasone mg tablet sig two tablet po q h every hours take tablet po bid for four days then tablet po qday for days then take one tablet qday for days then stop taking the medication acyclovir sodium mg recon soln sig mg recon solns intravenous q h every hours pantoprazole sodium mg recon soln sig one recon soln intravenous q h every hours clindamycin phosphate in d w mg ml piggyback sig mg intravenous q h every hours for days discharge disposition extended care facility rehab center discharge diagnosis pcp astrocytoma hypersensitivity to bactrim hematochezia h o dvt discharge condition good still w altered mental status but improving discharge instructions take your medications attend follow up appointments followup instructions provider field screening where center phone date time provider m d where center phone date time completed by [NEW_RECORD] admission date discharge date date of birth sex m service neurology allergies bactrim furosemide cefepime attending chief complaint altered mental status major surgical or invasive procedure egd with injection of epinephrine into duodenum for hemostasis history of present illness hpi year old gentleman recently diagnosed by biopsy with gliomatosis cerebri grade ii astrocytoma in s p xrt temodar patient was recently admitted at for pcp pneumonia which he developed in the setting of increasing symptoms course c b hypoxic respiratory failure requiring intubation transfer to icu during icu course developed hypotension requiring pressors occurring in the setting hypersensivity reaction to bactrim and one episode of hematochezia during anticoagulation for previous pe following transfer to floor ms albeit slowly improved patient was discharged to w plans to complete a day course of primaquine and clindamycin allergy to bactrim concern for pancreatitis with pentamidine patient was then admitted to on for altered mental status per d c summary pt had done well and his ms had improved since his d c from such that he was conversant w family on the pt was found unresponsive febrile sent to intubated for resp failure abg on while intubated lac cxr revealed patchy air space opacities c w multifocal pna pt underwent bronchoscopy with witnessed aspiration during the procedure and was started on cefepime vancomycin metronidazole pcp smears were neg but sputum cx grew out mrsa extubated h post admission he was also started on fragmin to h o dvt he was transferred from to for continuity of his care followed by dr per d w family nights prior to this admission pt was sitting up conversant he then had a slow decompensation over the next day and was brought back into for eval and treatment past medical history coronary artery disease s p mi years ago hypertension hyperlipidemia djd in the c spine depression h o dvt shingles recently finished treatment gliomatosis cerebri grade ii astrocytoma of the left temporal lobe with extension into the optic chiasm and left optic nerve diagnosed in after presentation with retrobulbar ischemic optic neuritis s p open brain biopsy s p xrt and low dose temodar repeat mri stable s p high dose temodar social history landfill worker retired pky h o smoking quit yrs agodenies etoh drugs family history non contributory physical exam pe t bp p r ra gen arousable to pain opens eyes follows simple commands heent r pupil reactive l fixed at mm white confluent lesion of roof of mouth small linear mucosal tear of upper l side lungs b l rhonchi anteriorly cv regular s s no m r g abd distended soft bs not obviously tender ext no le edema just removed stockings skin no rashes lines ngt peg j tube pertinent results past cultures sputum gram stain gram cocci oropharyngeal flora cmv vl negative hsv vzv direct antigen negative toxo igg positive igm negative crytococcal antigen negative bal pcp respiratory viruses adeno parainfluenza influenza rsv legionella afb all negative cultures from this admission urine ngtd blood ngtd blood ngtd csf spinal fluid ngtd gram stain final no polymorphonuclear leukocytes seen no microorganisms seen csf spinal fluid cryptococcal antigen not detected urine ngtd sputum pmns and epithelial cells x field per x field gram positive cocci in pairs and clusters per x field gram positive cocci in pairs and chains grew out mrsa urine ngtd blood ngtd blood ngtd urine ngtd laboratory data pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood fdp am blood fibrino am blood ret aut am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood ld ldh totbili dirbili indbili pm blood alt ast alkphos amylase totbili am blood lipase pm blood lipase am blood ck mb ctropnt am blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb mb indx ctropnt am blood calcium phos mg pm blood albumin calcium phos mg am blood osmolal am blood cortsol am blood cortsol am blood phenyto phenyfr pnd pm cerebrospinal fluid csf wbc rbc polys lymphs monos pm cerebrospinal fluid csf totprot glucose brief hospital course yo m with h o astrocytoma dvt recent admission for pcp pna requiring intubation transferred from w dx of aspiration pna after he was found unresponsive febrile pt was intubated at for his asp pna extubated h later transferred to for further care his course at was complicated by ugib from peg j tube erosion into duodenum intubation for egd and fast extubation probable nonconvulsive seizures ms change initially the patient s poor mentation was felt to be resolving infection asp pna in the setting of a low threshold for confusion because of his underlying astrocytoma he was continued on antibiotics see below imaging showed that his astrocytoma had not advanced and was not in and of itself the cause for his decreased mental capacity the possibility was also raised that there was a contribution to his confused state from the steroids that the patient received on his arrival to unclear reason why possibly initial concern that ms change was tumor progression no explanation in d c summary the patient had been on high dose steroids prior to his previous admission but these had been tapered over approx three wks and his mental status had improved several stim tests during this admission showed the patient s adrenal function to be intact he was continued on low dose dexamethasone mg qday while in house patient was evaluated for nonconvulsive seizure disorder by eeg with prior study showing subcortical dysfunction but not clear evid of sz activity first study on this admission showing cortical and subcortical dysfunction no clear evid of sz a second eeg from this admit on showed paroxysmal semi rhythmic epileptiform activity over both frontal regions the patient was started on dilantin and keppra at this time a final eeg during this admit on showed an area of cortical hypersynchrony likely to be a focus of sz activity though no such sz activity was observed during the study the patient s ms seemed to improve slightly as his dilantin and keppra doses were increased though eventually he plateaued in a state of minimal responsiveness aspiration pneumonia pneumonitis the patient had at least two likely aspiration events one prior to his admission to when he was found at with tube feeds all over his clothing and a second witnessed event during bronchoscopy at pt had completed d course of clinda primaquine and pcp smear was negative at mrsa from sputum was felt to be likely colonization given recent hospitalizations and rehab stay patient s respiratory failure was felt to be most likely to pneumonitis or bacterial pneumonia after admission he was continued on cefipime started at and flagyl was added given witnessed aspiration at to cover asp flora vancomycin was started to cover mrsa from sputum id was consulted rec lp atovaquone ppx for pcp developed a that was presumed from cefepime so this was stopped initial series of cxrs showed stable diffuse patchy opacification of the right lung patient s antibiotics were changed multiple times during his admission on transfer from the patient was on cefepime and levaquin immediately the levaquin was d c d and flagyl was added then on pt was noted to have reticular of trunk and thighs thought to be a drug cefepime was dc d and pt was started back on levofloxacin again instead patient was on the following abx while in house vanc x d levaquin x d clinda x d flagyl x d patient was off all antibiotics for three days then noted to have lll asp pna vs pneumonitis on and so levaquin and flagyl were started again on dvt neg cta and leni s here during previous admission fragmin started at was dc d on admission and pt maintained on prophylactic dose heparin then patient s lle was noted to be swollen on so lenis were done that showed b l dvts in superficial and common femoral veins patient was started on heparin gtt anticoagulation he was then transitioned to lovenox but both were stopped in the setting of a hct drop shortly thereafter with bleeding from his peg j site as patient was a poor candidate for anticoagulation ir placed an ivc filter patient was later noted to have a lue dvt but was not anticoagulated for this given his continued slow hct drop and likely continued ugib bleed if his hct stabilizes in the future and he can be re egd anticoagulation might be indicated however this is unlikely to happen in the near term given his continued gi bleeding and hct drop astrocytoma repeat ct scan showed a large mass in r temporal lobe extending into r frontal lobe no significant change since prior study with regard to the mass effect on r lateral ventricle no evid of brainstem compression patient s astrocytoma was not felt to have changed on this admission and as a result his symptoms were not felt to be directly related to this lesion it was felt that his tumor may have lowered his threshold for becoming confused somnolent but that either infection or seizures were the cause of his altered mental status patient was continued on low dose dexamethasone as well as dilantin and keppra gi bleed the patient had a peg placed on in the setting of anticoagulation he then began to have melena external bleeding from his peg j site and received transfusions of u prbc without adequate hct increase he was transferred to the for intubation for the purposes of preforming an egd egd showed bleeding around the peg j and a string associated with a clot and fresh blood in the duodenum the peg j tube was removed by ir over a wire and a peg tube was placed following the procedure the patient had an ivc filter placed as he has had a dvt and given his bleeding anticoagulation was not an option he continued to have a dropping hct after the procedure and was transfused several more units of prbcs over the remainder of his admission he was noted to still have gastrografin positive residuals on in the setting spoke with gi at that point who said that they would not re egd and re intubate the patient unless his bleeding became brisk again they rec to continue ppi supported with transfusions as necessary patient required a total of units before egd units while in for egd then units after back on the floor for a slow hct drop with guaiac positivity medications on admission meds on admission senna docusate acetaminophen sertraline mg qday albuterol neb q h prn levetiracetam dexamethasone mg iv q h esomeprazole mg qday atovaquone qday dalteparin u sc bid metoprolol mg tid ipratroprium neb qid vancomycin g q h plan to complete d course cefepime g q h plan to complete d course discharge medications ipratropium bromide solution sig one nebulizer treatment inhalation q h every hours nystatin unit ml suspension sig five ml po qid times a day atovaquone mg ml suspension sig five ml po bid times a day ml acetaminophen mg tablet sig tablets po q h every to hours as needed metoprolol tartrate mg tablet sig one tablet po bid times a day dexamethasone mg tablet sig two tablet po daily daily docusate sodium mg ml liquid sig ten ml po bid times a day senna mg tablet sig one tablet po bid times a day lactulose g ml syrup sig thirty ml po bid times a day levetiracetam mg tablet sig three tablet po bid times a day phenytoin mg ml suspension sig eight ml po qam qpm ml phenytoin mg ml suspension sig twelve ml po qnoon albuterol sulfate solution sig one treatment treatment inhalation q h every hours heparin flush picc units ml ml iv daily prn ml ns followed by ml of units ml heparin units heparin each lumen daily and prn inspect site every shift sodium chloride flush ml iv daily prn peripheral iv inspect site every shift sodium chloride flush ml iv daily prn picc please flush picc line with ns inspect site every shift heparin flush picc units ml ml iv daily prn ml ns followed by ml of units ml heparin units heparin each lumen daily and prn inspect site every shift pantoprazole sodium mg recon soln sig one recon soln intravenous q h every hours discharge disposition home with service facility healthcare discharge diagnosis altered mental status aspiration pneumonia nonconvulsive seizures upper gi bleed from peg j tube erosion hypernatremia constipation discharge condition stable though with continued decreased level of responsiveness discharge instructions please continue to take all medications as prescribed and to follow up with dr and the rest of your healthcare team if you develop worsening shortness of breath high residuals of your tube feeds bleeding from anywhere black stool or any other concerning findings please call dr office immediately for instructions on how to be re evaluated followup instructions please touch base with dr in the week after your discharge to schedule follow up appointments,"{
""admission_date"": ""2019-12-10"",
""discharge_date"": ""2019-12-12"",
""date_of_birth"": ""2019-12-10"",
""sex"": ""Male"",
""service"": ""Neurology"",
""allergies"": [
""Bactrim""
],
""chief_complaint"": ""Altered mental status"",
""history_of_present_illness"": ""pt is a 78 yo male with hx of gliomatosis cerebri grade ii astrocytoma in being treated with xrt timidar he is currently on a decadron taper after it was increased several months ago secondary to increasing ocular symptoms seen by pmd on w symptoms of cough productive of yellow sputum"
31954,unit no admission date discharge date date of birth sex m service nb identification baby is a day old former week twin who is being discharged from the nicu history this infant was born at weeks gestation to a year old g p mother with prenatal screens as follows blood type a negative antibody negative hbsag negative rpr nonreactive gbs unknown past maternal medical history was remarkable for gerd treated with zantac and reglan and obesity treated with abdominoplasty mom is a cigarette smoker past ob history was remarkable for delivery of a term and a week infant one was in and the other was in this pregnancy was notable for spontaneous diamniotic dichorionic twining and cervical shortening which was followed with serial scans the mother was admitted on with cervical dilatation betamethasone was given at that time the decision was made to deliver on the day of delivery due to continued cervical dilatation cesarean section was done under spinal anesthesia the infant emerged with good tone positive pressure ventilation was administered after bulb suctioning and the infant was intubated with a endotracheal tube the infant continued to receive ppv on transfer to the nicu without incident significant social issues the family has recently moved from and had not established pediatric care at the time of delivery but have subsequently established pediatric care the family is originally from her previous infant that was born at weeks is now years old and reportedly has behavioral issues on admission the infant s measures were a birthweight of grams which is th tile length of cm which is th tile head circumference of cm which is th tile physical exam at discharge physical examination at discharge shows an active and alert male infant heent anterior fontanel open and flat normal facies bilateral red reflex intact intact palate normal ears supple neck intact clavicles respiratory breath sounds clear and equal with no retractions comfortable respirations cardiac pink well perfused with normal pulses no murmur normal s s abdomen soft non distended with no masses patent anus active bowel sounds gu normal male with descended testes musculoskeletal hips stable spine straight no dimple moves all extremities well good tone neuro active and alert normal reflexes summary of hospital course by systems respiratory the infant developed respiratory distress on admission to the nicu he was given survanta x and weaned to cpap on day of life at that time caffeine citrate was started prior to extubation due to concerns for apnea of prematurity he was weaned from cpap to room air on day of life and has remained on room air since that time rare spells were noted and the caffeine citrate was discontinued on the infant has been spell free since that time and only has had some issues with desaturation during feeds which were associated with feed discoordination these also gradually improved and by the time of discharge infant had not had any significant desaturation episodes noted for over days of note the infant was noted at times to have mild inspiratory stridor this was not associated with respiratory distress or desaturation the stridor was thought to be most consistent with mild laryngomalacia and can be followed clinically cardiovascular the infant has maintained hemodynamic stability throughout while in the nicu with no audible murmurs pink well perfused normal blood pressures and heart rate no cardiovascular issues were identified fluid electrolytes and nutrition the uvc was placed on admission to the nicu to administer iv fluids the infant was npo at that time and iv fluids were initiated the infant was started on enteral feeding on day of life and achieved full feedings by calories were subsequently concentrated to calorie ounce breast milk or pe the infant began oral feedings at weeks adjusted age and at the time of discharge the infant has been p o feeding now for over days without difficulty weight at discharge is grams and infant is feeding bm supplemented to cals per oz urine and stool output have been normal throughout gi the infant developed hyperbilirubinemia with a peak bilirubin level of and received days of phototherapy the hyperbilirubinemia is a resolved issue at this time hematology the infant s hematocrit at birth was with a platelet count of the infant s blood type is positive dat negative the infant has required no blood product transfusions while in the nicu the most recent hematocrit was on with a reticulocyte count of infant has been maintained on iron supplementation infectious disease a cbc and blood culture were screened on admission to the nicu due to the preterm labor and respiratory distress the cbc was benign at that time the infant received hours of ampicillin and gentamicin which was subsequently discontinued when the blood culture remained negative at hours there have been no further issues with sepsis while in the nicu neurology the infant has had head ultrasounds done the first one was followed by one on both were normal the infant has maintained a normal neurological exam for gestational age while in the nicu development a left arm hemangioma was noted during admission that has increased gradually in size this can be followed clinically audiology a hearing screen was performed with automated auditory brainstem responses and the infant passed both ears ophthalmology the initial ophthalmologic exam was done on revealing immature retinas in both eyes but no retinopathy of prematurity follow up appointment is recommended within weeks with md pediatric ophthalmologist the mother has a business card with the physician s telephone numbers on them follow up eye exam is recommended for the week of or the week after psychosocial a social worker has been in contact with the family if there are any concerns the social worker can be reached at condition at discharge good discharge disposition home with the parents twin remains in the nicu at this time primary pediatrician is md telephone number care recommendations ad lib p o feeds of calorie breast milk or enfamil calorie ounce as needed as well as breast feeding medications ferrous sulfate ml once a day and goldline baby vitamins ml p o once a day iron and vitamin d supplementation iron supplementation is recommended for preterm and low birthweight infants until months corrected age all infants fed predominantly breast milk should receive vitamin d supplementation at iu may be provided as multivitamin preparation daily until months corrected age car seat position screening was done and the infant passed state newborn screens have been sent and all are within normal limits immunizations received the infant received the hepatitis b vaccine on synagis was given on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria born at less than weeks born between and weeks with of the following day care during rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings chronic lung disease or hemodynamically significant congenital heart defects influenza immunizations recommended annually in the fall for all infants once they reach months of age before this age and for the first months of a child s life immunization against influenza is recommended for household contacts and out of home caregivers this infant has not received the rotavirus vaccine the american academy of pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least weeks but fewer than weeks of age follow up appointment with the pediatrician will be on a vna referral has been done with care group vna telephone number is also early intervention follow up will be with early intervention in telephone number is also follow up appointment with dr for an ophthalmologic exam for the week of or the week of discharge diagnoses prematurity born at weeks gestation twin respiratory distress syndrome resolved apnea or prematurity resolved sepsis ruled out left arm strawberry hemangioma present hyperbilirubinemia resolved anemia of prematurity ongoing feed discoordination resolved md dictated by medquist d t job cc,"[
{
""date"": ""2019-10-10"",
""type"": ""NPN"",
""id"": 217512,
""status"": ""in"",
""admit"": ""217512"",
""discharge"": ""217512"",
""service"": ""NICU"",
""doctor"": ""JOHN SMITH 217512"",
""hospital2"": ""MICU"",
""hospital1"": ""MICU"",
""allergies"": ""None"",
""attending:[**First Name (Titles) 1015**] [**Last Name (Titles) 1015**] [**Last Name (Titles) 1015**] [**Last Name (Titles) 1015**"
6391,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint toxic ingestion in suicide attempt major surgical or invasive procedure intubated and extubated history of present illness yo male with h o depression and adhd who presented to ed with ingestion of nyquil and ibuprofen in suicide attempt patient notes history of depression secondary to recent death of sister and not taking his paxil for past months pt was on mass health but did not complete forms and lost coverage months ago so had no way to pay for paxil per pt s mother on night of admission pt called her to tell her he took some pills he drove to her house and she found him to be lethargic in ed given narcan with no result pt intubated for airway protection with dose of vercuronium for agitation pt given grams of n acetylcysteine and activated charcoal x ekg showed st at normal axis normal intervals twi in iii avf pt had mild transaminitis toxicology was consulted and recommended supportive care including follow lft s and re checking ekg tox screen was only pos for amphetamines past medical history depression no previous psychiatric admission pcp prescribes paxil adhd social history lives with roommate in plays piano gives lessons sister died months ago from crack overdose no etoh or drug use family history bipolar disorder physical exam pe hr bp rr os sat on vent ac x peep fio genl intubated sedated heent pupils sluggish mm no lad profuse salivation cv rrr no mrg resp cat abd soft nt nd bs ext no edema pedal pusles neuro sedated no babinski localizes to painful stimuli moves all limbs pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood plt ct am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili pm blood alt ast alkphos amylase totbili pm blood lipase am blood albumin calcium phos mg pm blood osmolal am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood freeca brief hospital course patient was admitted to the on he was kept intubated and sedeated overnight he was extubated without complications on his lft trended down when he was extubated we confirmed with patient that he took liquid nyquil and ibuprofen we restarted his paxil at mg per day psychiatry saw the patient and felt appropriate for in patient psychiatry evaluation pt does not want admission but criteria for involuntary admission social work was consulted for coping and for help with mass health and free care he was refused by mass health so application accepted for free care at so he can get his paxil paid for on day of discharge pt complained of sore throat and myalgias his temp was normal and wbc count slightly elevated his wbc is likely related to stress response and sore throat is likely related to intubation he was felt to be medically cleared for psychiatric hospitalization medications on admission paxil mg qd not taken for past mos adderal discharge medications paroxetine hcl mg tablet sig two tablet po daily daily cepacol mg lozenge sig lozenges mucous membrane prn as needed acetaminophen mg tablet sig tablets po q h every to hours as needed discharge disposition extended care discharge diagnosis depression s p toxic ingestion for suicide attempt discharge condition stable discharge instructions follow up with dr will be transferred to for inpatient psychiatric eval followup instructions follow up with your dr take medications as prescribed md,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2012-03-01"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Patient recorded as having no known allergies to drugs""
],
""admissionDate"": ""2012-03-03"",
""dischargeDate"": ""2012-03-05"",
""dateOfDeath"": ""2012-03-05"",
""chiefComplaint"": ""Toxic ingestion in suicide attempt"",
""historyOfPresentIllness"": ""YO male with h/o depression and ADHD who presented to ED with ingestion of Nyquil and Ibuprofen in suicide attempt.  Patient notes history of depression secondary to recent"
32439,admission date discharge date date of birth sex f service cardiothoracic allergies sulfa sulfonamides penicillins percocet codeine aspirin attending chief complaint murmur noted on physical exam echo revealed ai major surgical or invasive procedure avr mm tissue replacecment of ascending aorta total arch replacement w reimplantation of great vessels history of present illness pre op eval for breast lesion revealed heart murmur echo found ai and thoracoabdominal aneurysm past medical history ibs back pain former smoker breast ca social history smokes ppd no etoh retired lives alone family history twin sister s p valve replacement physical exam unremarkable pre op pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood calcium phos mg echocardiography report portable tte focused views done at am final referring physician information status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m m indication tamponade pericardial effusion icd codes test information date time at interpret md md test type portable tte focused views son rdcs doppler limited doppler and no color doppler test location west sicu ctic vicu contrast none tech quality adequate tape w machine vivid echocardiographic measurements results measurements normal range left atrium four chamber length cm cm right atrium four chamber length cm cm left ventricle ejection fraction findings left atrium mild la enlargement right atrium interatrial septum mildly dilated ra a catheter or pacing wire is seen in the ra and extending into the rv left ventricle mild symmetric lvh with normal cavity size and systolic function lvef suboptimal technical quality a focal lv wall motion abnormality cannot be fully excluded right ventricle normal rv chamber size moderate global rv free wall hypokinesis aortic valve bioprosthetic aortic valve prosthesis avr general comments echocardiographic results were reviewed by conclusions the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded right ventricular chamber size is normal with moderately depressed free wall contractility a well seated bioprosthetic aortic valve prosthesis is present there is a cm echogenic filled space anterior to the right ventricle and left ventricle which appears similar to the pre operative images of and likely represents epicardial fat electronically signed by md interpreting physician brief hospital course admitted the day of surgery taken to the or for avr tissue and raplacement of ascending aorta total arch please see operative note for details of procedure post op she was taken to the icu on neosynephrine drip for bp support initially she required some blood products iv fluids for labile bp she was placed on inotropes for cardiac index she was duiresed over the next few days and ultimately extubated on pod her pressors inotropes were also weaned off during those days on pod a speech swallow evalutaion was obtained due to some apparent difficulty swallowing she was diagnosed w mild to moderate dysphagia and a diet of ground solids and thin liquids was ordered she was transferred from the icu to the telemetry floor later on pod her beta blockers were started and increased continues with diuresis and has remained hemodynamically stable she remains slow to progress from a physical therapy standpoint she is now ready to be transferred to a rehab facility to continue with physical therapy speech swallowing therapy medications on admission glycolax tylenol prn lopressor lipitor asa sc heparin discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily acetaminophen mg tablet sig two tablet po q h every hours as needed atorvastatin mg tablet sig one tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours fluticasone mcg actuation aerosol sig two puff inhalation times a day ipratropium albuterol mcg actuation aerosol sig two puff inhalation q h every hours heparin porcine unit ml solution sig one injection tid times a day potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po bid times a day metoprolol tartrate mg tablet sig tablets po bid times a day furosemide mg tablet sig one tablet po bid times a day discharge disposition extended care facility nursing home discharge diagnosis thoraco abdominal aortic aneurysm aortic valve insuficiency breast cancer ibs chronic bronchitis discharge condition good discharge instructions diet ground solids and thin liquids shower pat incisions dry no lotions or powders to any incisions vital sign monitoring tight bp control sbp should remain s no lifting in weeks no driving for month followup instructions with dr in weeks with dr in weeks completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-13"",
""date_of_birth"" : ""1957-10-10"",
""sex"" : ""F"",
""service"" : ""Cardiothoracic"",
""allergies"" : [
""sulfa"" : ""Yes"",
""sulfonamides"" : ""Yes"",
""penicillins"" : ""Yes"",
""percocet"" : ""Yes"",
""aspirin"" : ""Yes"",
""attending_chief_complaint"" : ""Murmur noted on physical exam, echo revealed AI, major surgical or invasive procedure, AVR, MT tissue replacecment of ascending aorta total"
22834,admission date discharge date date of birth sex m service med date of death chief complaint bilateral pneumonia history of present illness the patient is a year old male with aml paroxysmal atrial fibrillation hypertension he was recently discharged on after a week admission for bacteremia secondary to infected hickman line with coag negative staph bronchoscopy on showed a bal negative for pcp culture and aspergillus also during his admission he had negative histo negative crypto and negative cmv since his discharge the patient was seen in clinic on and received units of packed red blood cells and platelets seen again on and reportedly continued to have night sweats and fevers which was attributed to his underlying cancer his saturations were percent on room air and he was given liters of oxygen the patient presented to the emergency department today for cough fatigue shortness of breath x days with chest pain x today while in the ed he was found to have a chest x ray consistent with increased bilateral infiltrates and oxygen requirements percent on liters the patient was given unit of packed red blood cells and decompensated from a respiratory standpoint he was intubated and sent to the he was also given cefepime g iv x clindamycin lasix mg prior to transfer the patient was unable to provide history and sister reports days of increased shortness of breath dyspnea on exertion fatigue cough with sputum chronic fevers emesis x day ago he was contact by his oncologist at home today encouraged the patient to go to the emergency department for evaluation of his chest pain past medical history mds converted to aml m versus erythroid in induction plus in hidac complicated by neurotoxicity in paroxysmal atrial fibrillation not on anticoagulation obesity hypertension history of dvt in the left lower extremity in after a fracture tte in with ef percent left atrial and right atrial enlargement plus mr plus ar allergies no known drug allergies medications atenolol mg p o q d folate mg p o q d levaquin mg p o q d indefinitely voriconazole mg p o b i d indefinitely compazine mg t i d p r n social history married retired businessman smokes pack year history quit in significant alcohol use no iv drug abuse he is a latvian immigrant family history father who died of colon cancer at age mother with atrial fibrillation sibling with non hodgkin lymphoma physical examination temperature degrees blood pressure pulse saturations percent on the ventilator settings of ac tidal volume with a respiratory rate of fio of percent peep of in general the patient was then intubated breathing comfortably on the ventilator heent pupils constricted anicteric moist mucous membranes og tube in place neck unable to appreciate jvd chest diffuse rales and upper airway sounds bilaterally with occasional expiratory wheeze cardiovascular regular rate and rhythm with normal s and s laterally displaced pmi abdomen distended nontender with good bowel sounds enlarged liver cm below the costal margin extremities to plus pitting edema bilaterally lower extremities to the knees neurological unresponsive sedated no spontaneous movements laboratory data white blood cell count with a differential of percent neutrophils percent bands percent lymphocytes percent monocytes percent blasts hematocrit platelets inr chem was remarkable for a potassium of bicarbonate of and a creatinine of baseline phosphorus of anc on was fibrinogen and d dimer were pending troponin was less than x albumin of alt ast ldh alkaline phosphatase total bilirubin amylase blood cultures pending blood cultures from showed no growth to date lactate was and then abg was on liters chest x ray at o clock showed cardiomegaly interval development of bibasilar and perihilar infiltrates chest x ray later on showed diffuse bilateral pulmonary infiltrates consistent with ards cardiomegaly ett to cm above the costal margin ekg showed atrial fibrillation left axis deviation wide qrs with no t changes impression this is a year old male with acute myelogenous leukemia paroxysmal atrial fibrillation and hypertension recently admitted for fever and neutropenia found to have coagulase negative staph bacteremia and hickman line was pulled he continued to have temperature spikes without a clear source he now returns with day increasing shortness of breath fevers and chest pain today his chest x ray is consistent with acute respiratory distress syndrome and he is now intubated hospital course fevers the patient had a bilateral diffuse pneumonia in an immunocompromised host the differential includes cap atypical pneumonia cmv hsv influenza parainfluenza histo crypto pcp aspergillus his anc is less than he was covered empirically with vancomycin flagyl cefepime and voriconazole blood and sputum cultures were checked the patient had a very high peep requirement throughout his hospitalization and we were unable to bronchoscope the patient he continued to have high fevers respiratory failure chest x ray was consistent with appearance of ards with high oxygen requirement on the ventilator subacute progression of symptoms started on home oxygen days ago this favors a fungal process the patient had worsening po on the night of admission despite maximum ventilatory support suggesting worsening ards peep and total volumes now were limited by plateau pressures in the s to s the patient was continued on ards ventilator strategy with low tidal volumes increased peep he was given bicarbonate ampule bolus and started on a bicarbonate drip however this also worsened his pulmonary edema he was continued on his paralytics unfortunately the patient was not able to maintain oxygenation even on maximum ventilatory support his last gas was and and he was continuing to drop hemodynamically the patient was unable to maintain his blood pressure he was started on pressors and was on levophed niacin and vasopressin with svp still in the s he was continued to be bolused with normal saline with bicarbonate but his lactate continued to rise and his urine output continued to decrease eventually the patient expired on from respiratory failure the patient also showed signs of coagulopathy with dic and dic with inr of platelets decreased to on admission hematocrit of also had acute renal failure and a severe metabolic acidosis with lactate continuing to rise the patient s wife was not available initially on admission but the next day his wife and sister were available his code status initially was changed to cpr not indicated and he had a very poor prognosis with very little hope for survival which was communicated to his sister and would be discussed with the wife when she came later in the afternoon later that afternoon on at p m the patient s family wife sister and several other members met with the administrator on the patient s bedside they changed the patient s code status to comfort measures only and elected to extubate the patient the patient was given a small bolus of fentanyl for comfort and then extubated to room air he died within minutes of extubation pronounced dead at p m on pupils were dilated and nonreactive no audible breath sounds or heart sounds were auscultated the patient s wife elected to have a postmortem examination performed and written permission was obtained dictated by medquist d t job,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""dateOfDeath"": ""2017-01-02"",
""sex"": ""Male"",
""service"": ""Medicine"",
""medication"": [
""Aspirin"",
""Atorvastatin"",
""Calcium Carbonate"",
""Celecoxib"",
""Clopidogrel"",
""Diltiazem"",
""Effexor"",
""Epogen"",
""Furosemide"",
""Glucophage"",
""Glucotrol"",
""Hydralazine"",
""Insulin"",
""Lantus"",
""Lopressor"",
""Lisinopril"",
""Lithium Carbonate"","
45186,admission date discharge date date of birth sex f service medicine allergies penicillins latex attending chief complaint altered mental status major surgical or invasive procedure central line placement and removal history of present illness ms is a year old woman with a history of prior cva s she has left sided hemiparesis at baseline and speaks only a few words she lives at a nursing facility her daughter visited her on her birthday she reports that the patient was less responsive and kept her mouth open during the whole visit it is unclear if she improved back to her baseline this am she was reportedly less responsive than normal per the staff at the nursing facility she was also diaphoretic an ambulance was called and she was brought to the ed her blood glucose en route was in the ed initial vital signs were on room air she spiked a temp to while in the ed labs were significant for sodium of creatinine of troponin of and lactate of after fluid urinalysis showed large leuk esterase she received l of normal saline her chest xray was clear there was no evidence of new stroke on ct her bp s continued to drop in the ed a central line was placed and she was started on levophed on arrival to the micu patient did not respond to questions or movement past medical history s p thromboembolic cva w l hemiplegia nonverbal atrial fibrillation on coumadin hyperlipidemia hypertension seizures social history patient lived at a nursing facility she was a phlebotomist at family history unable to obtain physical exam admission exam vitals t bp p rr o on ra general awke nonverbal no acute distress heent sclera anicteric mmm oropharynx clear eomi grossly intact but unable to follow commands to track finder perrl neck jvp not elevated cv tachycardic and irregular no murmurs rubs gallops lungs clear to auscultation bilaterally on the anterior no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly gu foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact grossly able to move rue did not see patient move lue lle or rle discharge exam physical exam is os incontinent of urine in was about cc vitals t bp hr rr o sat ra general asleep sometimes opens eyes to voice nonverbal unable to follow commands no acute distress comfortable appearing cv rrr irregular no murmurs rubs gallops lungs clear to auscultation bilaterally on anterior exam no wheezes rales rhonchi abdomen soft non distended bowel sounds present feeding tube in place in epigastric region with clean dry bandage gu no foley diaper healing stage ulcer with clean dry bandage ext rle and lle warm well perfused dp pulses bilaterally popliteal pulses bilaterally slow capillary refill bilaterally neuro deferred pertinent results blood counts pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso coagulation panel pm blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt chemistries pm blood glucose urean creat na k cl hco angap am blood urean creat na k cl am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood calcium phos mg microbiology urine culture final proteus mirabilis organisms ml presumptive identification piperacillin tazobactam sensitivity testing available on request sensitivities mic expressed in mcg ml proteus mirabilis ampicillin s ampicillin sulbactam s cefazolin r cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s tobramycin s trimethoprim sulfa s imaging cxr no acute cardiopulmonary process head ct encephalomalacia no evidence of acute hemorrhage several chronic changes tte biatrial enlargement moderate symmetric left ventricular hypertrophy with normal cavity size and preserved global and regional biventricular systolic function increased left ventricular filling pressure no valvular vegetations or abscesses appreciated indeterminate pulmonary artery systolic pressure r lower extremity arterial duplex no evidence of fixed arterial obstruction mild atherosclerotic disease with biphasic waveforms r arterial doppler study mild right lower extremity peripheral vascular disease based on abis and doppler waveforms no significant left sided arterial vascular disease pvrs seem discordant and are likely artifactually low brief hospital course this is a yo f pmhx afib w prior thromboembolic cvas w resulting nonverbal state and l hemiparesis who presented with hypotension hypernatremia to found to have a urinary tract infection treated with antibiotics and fluids course complicated by seizure now with lab values returning to baseline active issues septicemia uti hypovolemia patient was admitted w hypotension fever positive ua requiring d of vasopressors and aggressive fluid resuscitation she was initially covered with cefepime which was narrowed to ciprofloxacin once ucx grew proteus additionally she had coag negative staph grow from blood cultures thought to be contaminant but for which she received d of vancomycin she completed a day course of cipro completed on hypernatremia the was admitted with na thought to be secondary to a free water deficit estimated at liters she was volume resuscitated and given free water to correct her sodium over days subsequently the patient received increased free water flushes for treatment of her hypernatremia and serum na remained stable in the low s metabolic encephalopathy on admission patient was unresponsive to voice or light touch with correction of her hypotension and uti her mental status improved to baseline level of alertness responsive to voice and touch making vocal sounds though not speaking words not following verbal commands seizures the patient s micu course was c p seizures thought to be secondary to her metabolic abnormalities eeg showed diffuse slowing worse in the left temporal region with frequent spikes which can be seen in the post ictal state a ct head showed evidence of her prior strokes but no acute process neurology was consulted and patient was treated with keppra for seizure prophylaxis the patient developed leukopenia to after starting keppra so the patient was transitioned to vimpat with which the wbc count has been stable at acute renal failure admission creatinine was baseline is per the nursing home this was likely pre renal and improved to her baseline with fluids cre at discharge was atrial fibrillation patient with a history of thromboembolic cva afib patient s coumadin was uptitrated during a subtherapeutic episode given her history of prior cva s she will need to be bridged with enoxaparin for future inr the patient was also started on metoprolol for rate control peripheral vascular disease patient was noted to have decreased pulses in r lower extremity on exam initially given history of afib and a subtherapeutic inr there was concern for arterial thromboembolism however pulses remained dopplerable and arterial ultrasound did not demonstrate any fixed obstruction mild peripheral vascular disease was noted as patient was already optimized from a cardiovascular perspective atorvastatin metoprolol ezetimibe coumadin no additional medications were initiated cad continued atorvastatin ezetimibe started metoprolol for improved rate control hypertension patient was previously on amlodipine and ramipril these medications were held in the micu amlodipine mg was restarted she was started lisinopril mg daily therapeutic interchange while in hospital given ramipril was non formulary leukopenia mild thought to be drugs such as kappra she had recurrence of very mild leukopenia and ranitidine was held on she will need to have repeat lab on to check cbc inactive issues gerd patient was continued on ranitidine until given mild leukopenia she is on a ranitidine free trial to see if the leukopenia is from medication transitional full code patient should be bridged with enoxaparin for inr given seizures during this visit patient was scheduled for follow up with neurology repeat cbc on to monitor for leukopenia repeat inr pt ptt on to monitor warfarin therapy medications on admission potassium daily meq metoclopramide mg q hours jevity cc hr cc flush q hours cc flushes tid lipitor mg ramipril mg amlodipine mg ranitidine mg ezetimibe mg warfarin mg daily discharge medications atorvastatin mg po daily ezetimibe mg po daily lacosamide mg po bid warfarin mg po days mo we fr m w f second order for saturday warfarin mg po days tu th tues thurs second order for sunday amlodipine mg po daily metoprolol tartrate mg po tid hold for hr sbp ramipril mg po bid outpatient lab work please draw cbc inr pt ptt on this is for leukopenia and atrial fibrillation on warfarin please fax the result to the rehab center discharge disposition extended care facility nursing and rehabilitation discharge diagnosis primary septicemia with urinary tract infection metabolic encephalopathy seizure secondary s p thromboembolic cva w l hemiplegia nonverbal atrial fibrillation on coumadin discharge condition mental status confused always level of consciousness lethargic but arousable activity status bedbound discharge instructions dear ms you were admitted to because you had a urinary tract infection and dehydration your sodium level was also very high causing you to have a seizure you were treated with course of antibiotics and you received fluids your sodium improved you were started on a medication called vimpat to prevent seizures you were also started on a medication called metoprolol because of your fast heart rate and you are now ready for discharge we discontinued your ranitidine because you have a very mild low white blood cell count and you will need to have repeat lab on this can be monitored in the rehab setting thank you for allowing us to participate in your care all best wishes in your recovery followup instructions department neurology when thursday at pm with drs building sc clinical ctr campus east best parking garage completed by,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""2016-10-10"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Penicillins"",
""Latex""
],
""attending:[**First Name3 (LF) 1051**] [**Last Name (NamePattern2) 1051**] [**Last Name (NamePattern1) 1051**] [**Last Name (NamePattern3) 1051**] [**Last Name (NamePattern4) 1051**] [**Last Name (NamePattern5) 1051**] [**Last Name (NamePattern6) 1051**] [**"
23779,admission date discharge date date of birth sex m service cardiothoracic surgery history of present illness this is a year old gentleman with a prior history of two myocardial infarctions non insulin dependent diabetes mellitus and hypercholesterolemia he had increasing shortness of breath prior to his presentation as well as chest pain on the morning of presentation he was admitted for cardiac catheterization prior to this admission which was performed on the patient was referred to dr for his cardiac disease past medical history non insulin dependent diabetes mellitus myocardial infarction times two hypercholesterolemia medications on admission medications included atenolol lipitor aspirin lisinopril gemfibrozil glucotrol xl metformin folate and vitamin e allergies pertinent laboratory values on presentation preoperative laboratories revealed glucose was blood urea nitrogen was creatinine was sodium was potassium was chloride was and bicarbonate was anion gap was alt was ast was ldh was alkaline phosphatase was and total bilirubin was white blood cell count was and hematocrit was and platelet count was prothrombin time was partial thromboplastin time was and inr was pertinent radiology imaging cardiac catheterization showed left anterior descending artery lesion first diagonal circumflex lesion obtuse marginal branch followed by lesion in the obtuse marginal right coronary artery had an medial stenosis and a stenosis prior to the posterior descending artery ejection fraction was approximately hospital course on the patient underwent coronary artery bypass grafting by dr times four with a left internal mammary artery to the left anterior descending artery a vein graft to the right posterior descending artery a vein graft to the diagonal and a vein graft to the obtuse marginal the patient was transferred to the cardiothoracic intensive care unit in stable condition the patient arrived in the intensive care unit on intravenous propofol intravenous milrinone and intravenous levophed drips he was extubated at that afternoon he was hemodynamically stable note from postoperative day one is missing from the chart on postoperative day two the patient was in a sinus rhythm with a heart rate of he was maintaining a good blood pressure of he was extubated and was saturating his hematocrit was he was stable he was receiving oral percocet for pain and was on no drips at that time his postoperative blood urea nitrogen and creatinine were and he was seen by physical therapy and transferred out to the floor on postoperative day two on postoperative day three he had a blood pressure of and temperature maximum was his heart rate was regular in rate and rhythm his lungs were clear bilaterally his dressing was clean dry and intact with only minimal drainage his wires were removed his chest tube were removed and his hematocrit was he was seen by case management he was up and around ambulating by postoperative day three on postoperative day four the resident was called for an episode of ventricular tachycardia approximately a beat run which was self limited the patient was hemodynamically stable he had no fall in his blood pressure and he immediately reverted back to a sinus rhythm with occasional premature ventricular contractions his examination was otherwise unremarkable his sternum was stable his incision was clean dry and intact his potassium and magnesium were repleted he was continued on telemetry the episode was discussed with the chief resident at this time his potassium was and his magnesium was the patient was continued on intravenous vancomycin he was seen by the electrophysiology cardiologist for his beat run of ventricular tachycardia they suggested that the monomorphic nature might be due more to cardiac scarring rather than acute ischemia but they recommended having an electrophysiology study done which was done the patient was continued on a beta blocker and ace inhibitor on he had a diagnostic electrophysiology study done and an automatic internal cardioverter defibrillator was placed on the patient remained stable on the patient felt well with no complaints he had a good systolic blood pressure his wounds were intact his implantable cardioverter defibrillator was checked by the electrophysiology service and was interrogated appropriately discharge disposition on the patient was discharged to home in stable condition discharge diagnoses coronary artery disease status post coronary artery bypass grafting times four status post implantable cardioverter defibrillator placement myocardial infarction non insulin dependent diabetes mellitus hypercholesterolemia medications on discharge discharge medications were as follows percocet one to two tablets p o q h as needed for pain levofloxacin mg p o once per day for a day course to be finished on lopressor mg p o twice per day metformin mg p o twice per day glipizide xl mg p o once per day zestril mg p o once per day ibuprofen mg p o q h as needed tylenol mg p o q h as needed aspirin mg p o every day lasix mg p o twice per day times seven days colace mg p o twice per day milk of magnesia as needed for constipation keflex mg p o three times per day times six total doses discharge instructions followup the patient was instructed to follow up on two one week later for a wound check and to see dr in the office in six weeks the patient was to follow up with his primary care physician dr in one to two weeks after discharge the patient was to see his cardiologist dr in approximately one to two weeks after discharge condition at discharge condition on discharge was stable discharge status the patient was discharged to home on m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies vancomycin percocet attending chief complaint brbpr major surgical or invasive procedure tandemheart mechanical ventilation central line arterial line history of present illness m with sick social contacts day history of n v d fever chills mylagias had one episode of brbpr this morning bright red and mixed with stool and since that time more lightheaded fatigued here for further evaluation reports chest pain non pleuritic otherwise denies shortness of breath in the ed initial vs were ra exam notable for clear chest guaiac positive brown stool cxr ua unremarkable sbp s in s ng lavage showed coffee grounds that cleared given mg of vitk for inr of given the concern for gi bleed linezolid zosyn serial ekgs taken with the third looking wellinoid trop came back at ed thought it was demand ischemia gi and cards were consulted and then the patient bradied down and lost pulse coded in the ed for minutes two returns of spont circ shocked times for vfib vtach received epi lido ca amio bicarb given norepi and dobutamine l of ns bedside us no effusion sent to cath lab in cath lab patient was in pea arrest additional minutes of acls ensued with high pressure chest compressions received several rounds of epi atropine u of prbc also norepi and vasopressin a balloon pump trialed and replaced with tandem heart in the ccu phone numbers called no answer his cellular phone is dead his pcp was emailed ultimately family contact and will come in family meeting had with partner patient was medically unstable on levophed and epi drip began in sinus brady received mg of atropine of epi amp of bicarb bicarb drip started dopa added briefly patient went into vf times and shocked and came out into sinus tach lidocaine bolus followed by drip very difficult to ventillate non compliant bag masked throughout this medical code and then switched to ecmo past medical history diabetes dyslipidemia cad early onset cad s p cabg angio in demonstrated vein stump occluded svg to d om rpda but with patent lima lad graft mibi in demonstrated multiple fixed defects and akinesis no reversible defects patient has history of silent mi prior to cabg reported as anterior apical myocardial infarct chf mibi in demonstrated a lvef of placed for episode of v tach on day of cabg h o chronic systolic hf ef pa hypertension cardiac cath in demonstrated moderate pulmonary hypertension mm hg and severely elevated left sided filling pressures heart failure diagnosis pvd s p recent l toe amputation for gangrene left fem bypass thrombectomy of femoral popliteal bypass graft left side and revision with bovine pericardial patch of the distal anastomosis dm type ii on metformin glipizide insulin last a c diagnosed at age hepatitis patient reports possible hep a and hep b infections in past reports that follow up testing showed no chronic infection renal insufficiency began recently dm related followed at angiography in showing only patent lima lad psh cabg l rd toe amp l sfa angioplasty l th toe amp l sfa angioplasty and stent l cfa ak with vein then ptfe r th toe partial amp thrombectomy of l bpg revision with bovine pericardial patch of the distal anastomosis angioplasty of common femoral artery and proximal anastomosis angioplasty of above knee popliteal artery and distal anastomosis stenting of above knee popliteal artery for residual stenosis angiojet thrombectomy and rheolytic thrombolysis of the left common femoral artery to above knee popliteal artery ptfe bypass graft with balloon angioplasty of the left popliteal artery stent incision and drainage of left leg abscess social history the patient is a make up artist in a department store tob neg etoh occasional etoh use drugs denies ivdu history when he was in his s family history cad with mi in father in his s and mother in her s dm in both parents htn in both parents sister also has diabetescad with mi in father in his s and mother in her s dm in both parents htn in both parents sister also has diabetes physical exam ed exam temp hr bp resp o sat normal constitutional the patient is awake alert and oriented at the time of my examination he is nontoxic in appearance heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact his neck is supple no jvd chest lungs are clear bilaterally cardiovascular normal s s abdominal his belly is soft nontender nondistended he does not have any guarding or rebound no peritoneal signs rectal brown stool that is heme positive gu flank no cva tenderness extr back no lower extremity edema and his legs are warm neuro speech fluent psych normal mood normal mentation heme no petechiae on discharge the patient was deceased pertinent results pm type art temp po pco ph total co base xs intubated intubated comments tandem hea pm lactate pm o sat pm freeca pm type art po pco ph total co base xs pm lactate k pm hgb calchct pm freeca pm type art po pco ph total co base xs pm glucose lactate na k cl tco pm hgb calchct o sat pm freeca pm type art po pco ph total co base xs pm lactate pm freeca pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot ck cpk alk phos tot bili pm ck mb mb indx ctropnt pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm calcium pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm to ptt unable to inr pt unable to pm po pco ph total co base xs pm lactate pm hgb calchct o sat pm type art po pco ph total co base xs intubated intubated pm lactate pm hgb calchct pm type art po pco ph total co base xs intubated intubated pm glucose lactate na k cl pm hgb calchct o sat carboxyhb met hgb pm freeca pm hgb calchct pm urine hours random pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg pm urine color yellow appear clear sp pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria none yeast none epi pm urine granular hyaline pm urine mucous rare pm lactate k pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm alt sgpt ast sgot ld ldh ck cpk alk phos tot bili pm lipase pm ctropnt pm ck mb pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt echo dilated left ventricle with severe global systolic dysfunction moderate right ventricular systolic dysfunction in a rather small rv cavity mild mitral regurgitation at least mild pulmonary hypertension compared with the prior study images reviewed of rv size is smaller the tandemheart catheter now terminates in the right atrium and a small residual asd is seen if clinically indicated would consider reducing the apparent arterial ecmo flow rate or volume loading the patient cxr findings in comparison with the study of and the monitoring and support devices are all in good position diffuse bilateral pulmonary opacifications with enlargement of the cardiac silhouette is consistent with pulmonary edema however superimposed aspiration especially in the right upper zone could certainly reflect aspiration retrocardiac opacification with silhouetting the hemidiaphragm is consistent with some combination of volume loss in the left lower lobe pleural effusion and possible superimposed pneumonia pm blood culture final report blood culture routine final beta streptococcus group c final sensitivities sensitivity testing performed by sensititre clindamycin mcg ml sensitivities mic expressed in mcg ml beta streptococcus group c clindamycin s erythromycin s penicillin g s vancomycin s aerobic bottle gram stain final reported to and read back by dr pager on gram positive cocci in pairs and chains anaerobic bottle gram stain final gram positive cocci in pairs and chains am swab source l thigh abscess final report wound culture final beta streptococcus group c sparse growth brief hospital course mr was a yo m with cad dmii ischemic cardiomyopathy s p cabg ef disease mild cri the pt presented to the ed complaining of day history of n v d fever chills mylagias had one episode of brbpr he also reported chest pain that was non pleuritic in the ed the pt s sbps declined from the s to the s and serial ekgs demonstrated sign with a trop of the pt became bradycardic and lost his pulse and was subsequently coded for minutes in the ed with two returns of spontaneous circulation receiving shocks for vfib vtach as well as epi lido ca amio bicarb then norepi dobutamine l ns he was sent to the cardiac catheterization lab where he was found to be in pea arrest additional minutes of acls ensued with high pressure chest compressions he received several rounds of epi atropine u of prbc also norepi and vasopressin during chest compressions a balloon pump was trialed and replaced with tandem heart the patient was then transferred to the the ccu where he was medically unstable on levophed and epi drip he went into sinus brady received mg of atropine of epi amp of bicarb a bicarb drip was started and dopamine added briefly the patient went into vf times resulting in shocks and came out into sinus tach the pt was then bolused with lidocaine mg followed by drip the pt was very difficult to ventilate non compliant lungs had been bag masked throughout this medical code and then switched to ecmo during this time he was started on cardiac arrest cooling protocol and treated with broad spectrum antibiotics over the course of the pt s admission he developed signs of severe multi organ system failure dic coagulopathy shock liver arf cardiogenic and likely distributive shock with group c strep and had a cxr with evidence of massive acute alveolar filling and pleural effusions and ventilator mechanics c w severely reduced resp system compliance given the pt s poor prognosis taking into account his poor chronic baseline multiorgan system failure in addition to his minimal cardiac function ef without being a candidate for heart transplant the family decided to withdraw care and the pt passed shortly thereafter medications on admission warfarin mg tablet sig one tablet po once a day please alternate between mg of coumadin on even days and mg of coumadin on odd days as per your physician atorvastatin mg tablet sig one tablet po once a day clopidogrel mg tablet sig one tablet po once a day gabapentin mg capsule sig one capsule po once a day gabapentin mg capsule sig one capsule po at bedtime lantus unit ml solution sig twenty five units subcutaneous at bedtime lisinopril mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig tablet po twice a day ranitidine hcl mg capsule sig one capsule po twice a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day furosemide mg tablet sig one tablet po once a day discharge medications n a discharge disposition expired discharge diagnosis n a discharge condition deceased discharge instructions n a followup instructions n a,"[
""admission_date"" : ""2019-1-29"",
""discharge_date"" : ""2019-2-1"",
""date_of_birth"" : ""2019-1-29"",
""sex"" : ""M"",
""service"" : ""Cardiothoracic Surgery"",
""history_of_present_illness"" : ""This is a year old gentleman with a prior history of two myocardial infarctions, non-insulin dependent diabetes mellitus and hypercholesterolemia. He had increasing shortness of breath prior to his presentation as well as chest pain on the morning of presentation. He was admitted for cardiac catheterization prior to this admission which was performed on the patient was referred to Dr [**Last Name (STitle) 105"
41371,admission date discharge date date of birth sex f service medicine allergies erythromycin base prednisone attending chief complaint dizziness sob chest pain major surgical or invasive procedure none history of present illness year old woman with hypothyroidism and history of hodgkin s lymphoma who presented with fatigue and sob symptoms started weeks ago she saw her pcp where ecg showed rd degree heart block no recent febrile illness or tick exposure no cp or chest pressure she has a headache but no photo or phonophobia mild lightheadedness but no syncope remote history of hodgkins lymphoma but chemotherapy regimen was unclear of note she had exertional shortness of breath over the summer which resolved of note the patient was bitten by a dog recently and has erythema of her right hand the dog is known to the family the patient has pain and swelling but denies any other symptoms in the ed initial vitals were bedside echo showed av dissociation but no pericardial effusion labs were normal cxr showed no findings on wetread most recent set of vitals not provided by the ed past medical history cardiac risk factors none previously identified no prior history of cad or known coronary disease other past medical history history of hodgkin s lymphoma unclear which chemotherapy given hypothyroidism most recent tsh tendinitis past surgical history splenectomy social history social history she is divorced and has been living with a boyfriend for years she has two kids years old and years old she is currently working hours as an assistant working with the disabled kids in the school system no etoh use family history family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam on admission vs t bp hr rr o sat ra general nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple no jvp appreciable cardiac pmi located in th intercostal space midclavicular line rr normal s s no m r g no thrills lifts no s or s area of incision is taped will evaluate in am gauze is dry lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness no abdominial bruits extremities no c c e in le right hand is erythematous and edematous tooth mark present on dorsum pain on pressing on discharge general comfortable heent ncat no oxygen perrl eomi anicteric sclerae cv rrr normal s s no mrg lungs ctab no rhonchi or wheezes abdomen soft nttp no masses no rebound tenderness or guarding extremities warm well perfused hand is less erythematous than on admission but still has some erythema and swelling left arm is in sling neuro cn intact motor bilaterally in all extremities sensation is intact bilaterally no focal abnormalities elicited pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood neuts lymphs monos eos baso pm blood pt ptt inr pt pm blood pt ptt inr pt pm blood creat pm blood urean am blood glucose urean creat na k cl hco angap pm blood calcium phos mg am blood calcium phos mg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg echo the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal there are three aortic valve leaflets the aortic valve leaflets are moderately thickened there is mild aortic valve stenosis valve area cm moderate aortic regurgitation is seen the mitral valve leaflets are moderately thickened there is no mitral valve prolapse mild mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression normal global and regional biventricular systolic function mild degenerative aortic stenosis moderate aortic regurgitation mild mitral regurgitation moderate pulmonary hypertension given the appearance of the aortic and mitral valves is there a history of chest irradiation cxr impression blunting of left costophrenic angle which may be due to a small pleural effusion mild prominence of the right hilum for which further evaluation with dedicated pa and lateral views is recommended cxr pacemaker leads terminate in right atrium and right ventricle there is no definitive pneumothorax seen but minimal apical pleural air cannot be excluded and repeated radiograph is recommended in case patient is symptomatic left lower lobe consolidation has progressed since the prior study and might reflect developing infection worsening atelectasis or aspiration left and right pleural effusions are small unchanged since the prior study mild vascular engorgement is seen brief hospital course yo female with relatively healthy pmh hodgekin s lymphoma and hypothyroidism presented with complete heart block s p pacemaker placement patinet currently hypertensive and has erythema on right hand dog bite heart block the patient had a pacemaker placed on the day of admission she was observed overnight and tolerated the pacemaker on the day after admission the patient had a chest xray that showed no pneumothorax but small amount of air in the apex could not be ruled out definitively it was recommended that the patient get a repeat xray in the next week the patient was discharged in stable condition dog bite there was worry that the patient s dog bite would become infected her blood cultures were negative to be safe the patient was sent home on a week course of augmentin to prevent infection especially with a new foreign object pacemaker in the patient hypertension the patient did have hypertension to the s while on the floor however the patient admitted to anxiety she received her home dose of lorazepam mg that night and her hypertension resolved we encouraged the patient to see her pcp about the hypertension and she was started on lisinopril mg medications on admission levothyroxine mcg daily lorazepam mg fluoxetine mg daily discharge medications oxycodone acetaminophen mg tablet sig one tablet po every eight hours as needed for pain for days please take a day as needed for pain until you see your primary care physician limit these pills and try alternatives such as tylenol or ibuprofen disp tablet s refills fluoxetine mg capsule sig two capsule po daily daily lorazepam mg tablet sig one tablet po bid times a day as needed amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for weeks please make sure to complete this course of antibiotics disp tablet s refills levothyroxine mcg tablet sig one tablet po once a day lisinopril mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis complete heart block secondary diagnosis cellulitis hand secondary to dog bite htn discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms you came to us after experiencing dizziness chest pain and shortness of breath over the last few weeks while with us we found that your heart had an abnormal rhythm that required a pacemaker you received that pacemaker and did well while with us we also noticed that your right hand was swollen and tender and we determined that a dog had bit your hand recently given our concern for infection especially with your new pacemaker we decided to send you home on a longer course of antibiotics please start augmentin mg three times a day for days please start lisinopril mg daily for high blood pressure followup instructions please call your primary care physician and schedule follow up appointment in the next week you should speak with her about your high blood pressure you will need to have your blood drawn this week to check your electrolytes now that we have started you on a new blood pressure medication the dog bite on your hand and your new pacemaker if you hand becomes more swollen tender or painful please call your primary care doctor immediately to discuss management md completed by [NEW_RECORD] admission date discharge date date of birth sex f service neurology allergies erythromycin base prednisone attending chief complaint l arm and l leg weakness major surgical or invasive procedure none history of present illness the pt is a year old r handed woman with pmhx of hypothyroidism distant hx of hodgkins lymphoma s p chemotherapy and radiation now s p pacemaker placement on for rd degree heart block of unknown origin who presents as a code stroke with new l arm and l leg weakness pt reports that yesterday she had her pacemaker placed without issue but they told her she should be on bedrest so she didn t get up after her operation she noticed that her l arm and shoulder hurt near where the pacemaker was placed the next morning she woke up to go to the bathroom and other than some l arm soreness felt normal however she was then gotten out of bed at am to go to a cxr and she felt her l leg give out and she felt it was too weak to support her weight so she was sat down by the nurses told to rest and when the transportation team came to get her again at am she was able to get up and walk to the stretcher without difficulty she doesn t know how quickly the weakness went away over that hour time period she was then discharged home at around pm and had no difficulty walking to the car or walking out of the car into her home she was watching the football game at around pm although she thinks could have been as early as pm or as late as pm when she felt lightheaded and sweaty and then noticed she couldn t hold herself up on the cough and tried to scoot up however she realized at the point she couldn t move her l leg she didn t notice any difficulty with her l arm but she was trying to keep it from moving because of her recent pacemaker placement on that side her family debated if she should go to the hospital eventually decided and brought her to the ed in the ed a code stroke was called for her l leg weakness and she was found to have a r aca stroke as described below of note pt reports h a every other day since bilaterally behind my eyes and that she would frequently wake up with them but they never woke her from sleep on neuro ros the pt reports l leg weakness as above denies current headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies numbness parasthesiae no bowel or bladder incontinence or retention on general review of systems the pt denies recent fever or chills no night sweats or recent weight loss or gain denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash past medical history hodgkins lymphoma first diagnosed in given radiation and had remission but then relapsed in and had repeat radiation and chemotherapy no relapses since then hypothyroidism most recent tsh splenectomy when diagnosed with hodkins lymphoma s p pacemaker placement for rd degree heart block of unknown origin social history divorced living with her boyfriend who she calls husband for years she has kids and yo she works as an assitant working with disabled kids parttime she smoked a couple of cigarettes per day for abour years but quit yrs ago denies any current alcohol use but used to drink socially denies illicits family history no hx of stroke or mi no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam physical exam on admission vitals t p r bp sao ra general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple no carotid bruits appreciated no nuchal rigidity pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s no m r g noted c d i dressing of pacemaker pocket abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities no c c e bilaterally radial dp pulses bilaterally skin no rashes or lesions noted neurologic nih stroke scale score was a level of consciousness b loc question c loc commands best gaze visual fields facial palsy a motor arm left b motor arm right a motor leg left b motor leg right limb ataxia sensory language dysarthria extinction and neglect mental status alert oriented x able to relate history without difficulty but was slow to respond to some questions attentive able to name dow backward without difficulty language is fluent with intact repetition and comprehension normal prosody there were no paraphasic errors pt was able to name both high and low frequency objects able to read slowly but without difficulty speech was not dysarthric able to follow both midline and appendicular commands the pt had good knowledge of current events there was no evidence of apraxia or neglect cranial nerves i olfaction not tested ii perrl to mm and brisk vff to confrontation funduscopic exam revealed no papilledema exudates or hemorrhages iii iv vi eomi without nystagmus normal saccades v facial sensation intact to light touch vii no facial droop facial musculature symmetric viii hearing intact to finger rub bilaterally ix x palate elevates symmetrically strength in trapezii and scm bilaterally xii tongue protrudes in midline motor normal bulk tone throughout pt unable to hold up l arm to test for pronator drift no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta edb l r sensory no deficits to light touch pinprick cold sensation vibratory sense proprioception throughout no extinction to dss dtrs tri pat ach l r plantar response was flexor on the r and extensor on the l coordination no intention tremor no dysdiadochokinesia noted on rue unable to test on lue no dysmetria on fnf in rue unable to test on lue gait deferred physical exam on discharge non focal examination no pronator drift full strength steady gait clinically bilateral pleural effusions stable oxygen staurations and respiratory rate pertinent results laboratory investigations admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood calcium phos mg stroke risk factors and pertinent labs am blood calcium phos mg cholest am blood triglyc hdl chol hd ldlcalc am blood hba c eag am blood tsh pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood ctropnt am blood ck mb ctropnt am blood ck cpk am blood lipase discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood calcium phos mg urine pm urine color yellow appear clear sp pm urine blood sm nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln ph leuks neg pm urine rbc wbc bacteri none yeast none epi pm urine color red appear hazy sp pm urine blood lg nitrite neg protein glucose neg ketone bilirub neg urobiln ph leuks neg pm urine rbc wbc bacteri few yeast none epi pm urine casthy pm urine mucous occ pm urine mucous few pm urine color red appear hazy sp pm urine blood lg nitrite neg protein glucose neg ketone bilirub neg urobiln ph leuks sm pm urine rbc wbc bacteri mod yeast few epi pm urine ucg neg pm urine bnzodzp neg barbitr neg opiates neg cocaine neg amphetm neg mthdone neg microbiology pm blood culture final report blood culture routine final no growth pm urine site not specified old s c final report urine culture final no growth radiology chest portable ap study date of pm findings single portable ap view of the chest was obtained there is blunting of the left costophrenic angle which may be due to a trace effusion no focal consolidation is seen there is no pneumothorax there is mild prominence of the right hilum which could relate to underlying vasculature however recommend further evaluation with dedicated pa and lateral views the cardiac silhouette is top normal the mediastinum is unremarkable impression blunting of left costophrenic angle which may be due to a small pleural effusion mild prominence of the right hilum for which further evaluation with dedicated pa and lateral views is recommended chest pa lat study date of am ap and lateral radiographs of the chest were reviewed in comparison to pacemaker leads terminate in right atrium and right ventricle there is no definitive pneumothorax seen but minimal apical pleural air cannot be excluded and repeated radiograph is recommended in case patient is symptomatic left lower lobe consolidation has progressed since the prior study and might reflect developing infection worsening atelectasis or aspiration left and right pleural effusions are small unchanged since the prior study mild vascular engorgement is seen ct cta brain with perfusion cta neck study date of pm findings on the unenhanced head ct there is no evidence for acute ischemia there is no hemorrhage midline shift or mass effect evaluation of the cta of the neck demonstrates mild atheromatous irregularity of the right common and proximal ica but without significant stenosis there is also a mild plaque at the origin of the right vertebral artery which causes mild stenosis there is a plaque at the origin of the left ica and the left carotid bulb causing mild approximately stenosis the left vertebral artery is markedly hypoplastic and there appears to be poor flow proximally which could be related to high grade stenosis or hypoplasia the remaining of the left cervical vertebral artery also demonstrates irregularity which could be related to atherosclerotic disease or may be technical in nature there is moderate plaquing at the right subclavian artery beyond the takeoff of the vertebral artery cta images through the brain demonstrate no evidence for high grade stenosis or vascular occlusion no aneurysm is seen within limits of the examination there is mild irregularity and narrowing of the aca branches which may be related to atherosclerotic disease alternatively this could be technical there is possibility of an infundibulum at the origin of the left superior cerebellar artery bilateral pleural effusions are noted there are apparent goiterous changes in bilateral thyroid lobes which should be correlated with an ultrasound if not already performed there is a rounded focus of ground glass density in the right upper lobe which could represent pneumonia in the appropriate clinical setting there is also apparent consolidation in the left upper lobe clinical correlation is advised impression no evidence for vascular occlusion intracranially atherosclerotic disease in the bilateral carotid bifurcations and proximal icas left greater than right but which does not appear to be more than thyroid lesions which could represent goiter but consider further evaluation with ultrasound if not already performed biapical lung densities which could represent consolidation or pneumonia in the appropriate clinical setting bilateral pleural effusions chest portable ap study date of am portable ap radiograph of the chest was reviewed in comparison to pacemaker leads terminate in right atrium and right ventricle unchanged cardiomediastinal silhouette is stable the patient continues to be in even progressed pulmonary edema right basal opacity most likely represents part of the edema but might reflect an area of atelectasis or infection left retrocardiac consolidation is unchanged small to moderate bilateral pleural effusions are redemonstrated no evidence of pneumothorax is present chest portable ap study date of am impression ap chest compared to through previous mild pulmonary edema has improved but small bilateral pleural effusions have increased left lower lobe opacification could be a combination of atelectasis and edema since it has improved since heart size normal atrioventricular pacer defibrillator leads in standard placements no left pneumothorax chest pa lat study date of am findings there has been a slight improvement in bibasilar lung aeration as well as mild pulmonary edema however moderate pleural effusions persist bilaterally atrioventricular pacer defibrillator remains in the left hemithorax there is no evidence of new consolidation effusions or pneumothoraces impression mild improvement in bibasilar lung aeration persistent moderate pleural effusions persist cardiology ecg study date of am complete heart block with an escape rhythm which has a right bundle branch block pattern and left posterior fascicular block no previous tracing is available to assess whether this is a junctional rhythm with aberration or a fascicular rhythm tracing read by intervals axes rate pr qrs qt qtc p qrs t portable tte complete done at pm final conclusions the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal there are three aortic valve leaflets the aortic valve leaflets are moderately thickened there is mild aortic valve stenosis valve area cm moderate aortic regurgitation is seen the mitral valve leaflets are moderately thickened there is no mitral valve prolapse mild mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression normal global and regional biventricular systolic function mild degenerative aortic stenosis moderate aortic regurgitation mild mitral regurgitation moderate pulmonary hypertension given the appearance of the aortic and mitral valves is there a history of chest irradiation ecg study date of am dual chamber paced rhythm is present with atrial sensed ventricular paced rhythm intra atrial conduction defect is seen tracing read by intervals axes rate pr qrs qt qtc p qrs t ecg study date of pm atrial sensed ventricular paced rhythm intra atrial conduction defect t wave inversion anterolaterally is new since tracing acute ischemic injury needs to be assessed tracing read by intervals axes rate pr qrs qt qtc p qrs t brief hospital course rhf with pmh of hypothyroidism distant history of hodgkin s lymphoma s p chemotherapy and radiation and rd degree heart block of unknown origin s p pacemaker placement on who represented as a code stroke on with left leg arm weakness in keeping with right aca ischemia of note she had been started on lisinopril just prior to presentation which was felt to perhaps be the inciting event her exam was initially notable for left proximal arm weakness and complete left leg plegia she was admitted to the icu and started on pressors with significant improvement in her weakness suggesting hypoperfusion as opposed to infarction cta it was not possible to perform mri scanning due to the presence of her pacemaker revealed a stenotic right aca and no clear acute infarction she developed orthopnoea and dyspnea on exertion and cxr revealed bilateral pleural effusions and pulmonary edema likely due to her aggressive iv fluid resuscitation to maintain her bp she received a single dose of iv furosemide in the icu and no further diuresis given concern for further hypoperfusion she was transferred to the floor and remained stable and although initially symptomatic as a result of her effusions this improved and she was mobilising well home antihypertensives were stopped she remained stable and was discharged home with services for cardiovascular monitoring on she has neurology and cardiology follow up neurology patient was recently s p pacemaker placement on and represented as a code stroke on with left leg left arm weakness in keeping with right aca ischemia of note she had been started on lisinopril just prior to presentation which was felt to perhaps be the inciting event resulting in perhaps symptomatic hypoperfusion initial examination revealed left proximal arm weakness and complete l leg plegia and notably this improved somewhat with elevation of her bp ct head revealed no evidence for acute ischemia hemorrhage midline shift or mass effect cta head showed mild irregularity and narrowing of the aca branches particularly on the right felt likely due to atherosclerosis in addition to no other evidence for high grade stenosis or vascular occlusion ct perfusion revealed decreased perfusion in the right aca territory cta neck showed atherosclerotic disease in the bilateral carotid bifurcations and proximal icas left greater than right but which does not appear to be more than in addition to mild plaque at the origin of the right vertebral artery which causes mild stenosis and the left vertebral artery was noted to be markedly hypoplastic with poor flow proximally which was felt could be related to high grade stenosis or hypoplasia in addition there was incidental note of apparent goiterous changes in bilateral thyroid lobes she was admitted to the icu given likely hypoperfusion and was started on pressors with significant improvement in her weakness as a result her lisinopril was stopped phenylephrine drip was weaned off on and she was maintained on ivf with a goal sbp her weakness continued to improve rapidly and by she had regained full strength throughout her left arm and leg however she began to complain of shortness of breath when lying flat and a cxr showed pulmonary edema and moderate bilateral pleural effusions fluids were stopped and she received mg iv furosemide on advice of cardiology and out of concern for dropping her bp and causing hypoperfusion symptoms she received no further diuretics she remained on close bp monitoring with goal sbp she was followed by cardiology and had a pacemaker interrogation on which showed normal function and although she had episodes of paced tachycardia in the s and per cardiology this tachycardia represented pacing from sa node she was transferred to the floor on stroke risk factors were addressed she was monitored on telemetry and this showed a paced rhythm throughout pre op tte on showed normal systolic function with no evidence of cardioembolic source and this was not repeated lipid panel revealed total chol ldl tg hdl hba c was she was started on aspirin mg daily and atorvastatin mg daily and as above lisinopril was held the diagnosis was felt to be likely aca hypoperfusion given aca narrowing on cta and perfusion deficit on ctp with resolution of symptoms with higher bps she remained stable on transfer to the floor with a good bp and non focal examination throughout the rest of her stay although she was initially symptomatic as a result of her bilateral pleural effusions with orthopnoea and dyspnoea on exertion this improved and repeat cxrs showed better aeration but still moderate pleural effusions she was mobilising well and pt cleared her to go home we stopped lorazepam on discharge out of concern for possible hypotension she remained stable and was discharged home with services for cardiovascular monitoring on she was advised that if she had any further weakness on the left side she should return to the ed and in the interim should try and lie flat to improve blood pressure she has neurology follow up cvs patient was followed by cardiology and maintained on telemetry monitoring her pacemaker was interrogated on and was found to be functioning normally she began to complain of shortness of breath when lying flat on repeat cxr showed pulmonary edema and bilateral moderate pleural effusions this was felt likely to her aggressive iv fluid resuscitation during her stay fluids were stopped and she received mg iv furosemide in the icu and no further fluids due to concern for further hypoperfusion echo was not repeated as recent pre op echo on demonstrated normal systolic function she had episodes of paced tachycardia in the s and per cardiology this tachycardia represented pacing from sa node she has cardiology follow up id she remained afebrile with no leukocytosis and no leukocytosis she was continued on augmentin mg q h for a planned day course for r hand cellulitis resulting from a dog bite ua was equivocal and ucx revealed no growth bcs were negative pulm cxr on showed pulmonary edema with bilateral pleural effusions this had slightly improved on although still showed b l pleural effusions o sats remained stable on ra throughout her stay ivf were stopped and her respiratory status was monitored closely in the icu on transfer to the floor she was initially symptomatic as above with orthopnoea and dyspnoea on exertion this improved and repeat cxrs showed better aeration but still moderate pleural effusions endo tsh was found to be elevated at patient has a history of hypothyroidism and note incidental finding on ct of apparent goiterous changes in bilateral thyroid lobes she was maintained on fingersticks and insulin sliding scale during her admission hba c was fen she was cleared by speech for a regular diet electrolytes were monitored and repleted as needed ivf were discontinued due to concern for pulmonary edema ppx she was maintained on pneumoboots and s c heparin throughout her admission medications on admission metronidazole mg rx d for pelvic abdominal pain levothyroxine mcg qd ativan mg fluoxetine mg qd lisinopril mg qd just discharged on this as a new med augmentin mg tid x days just discharged on this as a new med for r hand cellulitis from a dog bite discharge medications amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for days started for day course to finish disp tablet s refills levothyroxine mcg tablet sig one tablet po daily daily fluoxetine mg capsule sig two capsule po daily daily aspirin mg tablet sig one tablet po daily daily disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily discharge disposition home with service facility discharge diagnosis right anterior cerebral artery ischemia in the setting of right aca stenosis bilateral moderate pleural effusions secondary to iv fliuds third degree heart block status post pacemaker dog bite treated with augmentin discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent neurologic non focal examination no pronator drift full strength steady gait clinically bilateral pleural effusions discharge instructions dear ms you were admitted to on with left arm and leg weakness you were found to have decreased blood flow to the right front part of your brain you were initially admitted to the intensive care unit for medicines to increase your blood pressure imaging of the blood vessels of your head revealed a narrowing in the corresponding artery which supplie this area called the anterior cerebral artery your weakness improved greatly after being started on medications to increase your blood pressure for this reason we believe the most likely cause of your weakness was relatively low blood pressure causing inadequate flow to your brain through this narrowed vessel after starting lisinopril we have therefore stopped your lisinopril for this reason please do not restart the lisinopril at this time we started aspirin and a cholesterol lowering called atorvastatin to reduce stroke risk if you have any further weakness on this side you must come back to the ed and in the interim should try and lie flat as this improves blood pressure in order to increae your blood pressure we used a large volume of iv fluids and this resulted in fluid collections in the outside of both lungs however on the day of discharge you were breathing comfortably the fluid collections should go away on their own over time you developed some bleeding in the urine likely as a result of the placement of a catheter please contact us if this does not resolve we made the following changes to your medications we held lorazepam as this can lower blood pressure we prefer that you discontinue this we stopped lisinopril we started aspirin mg daily we started atorvastatin mg daily please continue augmentin for your dog bite and possible urinary infection to finish on if you experience any of the below listed danger signs please call your doctor or go to the nearest emergency department it was a pleasure taking care of you during your hospital stay followup instructions please follow up with your pcp week we have organised the following neurology follow up department neurology when wednesday at pm with drs haussen building sc clinical ctr campus east best parking garage we have organised the following cardiology appointment department cardiology when wednesday at pm with md address md,"{
""date"": ""2022-10-10"",
""discharge_date"": ""2022-10-11"",
""date_of_birth"": ""2001-10-14"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Erythromycin"",
""Prednisone""
],
""admission_date"": ""2022-10-10"",
""chief_complaint"": ""Dizziness/Sob"",
""history_of_present_illness"": ""Year old woman with hypothyroidism and history of Hodgkin's lymphoma who presented with fatigue and sob symptoms started weeks ago she saw her PCP where ECG showed RD degree heart block no recent fever"
13776,admission date discharge date date of birth sex m service nsu history of present illness this is a year old gentleman with difficulty walking first noting left leg weakness about years ago over the past several years increased left leg weakness and difficulty lifting left leg up has been dragging left leg for past year he has been using cane for past weeks no bowel or bladder incontinence ppd negative biopsy reportedly negative past medical history negative past surgical history appendectomy medications propoxy n apap allergies no known drug allergies social history nonsmoker works as a bus driver physical exam he is feet inches pounds spastic gait using cane upper extremities strength ip on the right on the left plus hamstrings on the right on the left plus quads on the right on the left dorsiflexion on the right on the left plus plantar flexion on the right on the left plus patellar reflexes upper extremity hyperactive eight beat clonus on the right a sustained clonus on the left mri shows t destructive process with paraspinal mass and irregular enhancement there was positive cord compression at t with his pharynx extending to the c spine impression at the time was thoracic myelopathy hospital course the patient received a thoracic laminectomy and placement of syringopleural shunt postoperative course was uncomplicated physical therapy and occupational therapy were consulted he was discharged to extended care facility for acute rehab discharge instructions keep the staples dry call for fever or any signs of infection redness swelling or drainage from wound please monitor for the following fevers chills nausea vomiting inability to tolerate food or drink if any of these occur please contact your physician final diagnoses syringomyelia status post thoracic laminectomy and placement of syringopleural shunt recommended follow up follow up with dr for staple removal weeks postop call for an appointment at major surgical or invasive procedure thoracic laminectomy and placement of syringopleural shunt discharge condition neurologically stable discharge medications percocet colace dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service history of present illness the patient is a year old gentleman with chronic low back pain which radiates down his left leg and which he has had for three to four years he had an x ray on which showed mid to low thoracic spine degenerative changes and loss of vertebral height at t with some type of underlying lesion he has had complaints of the inability to lift his left leg into his pants and initial complaints of numbness and tingling with decreased ability to ambulate past medical history he had an appendectomy in positive frequency and positive constipation he has no known drug allergies he is on darvon q hours physical examination blood pressure pulse he is an obese gentleman in no acute distress while seating but with painful ambulation with a cane heent non icteric no lymphadenopathy no thyromegaly neck is supple chest clear to auscultation cardiac s and s irregular rate tachycardia abdomen obese soft and non tender liver edge palpable negative bruits extremities trace pitting edema palpable pedal pulses gait slow and shuffling with shifting of the right leg which swings through to the left assessment and plan irregular heart rate with t wave inversion and flattening anesthesia to order cardiac workup thoracic disc disease the patient will be admitted for t vertebrectomy with t to t fusion hospital course on the patient was seen by the cardiology service who recommended an echocardiogram the patient was in atrial flutter they recommended that the patient have the echocardiogram and then electrophysiology postoperatively for ablation if deemed appropriate for atrial flutter and also possible cardioversion of atrial fibrillation postoperatively if needed the patient underwent a transthoracic approach to t vertebrectomy and t to t fusion with harms cages there were no intraoperative complications postoperatively the vital signs remained stable and the patient was afebrile he remained intubated in the pacu overnight he was extubated on postoperative day and sent to the surgical intensive care unit for close monitoring neurologically his motor strength in his lower extremities was anti gravity his vital signs remained stable he remained on neo synephrine at mcg to keep his blood pressure greater than and on a solu medrol drip for an additional hours the patient s vital signs were stable he was afebrile he was fitted for a tlso brace on postoperative day the tlso brace arrived and the patient was out of bed in his brace he had postoperative films which were checked and looked good with hardware in good position he was followed by the cardiology service who recommended starting him on amiodarone intravenously for his atrial fibrillation flutter he was also started on digoxin and lopressor for rate control his vital signs have remained stable he has been afebrile he has been out of bed and ambulating with his brace in place his dressing is clean dry and intact his motor strength in his lower extremities is now throughout the patient is being transferred to acute rehabilitation prior to discharge home his medications at the time of discharge are zantac mg p o b i d lopressor mg p o b i d amiodarone mg p o q day and digoxin mg p o q day decadron has been discontinued the patient should follow up with dr in one week for staple removal the patient was in stable condition at the time of discharge m d dictated by medquist d t job,"[
""admission_date"" : ""2019-1-29"",
""discharge_date"" : ""2019-2-1"",
""date_of_birth"" : ""2010-10-15"",
""sex"" : ""Male"",
""service"" : ""Neuro"",
""nursing_note"" : ""This is a year old gentleman with difficulty walking first noting left leg weakness about years ago over the past several years increased left leg weakness and difficulty lifting left leg up has been dragging left leg for past year he has been using cane for past weeks no bowel or bladder incontinence ppd negative biopsy reportedly negative past medical history negative past surgical history appendectomy medications propoxy n apap allergies no known drug allergies social history nonsmoker works"
55739,admission date discharge date date of birth sex f service medicine allergies dapsone ibuprofen penicillins amoxicillin sulfa sulfonamide antibiotics attending chief complaint hematemesis major surgical or invasive procedure egd history of present illness ms is a year old woman with hcv cirrhosis hiv grade iii esophageal varices no etoh hx admitted to hospital overnight for hematemasis and one dark bloody stool transferred to micu from hospital pacu after upper endoscopy with no intervention she reports having vomited about cups full of bright red clotted blood while making dinner last night about episodes of emesis at that time no prior history of hematemesis hemtochezia or melena patient with stable vitals on presentation last night with sbps in low s and hr s on nadolol but this morning sbps noted to be in s maps in s prior to sedation her hct dropped overnight after l of ivfs patient was given small amounts of propofol fentanyl and versed for endoscopy sedation after which bp dropped further she was transfused with units of prbcs and given another l total of lactated ringers with some improvement in sbps endoscopy this morning at hospital showed a large clot in the fundus of stomach which was not removed grade iii esophageal varices and portal hypertension ccs blood was seen but no active bleeding was noted so no intervention was done patient had no complaints of abdominal pain or ascites and was alert and oriented x vitals in pacu were as follows sbps in s and hr on nadolol after discussion with gi team hospital medical team requested transfer to for question of tips and angiography if patient continues to bleed patient had stated that she is on transplant list here at on arrival to the micu patient stable with no complaints other than general tiredness she reports no further emesis or blood in stools she has passed a couple more bowel movements today with no further blood noted past medical history cirrhosis secondary to hepatitis c grade iii esophageal varices grade ii in hiv most recent cd on and undetectable viral load nadir in hepatitis c genotype developed rash to interferon reports that she was diagnosed about yrs ago hepatosplenomegaly gastritis h pylori negative in hiatal hernia thrombocytopenia ptsd depression renal calculi s p tubal ligation social history lives with year old daughter two other children oldest is year old son currently volunteers with aids action committee used to work at pre term abortion clinic where she got a needle stick likely where she contracted hiv tobacco quit yrs ago smoked for years ppd at peak etoh occasional in past but none for years illicits denies except for marijuana when much younger family history strong cad hx father and uncle died of mis at in mid s brother and sister with acute mis in mid s grandmother with diabetes sister with asthma sister with uterine cancer physical exam on admission to the micu vitals t f bp p r o ra general alert oriented x no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s s soft early systolic murmur loudest at lusb abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no fluid wave small vertical well healed old scar from umbilicus gu no foley ext warm well perfused strong pulses no clubbing cyanosis or edema skin small telangiectasias upper right chest pertinent results on admission to the micu pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos totbili pm blood albumin calcium phos mg egd cords of grade iii varices were seen in the lower third of the esophagus and middle third of the esophagus there were stigmata of recent bleeding bands were successfully placed in the lower third of the esophagus impression varices at the lower third of the esophagus and middle third of the esophagus varices at the ge junction contiguous with esophageal varices blood in the fundus abnormal mucosa in the duodenum ligation otherwise normal egd to third part of the duodenum brief hospital course f with hx of hcv cirrhosis with known grade iii esphogeal varices gastritis hiv presenting to osh with hematemesis s p upper endoscopy at outside hospital with no intervention transferred to for question of tips and further management upper gi bleed patient had hematemesis of cups and episode of melena she intially presented to hospital she was initially hemodynamically stable hct was bp dropped to s s the evening prior to transfer and the patient was given l ivf on the morning of transfer hct was patient was transfused u prbc egd at osh showed blood in the fundus grade iii varices without active bleeding she was then transferred to for further management at vs were stable on arrival hct was the patient was intubated electively for egd egd showed cords of grade iii esophageal varices were banded bands total additional varices were seen clotted blood was also seen in the stomach the patient was continued on octreotide drip x days as well as ciprofloxacin x days and protonix mg hct stabilized in the event of rebleed it was thought that the patient may require tips patient was transferred to the floor where she remained hemodynamically stable with no subsequent episodes of hematemesis she was started on sucralfate g x d and discharged to complete course of cipro on omeprazole mg daily she was also started on nadolol titrated to mg for a goal hr of s s she will have repeat egd in mid hcv cirrhosis hcv genotype meld score of showed evidence of synthetic dysfunction with inr albumin patient reported no history of significant ascites or paracentesis appears that she has been started in interferon treatment in the past but could not appear to have been able to tolerate it upon further discussion she did not have a hepatologist yet and has not been evaluated for transplant home lactulose was continued she was set up with outpatient liver follow up to initiate transplant workup age appropriate screening labs were sent gastritis patient was continued on pantoprazole gtt as above then transitioned to mg po daily pancytopenia thought to be secondary to chronic liver disease and possible marrow suppression from chronic hiv per osh records baseline is s s hiv restarted haart on hd patient s last viral load undetectable in with cd count of the patient received subq heparin for dvt prophylaxis communication was with the patient and her sister the patient remained full code during this admission medications on admission fosamprenavir lexiva mg daily truvada mg lactulose g ml x tablespoons daily lidocaine topical ointmt x daily nadolol mg daily omeprazole mg daily discharge medications lactulose gram ml syrup sig thirty ml po tid times a day as needed for please titrate to bms per day emtricitabine tenofovir mg tablet sig one tablet po daily daily fosamprenavir mg tablet sig one tablet po q h every hours nadolol mg tablet sig one tablet po bid times a day disp tablet s refills sucralfate gram tablet sig two tablet po bid times a day for days disp tablet s refills cipro mg tablet sig one tablet po twice a day for days disp tablet s refills zofran mg tablet sig tablets po three times a day as needed for nausea disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day disp capsule delayed release e c s refills discharge disposition home discharge diagnosis bleeding esophageal varices discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to the hospital because you had some vomited up a large amount of blood at home it was found to be from varices in your esophagus you had an endoscopy where some of these varices were banded to stop the bleeding you were also given medications to stop the bleeding since then your hematocrit has been stable you are now tolerating a full diet and new medications if you begin vomiting blood have significant abdominal discomfort become lightheaded dizzy or short of breath please call or return to the emergency department please start taking the following medications ciprofloxacin mg every h x more days sucralfate g every h x more days as needed use zofran every h for nausea the following medications have changed nadolol has been increased to mg every h omeprazole mg daily followup instructions an appointment will be scheduled for you in the liver clinic in wks you will also be scheduled for a follow up endoscopy in wks please call in days to find out the date of your appointments md,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""2013-1-1"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Dapsone"",
""Ibuprofen"",
""Penicillins"",
""Amoxicillin"",
""Sulfa"",
""Sulfonamide""
],
""discharge date"": ""2013-1-2"",
""date of death"": ""2013-1-2"",
""service of admission"": ""Medicine"",
""chief complaint"": ""Hematemesis"",
""history of present illness"": ""Ms. [**Known lastname 1051**] is a year old woman with h"
92629,admission date discharge date date of birth sex f service medicine allergies sulfonamides hydrochlorothiazide lipitor zocor glucophage neurontin lasix lyrica tylenol codeine no attending chief complaint hyperkalemia arf major surgical or invasive procedure cta of the chest showed evidence of pneumonia ct of the head normal history of present illness year old female with hx of dmii now presenting to er due to outside blood work yesterday showeing k of at her annual physcial and an elevated cr to it was rechecked today and still elevated depsite today stopping her acei and aldactone she was instructed to go the er while in er pt felt like her sugar was low and had a fs of she was given detrose and bs improved to she reports that she previously had bs always despite taking lantus and humalog tid this week she stopped her insulin due to several low bs in s she was started on metformin mg yesterday today while her bs was low she felt some palpitaions which resolved after mintues she recently started a carb free diet and has been loosing wt and exercising in er vs were she was given the detrose mentioned above amp d ns ml and liter ns k was checked and was on recheck was so no other meds given ekg showed sinus rate at some mild t wave peaking in ii v v but same as prior she was admitted for arf hypoglycemia and hyperkalemia vs on transfer were ra on floor patient was found to be hypoxic in the setting of no cpap and napping she was diaphoretic tachypnic tachycardic triggered for hypoxia concerning for pe on cxr found to have question of rul pneumonia then on ct noted to have right sided diffused intrapulmonary process ct head was negative she was transfered to micu for observation overnight bp s hr temp sat on l sr and rare pvc micu course patient had an uneventful night at micu had similar headaches throbbing nausea and vomited once desated in the setting again without her cpap she spiked a fever up to did not intake as much water as she usually has reports at home takes in about l of fluids h o she was cultured and had trended for potassium and creatinine on floor she was noted to be in good spirit communicative though still feels very nauseated review of systems per hpi denies fever chills night sweats recent weight gain denies headache sinus tenderness rhinorrhea or congestion denied cough shortness of breath denied chest pain or tightness palpitations denied nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denied arthralgias or myalgias past medical history gout psoriatic arthitis and rash adult onset diabetes mellitus yrs just stopped insulin hyperlipidemia back pain peripheral edema polycystic ovarian syndrome s p hysterectomy fatty liver sleep apnea uses cpap at night gastritis upper gi bleed hx colonic polyps colonoscopy months ago thyroid cancer both folicular and papillary resected thryoid and s p radiation tx neuropathy requires nacotics obesity food allergies msmg asthma social history lives with her mother at in blood bank non smoker no etoh no drugs family history father with dm aunt with breast ca physical exam vitals ra general alert oriented no acute distress cushingnoid appearance heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s s murmurs abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly back no cva tenderness ext warm well perfused pulses no clubbing edema neuro cn grossly intact moving all extremities pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili pm blood ctropnt pm blood ck mb notdone ctropnt am blood ck mb notdone ctropnt am blood ck mb notdone ctropnt am blood calcium phos mg am blood caltibc vitb folate greater th ferritn trf am blood osmolal pm blood tsh pm blood free t am blood cortsol brief hospital course yo f with hx of dmii osa admitted with arf hypoglycemia and hyperkalemia who developed ams and hypoxia in the setting of being asleep without her cpap receiving high dose oxycontin and possibly aspirating emesis she recovered after one night in the micu and was discharged in stable condition respiratory distress hypoxia and hypercarbia was due to her severe osa she fell asleep without her cpap in the setting of not sleeping overnight and recieved oxycontin for her neuropathic pain this was complicated by an likely aspiration pneumonitis seen on her cxr and ct scan rul ground glass opacities she recovered after one night in the micu and was transferred to the floor prior to transfer she spiked a temperature and was placed on ceftriaxone and azithromycin she was in stable condition at the time of discharged arf unclear cause of renal failure her urine lytes showed fena and feurea ua was negative bun was also elevated patient may be dehydrated in setting of diuretic medications and possible type iv rta given dm history hyperkalemia was attributed to a combination of medications and renal failure this resolved after patient was given ivf holding her home medications hyperkalemia initial ekg was notable for tall t waves though seen in prior from normal qtc low voltage due to ace and spironolactone use in the setting of acute renal failure resolved after restricting medications ivf and potassium restrict diet there was a question this may be due to other hypoaldosterone states she will follow up with endocrine clinic as an outpatient for further work up hypoglycemia dmii patient noted to have recently switched for insulin to metformin she also started a diet and exercise routine was consulted on management of dm she was placed on a iss in house and metformin was held this continued at the time of her discharge she will follow up with and endocrine as an outpatient anemia hct is slight decreased from to stable and not deficient in b or folate htn bp stable held acei initially hx thyroid ca stable continue home medication neuropathy stable continue oxycotin and percocet and lidocaine cream osa used cpap gout stable initially but had a flare prior to discharge allopurinol was initially renally dosed but was stopped due to the flare colchicine and indomethacine was started psoriatic arthitis stable continued indomethcine code full emergency contact mother medications on admission albuterol mcg aerosol puffs q hrs prn cough allopurinol mg tablet daily colchicine mg prn flare of gout desonide cream to axillae duloxetine cymbalta mg capsule enalapril maleate mg stopped indomethacin mg capsule qday insulin glargine units stopped insulin lispro humalog pen units tid stopped levothyroxine mcg po qday oxycodone oxycontin mg oxycodone acetaminophen percocet mg mg tablet q hrs prn spironolactone mg tablet po qday stopped lidocaine cream apply nightly as directed to feet multivitamins with minerals daily metformin mg started days ago cinnamon b complex milk thistle asa mg x tabs fish oil b discharge medications desonide cream sig one appl topical times a day senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills levothyroxine mcg tablet sig two tablet po daily daily lidocaine hcl ointment sig one appl topical hs at bedtime as needed for foot pain duloxetine mg capsule delayed release e c sig two capsule delayed release e c po bid times a day indomethacin mg capsule sig two capsule po qdaily note may take mg twice a day during acute gout attacks otherwise take usual mg daily dose enalapril maleate mg tablet sig three tablet po daily daily disp tablet s refills colchicine mg tablet sig one tablet po three times a day as needed for gout attacks take up to tablets daily one every hours as needed for gout flares discontinue if severe diarrhea nausea emesis albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation every four hours as needed for cough spironolactone mg tablet sig one tablet po once a day disp tablet s refills milk thistle oral vitamin b complex oral aspir mg tablet delayed release e c sig one tablet delayed release e c po once a day fish oil oral percocet mg tablet sig one tablet po every four hours as needed for pain colace mg capsule sig one capsule po twice a day as needed for constipation disp capsule s refills lantus unit ml cartridge sig six units subcutaneous at bedtime humalog unit ml cartridge sig per sliding scale subcutaneous once a day see attached sliding scale discharge disposition home discharge diagnosis primary respiratory distress aspiration pneumonitis mixed non anion gap metabolic and respiratory acidosis acute renal failure hyperkalemia tachycardia hypoglycemia type ii diabetes mellitus secondary anemia hypertension history of thyroid cancer neuropathy obstructive sleep apnea gout psoriatic arthitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions it was a pleasure taking care of you in you came to the hospital with high potassium renal failure and low glucose we provided fluid hydration and restricted your diet to low potassium diet we also stopped a couple of your medications that may have caused you to have elevated potassium your glucose levels were evaluated and we had clinic doctors you were placed on an insulin sliding scale while you were in the hospital during your hospitalization you had an episode where you did not put on your face mask and your oxygen saturation levels dropped in this state you vomited and aspirated as the result you had an aspiration pneumonia you stayed in the intensive care unit for one night you recovered and you were then placed on antibiotics for the aspiration pneumonia your followup chest xray did not show a pneumonia so you were not continued on antibiotics the chest findings were likely due to solely aspiration you also had some abnormal thyroid lab studies which should be worked up further as an outpatient in addition an endocrine follow up is also being set up so that you can be tested for high cortisol levels it is very important that you start to use your cpap machine during any naps that you take during the day as well as when sleeping at night please follow up with your upcoming doctor s appointments which have been made for you below medication changes instructions hold your home allopurinol until your gout resolves continue taking colchicine up to three times daily for gouty flare up stop taking when symptoms resolve or stop if experience diarrhea gi side effects continue to take mg indomethacin times daily for gout flare and then drop to usual mg daily dose please take this medication with food your metformin was stopped and recommended units of lantus at night and a humalog sliding scale for your home diabetes regimen see the attached sliding scale you said that you did not need prescriptions for these please decrease aspirin use to mg daily we restarted your usual enalapril at a lower dose of mg daily we added colace and senna for prevention of constipation we decreased your usual spirinolactone to mg at discharge because of your recent elevated potassium levels you were discharged on percocet for pain control please wait to restart your home oxycontin dose until you discuss this medication with dr at your upcoming appointment otherwise you can resume your home medications that you had been taking followup instructions provider md phone date time please follow up in the clinic with dr at on the of the building appointment date is at pm phone you also need clinic followup in the next two weeks they were considering starting byetta with you call for an appointment md,"{
""name"": ""Jane Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Sulfonamides"",
""Hydrochlorothiazide"",
""Lipitor"",
""Zocor"",
""Glucophage"",
""Neurontin"",
""Lasix"",
""Tylenol"",
""Codeine""
],
""admissionDate"": ""2017-01-01"",
""dischargeDate"": ""2017-01-03"",
""dateOfDeath"": ""2017-01-03"",
""chiefComplaint"": ""Hyperkalemia"",
""historyOfPresentIllness"
66037,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint dyspnea on exertion palpitations major surgical or invasive procedure mitral valve repair p resection and mm ring history of present illness year old gentleman with a history of mitral valve prolapse with mitral regurgitation who has been followed by serial echocardiograms over the past year his echocardiograms have shown progressive dilation of the left ventricular end systolic dimensions which is now at mm given the progression of his mvp mitral regurgitation he has been referred for surgical repair past medical history anxiety lumbar disc disease mild benign prostatic hypertrophy s p esophageal dilatation social history lives with mother occupation officer tobacco quit yrs ago after pk yr hx etoh drinks week family history mother with afib father with cad mi died at cva physical exam pulse resp o sat b p right left height weight general nad fit well appearing skin dry x intact x heent perrla x eomi x anicteric sclera op benign neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur sem throughout precordium and radiating to carotids abdomen soft x non distended x non tender x bowel sounds x no hsm cva tenderness extremities warm x well perfused x edema varicosities none x neuro grossly intact non focal mae strengths pulses femoral right left dp right left pt left radial right left carotid bruit right left murmur radiates to bilateral carotids pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood urean creat k prebypass no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity is moderately dilated overall left ventricular systolic function is mildly depressed lvef intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation right ventricular chamber size and free wall motion are normal the aortic root is moderately dilated at the sinus level the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are elongated there is moderate severe mitral valve prolapse there is partial mitral leaflet flail the mitral regurgitation vena contracta is cm severe mitral regurgitation is seen there is no pericardial effusion dr was notified in person of the results on at am post bypass patient is in sinus rhythm and receiving an infusion of phenylephrine and epinephrine biventricular systolic function is unchanged annuloplasty ring seen in the mitral position leaflets move well and the annuloplasty ring appears well seated trivial central mitral regurgitation present mean gradient across the mitral valve is mm hg aorta appears intact post decannulation brief hospital course admitted same day surgery and underwent mitral valve repair see operative report for further details he received cefazolin for perioperative antibiotics postoperatively he was transferred to the intensive care unit for management in first twenty four hours he was weaned from sedation awoke neurologically intact and was extubated without complications he was transfered to the floor on post operative day one for the remainder of his stay physical therapy worked with him on strength and mobility he did have a brief episode of atrial fibrillation which converted to sr with amiodarone he remained in sinus rhythm he continued to do well and was ready for discharge home on post operative day five medications on admission lorazepam mg discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills lorazepam mg tablet sig one tablet po bid times a day as needed for anxiety disp tablet s refills ranitidine hcl mg tablet sig one tablet po once a day disp tablet s refills hydromorphone mg tablet sig one tablet po q h as needed for pain disp tablet s refills metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day mg x week then mg x week then mg daily until further instructed disp tablet s refills discharge disposition home with service facility vna discharge diagnosis mitral regurgitation s p mv repair mild benign prostatic hypertrophy anxiety discharge condition alert and oriented x ambulating with steady gait sternal pain managed with dilaudid discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than pounds for weeks please call with any questions or concerns followup instructions provider md phone date time please call to schedule appointments primary care dr in weeks cardiologist dr in weeks wound check appointment your nurse will schedule completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-13"",
""date_of_birth"" : ""2049-10-10"",
""sex"" : ""Male"",
""service"" : ""Cardiothoracic"",
""allergies"" : [
""Patient recorded as having no known allergies to drugs.""
],
""attending_chief_complaint"" : ""Dyspnea on exertion, palpitations"",
""chief_complaint"" : ""Dyspnea on exertion, palpitations"",
""history_of_present_illness"" : ""Year old gentleman with a history of mitral valve prolapse with mitral regurgitation who has been followed"
78551,admission date discharge date date of birth sex m service neurosurgery allergies morphine attending chief complaint lower extremity weakness major surgical or invasive procedure t to t lamenectomies for tumor debulking history of present illness mr is a yo m with widely metastatic prostate ca who preents with days of progressive lower extremity weakness the patient had been ambulating normally days prior then yesterday he required assistance and was leaning on furniture to stand today he was completely unable to stand walk and could not move his legs he denies any neck or back pain he denies headache at baseline he ambulates independently and has used a cane infrequently for long distances the patient endorses numbness in the legs for days as well he endorses an altered sensation in the groin area but states it is not completely numb he had incontinence of urine today he was not able to feel himself urinating at first and then became aware but was unaware to get himself to the bathroom he has not moved his bowels in several days and has not had the urge to do so he c o chest pain for week likely due to bony mets and cough for month past medical history metastatic prostate ca with diffuse skeletal mets initially diagnosed in s p radical prostatectomy and penile prostheses s p hormone therapy and chemotherapy on lupron and a clinical phase i trial of mdv selective androgen receptor modulator htn gerd hyperlipidemia glaucoma social history drinks glasses wine day currently smokes pp x years denies illicits lives in northern nh with his wife and son retired from transportation family history both parents died of complications related to alcoholism no fhx of cancers physical exam o t hr bp rr ra gen wd wn uncomfortable with movement nad heent pupils eoms neck supple lungs cta bilaterally cardiac rrr s s abd soft nt bs extrem warm and well perfused pitting edema bilaterally neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date motor normal tone d b t we wf ip q h at g r l sensation decreased sensation to light touch at right lateral and anterior thigh reflexes b t br pa ac right left beats clonus on r toes r upgoing l downgoing rectal exam normal tone sensation intact on discharge motor exam improved to strength pertinent results mri spine impression widespread extensive metastatic bone infiltration throughout the spine mildly enhancing extramedullary and intradural lesion extending from t to t narrowing the canal and mildly compressing the cord consistent with a metastatic process multilevel degenerative changes in the cervical spine with canal narrowing as described above dural enhancement from the posterior fossa extends down the posterior cervical canal due to metastatic process lumbar spine demonstrates multilevel degenerative changes and moderate to severe canal narrowing at multiple levels due to predominantly epidural fat and combination of other degenerative factors small enhancing epidural lesion involving the right l pedicle and deforming the thecal sac mri brain impression interval development of a new extra axial metastatic lesion in the left anterior temporal region and a small lesion in the left cerebellum and interval increase in minor dural enhancement on the right new flair signal changes from vasogenic edema in the left temporoparietal lobe and left cerebellum marked reduction in the size of extra axial enhancing mass in the left frontoparietal region no acute infarction ct torso impression increase in size of right lateral chest wall metastases with new right pleural based pleural effusion new right hepatic metastases extensive sclerosis involving the entire appendicular and axial skeleton new pathological fracture of the right lateral th rib adjacent to the enlarging chest wall lesion the degree of cord compression in the thoracic spine as seen on prior mri is difficult to fully visualise on this non dedicated ct ct t spine impression status post t t laminectomy with post surgical changes in the spinal canal and posterior soft tissue with drain in place no large fluid collections seen please note evaluation of the spinal canal is suboptimal brief hospital course mr was admited thru the ed to the neurosurgical service after an mri showed an epidural mass at t to t with cord compression the patient went to the icu and was started on steroids which improved his motor exam he was taken to the operating room on hd for a thoracic decompression and tumor debulking intraoperatively he recieved four units of prbcs and two units of ffp to correct his coagulopathy he had a cc blood loss he was taken to the icu intubated and extubated in the evening a post operative ct did not reveal any evidence of an epidural hematoma upon transfer to the floor the patient was seen by pt and ot on drains and pca were discontinued foley trial was initiated lung sounds revealed crackles bilaterally at bases pt stated that he was on advair at home so this was started and had nebs prn his drain was discontinued on his foley was discontinued but he failed voiding trials and a foley was replaced in the evening on at the time of discharge on he is tolerating a regular diet ambulating with an assistive device afebrile with stable vital signs medications on admission bimatoprost lumigan prescribed by other provider dosage uncertain citalopram mg tablet tablet s by mouth daily hydromorphone mg tablet or tablet s by mouth every hours as needed for pain irbesartan avapro prescribed by other provider dosage uncertain leuprolide month lupron depot month mg syringe im every three months lorazepam ativan mg tablet tablet s by mouth take one or two pills as needed as needed for for anxiety or sleep morphine mg tablet extended release or tablet s by mouth three times a day omeprazole prilosec mg capsule delayed release e c take one day in the am capsule s by mouth take one a day in the am pegfilgrastim neulasta mg ml syringe inject into skin every three weeks two days after chemotherapy pravastatin pravachol prescribed by other provider dosage uncertain prochlorperazine maleate mg tablet tablet s by mouth as needed every hours as needed psa test psa test monthly starting please give results to patient and fax to dr at warfarin coumadin mg tablet tablet s by mouth daily zoledronic acid zometa mg ml solution iv every three months to six months medications otc loperamide imodium a d prescribed by other provider dosage uncertain discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever insulin regular human unit ml solution sig sliding scale injection asdir as directed glucagon human recombinant mg recon soln sig one recon soln injection q min as needed for hypoglycemia protocol bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily docusate sodium mg capsule sig one capsule po bid times a day citalopram mg tablet sig two tablet po daily daily prochlorperazine maleate mg tablet sig one tablet po q h every hours as needed for nausea loperamide mg capsule sig one capsule po daily daily as needed for loose stool latanoprost drops sig one drop ophthalmic hs at bedtime morphine mg tablet extended release sig three tablet extended release po q h every hours gabapentin mg capsule sig one capsule po tid times a day pravastatin mg tablet sig one tablet po daily daily duloxetine mg capsule delayed release e c sig one capsule delayed release e c po daily daily losartan mg tablet sig one tablet po daily daily lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily as needed for shoulder pain left dextromethorphan poly complex mg ml suspension extended rel hr sig one po q h every hours as needed for cough nicotine mg hr patch hr sig one patch hr transdermal daily daily albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheezing furosemide mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po pm fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day lactulose gram ml syrup sig thirty ml po tid times a day magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation morphine mg tablet sig tablets po q h every hours as needed for pain aspirin mg tablet chewable sig one tablet chewable po daily daily warfarin mg tablet sig one tablet po daily daily protonix mg tablet delayed release e c sig one tablet delayed release e c po once a day dextrose in water d w syringe sig one intravenous prn as needed as needed for hypoglycemia protocol valium mg tablet sig one tablet po every eight hours as needed for spasm dexamethasone mg tablet sig two tablet po every eight hours for days on dexamethasone mg tablet sig one tablet po every eight hours for days on then stop dexamethasone on discharge disposition extended care facility me discharge diagnosis spinal metastasis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions do not smoke keep your wound s clean and dry no tub baths or pool swimming for days from your date of surgery you have staple and desolveable sutures the staples can be removed at days postop however the sutures shoult not be removed they will desolve in weeks you may shower after seven days and get your wound wet no pulling up lifting more than lbs or excessive bending or twisting limit your use of stairs to times per day have a friend or family member check your incision daily for signs of infection take your pain medication as instructed you may find it best if taken in the morning when you wake up for morning stiffness and before bed for sleeping discomfort increase your intake of fluids and fiber as pain medicine narcotics can cause constipation we recommend taking an over the counter stool softener such as docusate colace while taking narcotic pain medication clearance to drive and return to work will be addressed at your post operative office visit call your surgeon immediately if you experience any of the following pain that is continually increasing or not relieved by pain medicine any weakness numbness tingling in your extremities any signs of infection at the wound site redness swelling tenderness and drainage fever greater than or equal to f any change in your bowel or bladder habits such as loss of bowl or urine control followup instructions follow up instructions appointments no radiation therapy for at least weeks postop to allow for wound healing do not remove sutures they will dissolve on their own staples will need to be removed at days postop please call to schedule an appointment with dr to be seen in weeks you will need a thoracic spine mri with and without contrast prior to your appointment completed by,"{
""name"": ""MR [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051**] [**Name (NI) 1051"
29881,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint nausea vomiting flank pain major surgical or invasive procedure femoral line placement history of present illness the patient is a yo f with no significant pmh p w nausea vomiting and back pain x days the patient reports that days ago she started having back pain and some nausea yesterdady started feeling febrile per report from the daugther the patient was shivering and cold this morning and complained that her whole body ached she went to her pcp s office and fainted and was sent to the er ros denies chest pain shortness of breath abdominal pain dysuria per patients cousin the patient has been complaining of dizziness and low blood pressure over the past months in the ed initial vital signs were t hr bp rr ra she was found to have an elevated wbc a lactate of and a positive ua ucg negative she received a dose of cipro mmg iv x and l ns she was monitored in obs and the plan was to d c after observation during the afternoon she developed chills and received toradol mg x and morphine but vital signs remained stable hrs after presentation the patient was again febrile to bp sbp s normal resp rate hours later the patient was found to have a bp t hr and a repeat lactate of she received l ns and was moved back into the core of the ed she was subsequently found to have an sbp in the s and was increasingly somnolent with hr s a urgent right groin line was placed and the patient was put on levophed sbp s were then in the s her levophed was decreased to and she had received l at the time of transfer to the icu she received ceftriaxone g x in addition to the cipro for broader coverage past medical history none s p uncomplicated vaginal deliveries social history the patient is divorced she works as a housekeeper and lives with her children ages and she does not smoke or do illgeal drugs occasional etoh excercises vigorously daily family history non contributory physical exam vitals ra general patient very sleepy arousable but quickly falls back to sleep heent perrl eomi cv tacycardic no murmur appreciated lungs cta b l abdomen mild lower abdominal tenderness non distended well healed lower abdominal scar ext no edema dp pt pulses bilaterally pertinent results am plt smr normal plt count am neuts bands lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am glucose urea n creat sodium potassium chloride total co anion gap am lactate pm urine rbc wbc bacteria mod yeast none epi pm urine blood mod nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn neg ph leuk mod am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso atyps metas myelos am blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos amylase totbili am blood albumin calcium phos mg ct abd w w o c pm ct abd w w o c ct pelvis w w o c reason please evaluate for obstruction or stone contrast optiray medical condition year old woman with pyelonephritis and hypotension hypotension now improved but with persistent back pain reason for this examination please evaluate for obstruction or stone contraindications for iv contrast none indication pyelonephritis and hypotension hypotension persistent back pain evaluate for stones or obstruction comparison none technique mdct acquired axial images of the abdomen and pelvis were obtained with and without iv contrast multiplanar reformatted images were also displayed ct of the abdomen with and without iv contrast large bilateral pleural effusions right greater than left with associated atelectasis are seen at the visualized lung bases the liver is grossly unremarkable perihepatic ascites and small amount of free fluid within the abdomen are noted gallbladder wall thickening noted without evidence of gallbladder distention the pancreas appears to enhance homogeneously the spleen and adrenal glands appear grossly unremarkable no renal stones identified multiple foci of hypoenhancement are seen within the left kidney consistent with known history of pyelonephritis larger more rounded lower attenuation lesion measuring upwards of cm seen in left kidney possibly representing hemorrhagic cyst underlying cystic lesion or more focal area of infection no drainable collection seen smaller low attenuation lesions seen within the kidneys bilaterally possibly represent cysts although too small to characterize by ct there is no evidence of hydronephrosis no abnormally dilated loops of bowel are seen small to moderate amount of free fluid is seen throughout the abdomen with mesenteric stranding scattered retroperitoneal lymph nodes are seen however none appear to meet ct criteria for pathologic enlargement soft tissue edema is seen consistent with mild anasarca ct of the pelvis with iv contrast the rectum and sigmoid appear unremarkable small to moderate amount of free fluid is seen within the pelvis foley catheter is seen within the bladder bone windows no suspicious lytic or blastic lesions are identified impression foci of hypoattenuation seen within the left kidney consistent with known history of pyelonephritis more cystic appearing lesion warrants followup mri after treatment or sooner if patient continues to appear infected discussed with dr on no evidence of renal stones or hydronephrosis moderate ascites large bilateral pleural effusions and soft tissue edema suggesting mild anasarca gallbladder wall thickening likely from third spacing of fluid clinical correlation is recommended chest portable ap am chest portable ap reason please evaluate for interval change medical condition year old woman with no significant past medical history was admitted with pyelonephritis and hypotension and now with mild hypoxia in the setting of aggressive fluid resuscitation reason for this examination please evaluate for interval change indication year old woman with hypoxia status post aggressive fluid resuscitation comparisons chest radiograph dated findings a single ap portable upright view of the chest reveals new bibasilar hazy opacities suggestive of pleural effusions there is new perihilar predominant air space opacity compatible with moderate to severe pulmonary edema there is no pneumothorax and the cardiomediastinal silhouette appears stable accounting for differences in patient positioning impression new pleural effusions and moderate to severe pulmonary edema renal u s am renal u s reason abscess please evaluate cyst and interval enlargement medical condition year old woman with pyelonephritis being treated still spiking reason for this examination abscess please evaluate cyst and interval enlargement indication year old woman with pyelonephritis who is still febrile despite treatment comparison ct of the abdomen and pelvis from renal ultrasound the right kidney measures cm the left kidney measures cm the areas of hypoattenuation seen on the recent ct scan in the left kidney are not demonstrated on the current study a mm focus of hyperechogenicity in the lower pole of the left kidney likely represents an angiomyolipoma as was also seen on the recent ct there is no evidence of drainable fluid collection and no hydronephrosis the bladder appears unremarkable the vascularity within the left kidney also appears normal impression areas of hypoattenuation seen in the left kidney on recent ct dated are not visualized by ultrasound as was previously recommended on the ct followup mri after treatment can be performed to evaluate one of the more cystic appearing lesions seen on the ct study if these are areas of pyelonephritis it is entirely likely that these will not be visible on ultrasound no drainable fluid collections brief hospital course yo f with no pmh admitted with pyelonephritis complicated by hypotension requiring levophed now with significantly improved blood pressure hypotension patient was hypotensive requiring levophed on admission and with lactate elevated to hypotension was thought most likely secondary to septic shock etiology thought likely secondary to pyelonephritis elevated wbc lactate originally ua positive flank pain patient was aggressively fluid resuscitated with l of normal saline and responded with improvement in bp and decrease in lactate to cxr was not suggestive of infection and blood cultures have not yet grown any organisms pyelonephritis patient with significant back pain and leukocytosis on admission with positive ua ctu on was consistent with pyelonephritis and did not find stones or obstruction patient was started on broad spectrum antibiotics with ceftriaxone and ciprofloxacin urine cultures have not yet grown any organisms the patient s ceftriaxone was discontinued after two days once the patient was afebrile and hemodynamically stable she was continued on ciprofloxacin and instructed to complete a day course of note a cystic lesion was observed on the patient s kidney and follow up with mri was recommended for better characterization if she does not improve hypoxia patient has intermittently decreased sao to high s s while in micu cxr shows moderate to severe pulmonary edema and bilateral pleural effusions she was not diuresed but was instruced to sit upright on transfer to the floor her oxygen requirement was gradually weaned and she had adequate oxygen saturation on room air the day before discharge medications on admission none discharge medications acetaminophen mg tablet sig tablets po q h every hours as needed cipro mg tablet sig one tablet po twice a day for days take for tablet twice daily for ten more days stopping on disp tablet s refills combivent mcg actuation aerosol sig puffs inhalation qid prn as needed for shortness of breath or wheezing take puffs four times daily as needed for wheezing shortness of breath disp actuation aerosol refills ranitidine hcl mg tablet sig one tablet po bid times a day discharge disposition home discharge diagnosis pyelonephritis septic shock discharge condition good discharge instructions you were admitted to the hospital with an infection of your urinary system called pyelonephritis while in the hospital the infection became so severe as to cause your blood pressure to drop you were treated with aggressive fluid resuscitation along with pressure increasing medications in addition to antibiotics your blood pressure resultingly returned to please return to the hospital if you experience fever chest pain or shortness of breath please return to the hospital if you experience worsening back pain please contact your pcp to schedule an appointment for next week followup instructions please contact your pcp to schedule an appointment for next week md,"{
""date"": ""2019-10-10"",
""type"": ""admission"",
""subtype"": ""N/A"",
""code"": ""2190-10-10"",
""age"": 73,
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Percocet""
],
""attending:[**First Name3 (LF) 1055**] [**Last Name (NamePattern1) 1056**] [**Last Name (NamePattern1) 1057**] [**Last Name (NamePattern1) 1058**] [**Last Name (NamePattern1) 1059**] [**Last Name (NamePattern1) 1060**] [**Last Name (NamePattern"
11254,admission date discharge date date of birth sex m service cardiothoracic allergies aspirin levaquin chocolate flavor attending chief complaint cva currently asymptomatic major surgical or invasive procedure minimally invasive asd closure history of present illness yo m who presented with slurred speech ride sided numbness and weakness and headache in mri confirmed stroke stroke w u revealed asd past medical history cva headaches concussion as teenager social history pt lives alone in an apartment he smokes tobacco rarely he has approximately one drink day but can have up to drinks at a sitting on some occasions he admitted to use of marijuana most recently last night but denied ever using cocaine or intravenous drugs family history notable for mother and sister with migraine headaches his mother had two miscarriages no history of young stroke or epilepsy in other family members known history of hypercoagulable disorders connective tissue disorders physical exam nad hr papular rash over back eomi perrla no lad lungs ctab rrr abd benign well healed rlq scar from bike accident extrem warm neuro grossly intact pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood glucose urean creat na k cl hco angap am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood glucose urean creat na k cl hco angap echocardiography report complete done at pm preliminary referring physician information division of cardiothoracic status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication congenital heart disease left ventricular function icd codes test information date time at interpret md md test type tee complete son md doppler full doppler and color doppler test location anesthesia west or cardiac contrast none tech quality adequate tape aw machine echocardiographic measurements results measurements normal range left ventricle ejection fraction to findings left atrium normal la size no spontaneous echo contrast or thrombus in the body of the laa all four pulmonary veins identified and enter the left atrium right atrium interatrial septum normal ra size no thrombus in the raa left to right shunt across the interatrial septum at rest small secundum asd left ventricle wall thickness and cavity dimensions were obtained from d images normal lv wall thicknesses and cavity size right ventricle mildly dilated rv cavity normal rv systolic function aorta normal ascending transverse and descending thoracic aorta with no atherosclerotic plaque normal aortic root diameter normal descending aorta diameter aortic valve normal aortic valve leaflets no as no ar mitral valve normal mitral valve leaflets with trivial mr tricuspid valve normal tricuspid valve leaflets with trivial tr mild tr pulmonic valve pulmonary artery normal pulmonic valve leaflets with physiologic pr pericardium trivial physiologic pericardial effusion general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations no tee related complications the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope the patient was under general anesthesia throughout the procedure regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions pre cpb the left atrium is normal in size no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage no thrombus is seen in the right atrial appendage a left to right shunt across the interatrial septum is seen at rest a small secundum atrial septal defect is present left ventricular wall thicknesses and cavity size are normal the right ventricular cavity is mildly dilated right ventricular systolic function is normal the ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation there is a trivial physiologic pericardial effusion venous and arterial access cannulas were positioned under tee guidance post cpb preservrd biventricular systolic function interrogation of ias shows a small l to r shunt on clolor flow doppler which further decreased with protamine infusion interpretation assigned to md interpreting physician radiology detail ccc record preliminary report pa and lateral chest history asd closure impression pa and lateral chest compared to through postoperative opacification in the right lower lobe has improved but not cleared depending upon clinical circumstances this could be consistent atelectasis or aspiration tiny bilateral pleural effusion and a miniscule right apical pneumothorax probably of no active clinical significance heart is normal size and there is no pulmonary edema subcutaneous emphysema noted in the anterior chest wall dr caregroup is all rights reserved brief hospital course on he underwent a minimally invasive asd closure with dr he was transferred to the csru in stable condition on a propofol drip he was extubated later that same day his chest tube was removed on pod without incident and he was transferred to the floor to begin increasing his activity level he was started on nsaids around the clock for two weeks he was ready for discharge on pod to home with services pt is to make all follow up appts as per discharge instructions medications on admission patanol eyedrops daily at home discharge medications docusate sodium mg capsule sig one capsule po bid times a day for weeks then as needed only disp capsule s refills fexofenadine mg tablet sig one tablet po bid times a day ranitidine hcl mg tablet sig one tablet po bid times a day for months disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours for weeks around the clock x weeks then prn disp tablet s refills hydromorphone mg tablet sig one tablet po q h every hours as needed disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis asd pmh headaches cva discharge condition good discharge instructions call with fever redness or drainage from incision or weight gain more than pounds in one day or five in one week shower no baths no lotions creams or powders to incisions no driving for two weeks or while taking narcotics no lifting greater than pounds for weeks p instructions dr weeks dr weeks dr weeks completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-12"",
""date_of_birth"" : ""1973-1-1"",
""sex"" : ""Male"",
""service"" : ""Cardiothoracic"",
""allergies"" : [
""aspirin""
,""levaquin""
,""chocolate flavor""
],
""attending_chief_complaint"" : ""CVA currently asymptomatic"",
""chief_complaint"" : ""slurred speech, ride sided numbness and weakness, headache"",
""history_of_present_illness"" : ""YO M who presented with slurred speech, ride sided numbness and weakness, and"
51179,admission date discharge date date of birth sex m service cardiothoracic allergies sulfa sulfonamide antibiotics attending chief complaint further treatment of alveolopleural fistula major surgical or invasive procedure right thoracotomy excision of th rib repair of alveolar pleural fistula with glue and pleural tent bronchoscopy right pleurodesis with doxycycline via chest tube bronchoscopy with ibv valves deployed to anterior and posterior segment of the rul history of present illness mr is a year old male with copd on l home o and l with exertion and rul mass which was pet avid thought to be cryptogenic organizing pna by pathology admitted and underwent vats wedge resection with placement of chest tube in procedure complicated by persistent alveolopleural fistula still requiring chest tube on constant suction he is being admitted for elective endobronchial intervention to see if the fistula can be sealed possibly with an endobronchial valve or plug past medical history alveolopleural fistula following vats resection on organizing pna in lul htn sarcoidosis in h o alcoholism gerd iron deficiency h o tobacco abuse adhd bone graft in the wrist social history pack yr hx of smoking quit yrs ago former etoh denies now no illicits lives in with wife two sons live in and prior to was able to play golf perform adls family history father had mi mother died of chf physical exam admission vitals t bp p on my exam r o nrb general alert oriented appears slightly uncomfortable but improving at end of exam speaking in full sentences heent sclera anicteric mmm oropharynx clear facemask in place neck supple jvp not elevated no lad lungs moderate symmetric air entry bibasilar insp crackles continuous gurgling sound above chest tube site under r scapula cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses mild clubbing no cyanosis or edema neuro cns intact motor function grossly normal discharge vital signs t bp hr after walking o sats l nc walking on nrb discharge physical exam gen pleasant dyspneic at baseline alert and oriented x without deficit perrla lungs diminished b l right thoracotomy site healing right chest tube to water seal via pneumostat cv rrr s s no mrg abd soft nt nd ext warm without edema pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso pm blood pt inr pt am blood glucose urean creat na k cl hco angap am blood calcium phos mg discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct renal glucose glucose urean creat na k cl hco angap calcium phos mg anca neg hiv neg neg prealbumin aspergillus galactomannan antigen test result reference range units aspergillus antigen histoplasma antibody by cf and id test result reference range units yeast phase antibody mycelial phase antibody interpretive criteria antibody not detected or antibody detected coccidioides antibody immunodiffusion test result reference range units coccidioides antibody id negative negative interpretive criteria negative antibody not detected positive antibody detected angiotensin converting test result reference range units ace serum u l blastomycosis antibody by cf and id test name in range out of range reference range blastomyces antibody panel cf and id blastomyces antibody cf interpretive criteria antibody not detected or antibody detected b glucan test fungitell tm assay for b d glucans results reference ranges pg ml negative less than pg ml indeterminate pg ml positive greater than or equal to pg ml report comment pleural fluid chemistry total protein pleural g dl glucose pleural mg dl lactate dehydrogenase pleural iu l pleural analysis wbc rbc polys lymphs monos eos pleural fluid ph pm serology blood source line l picc final report cryptococcal antigen final cryptococcal antigen not detected pm pleural fluid pleural fluid gram stain final per x field polymorphonuclear leukocytes no microorganisms seen fluid culture final no growth anaerobic culture final no growth fungal culture preliminary no fungus isolated acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary no mycobacteria isolated pm sputum source expectorated gram stain final pmns and epithelial cells x field gram stain indicates extensive contamination with upper respiratory secretions bacterial culture results are invalid please submit another specimen respiratory culture final test cancelled patient credited fungal culture preliminary gram stain of this specimen indicates contamination with oropharyngeal secretions and invalidates results specimen is only screened for cryptococcus species new specimen is recommended acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary no mycobacteria isolated imaging pcxr findings no previous images evidence of prior surgical procedure on the right with a small amount of subcutaneous gas along the chest wall no evidence of pneumothorax diffuse prominence of interstitial markings consistent with the clinical observation of pulmonary fibrosis left central catheter extends to the lower portion of the svc pcxr there is interval worsening of now moderate right pneumothorax a right sided chest tube remains in the right lateral pleural space unchanged clips in the right superior hilum and suture lines in the right upper lung are compatible with the reported wedge resection there is no left sided pneumothorax there is also interval increase of right lateral chest wall subcutaneous gas unchanged moderate bibasilar honeycombing is grossly similar in severity the cardiomediastinal silhouette is normal impression interval increase of right pneumothorax with increase of right lateral chest wall subcutaneous gas pcxr one view comparison with the previous study done there is interval increase in a small right pneumothorax a right chest tube has been withdrawn bilateral pulmonary opacities persist left apical capping is unchanged a left picc line remains in place mediastinal structures are stable subcutaneous emphysema is again demonstrated on the right impression interval increase in right pneumothorax post chest tube withdrawal tte the left atrium is normal in size no atrial septal defect is seen by d or color doppler the estimated right atrial pressure is mmhg there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of no change ct chest impression small right apical and anterior pneumothorax which is slightly increased in size since the prior study new irregularly shaped pulmonary nodule in the right upper lobe measuring up to cm most consistent with cop given its appearance and relatively rapid appearance since the prior study severe emphysema and severe pulmonary fibrosis stable prominent mediastinal lymph nodes are stable and likely reactive to the underlying pulmonary process cxr impression ap chest compared to p m on moderate to large right pneumothorax is unchanged small fluid component has decreased pulmonary fibrosis and left apical pleural thickening are unchanged heart size is normal apical pleural tube unchanged in position brief hospital course mr was admitted to from for management of alveolarpleural fistula with ongoing airleak via chest tube he was admitted initially to the medicine service with a chest tube to suction on inteventional pulmonology was consulted and performed ibv valve placement after irb approval on doxycycline pleurodesis was done on however despite this the alveolar pleural fistula continued thoracic surgery was initally consulted and followed along on dr took the patient to the operating room for a right thoracotomy excision of th rib repair of alveolar pleural fistula with glue and pleural tent and bronchoscopy from the operating room he transfered to the sicu intubated sedated chest tubes an bupivicaine epidural and foley on he was successfully extubated however required high amounts of oxygen for several days pulmonary medicine was consulted to assist in augmenting medical management see their note for full recommendations labs all drawn and negative see results section an echo was done showing moderate pulmonary hypertention the patient was actively diuresed and over time his oxygen requirement went down from facemask to l nc he remained in the sicu for close respiratory monitoring given his poor lung function ongoing chest tube leak despite multiple interventions we discussed lung transplantation with who recommended six minute walk which was done twice first on which he performed feet walk in minutes he repeated this on which he passed below is systems review of his hospital course neuro the patient was mentally intact throughout his stay he required ativan for anxiety control and pain was controlled with percocet as mentioned above he had bupivicaine epidural and dilaudid pca which was stopped pulmonary pulmonary toilet has continued throughout his stay as noted above his oxygen requirements on admit were l now l nc he was intubated for a day during surgery he has one remaining chest tube from surgery to water seal x day with stable pneumothorax and obligate space following pleural tent a cxr was done on pneumostat with persistent ptx secretions are not an issue if the patient developed worsening dyspnea or desaturation we would recommend stat portable chest xray and if worse ptx convert pneumostat to pneumovac to wall suction cv the patient remained hemodynamically stable in sr throughout his stay nutrition the patient was able to eat throughout his stay nutrition consulted and recommended ongoing supplementation with magic cup tid and ongoing monitoring as his prealbumin is low gi constipation became an issue on therefore a bisacodyl suppository was added to his regimine of stool softeners with a large bm prior to discharge renal he was gently diuresed mg iv daily to maintain euvolemia and assist improve oxygenation his lasix was changed to mg po daily starting his renal function within normal limits with good urine output his electrolytes were replete as needed please assess this daily along with electrolytes lines double lumen left picc maintained from in good condition id no issues throughout his stay nor antibiotic requirements endo the patient s blood sugars were watched and covered with insulin sliding scale disposition pt ot consultation was made pt ambulated and got out of bed it was recommended the patient go to acute rehab accepted the patient and he was deemed stable by dr for discharge on did not have the acute care rehab therefore it was decided he would best be served staying in the city the wife was called and plan communicated that patient was transferring report called to dr pt was in agreement to transfer he was stable at time of transfer medications on admission aspirin mg qod calcium vit d tabs advair puff spiriva mcg ih daily mvi daily protonix mg po daily fish oil iron tab daily discharge medications fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily albuterol sulfate mg ml solution for nebulization sig three ml inhalation q h every hours as needed for wheezing pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours heparin porcine unit ml solution sig one sq injection tid times a day lorazepam mg tablet sig tablets po q h every hours as needed for anxiety oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain senna mg tablet sig one tablet po bid times a day as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day sertraline mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily simethicone mg tablet chewable sig one tablet chewable po qid times a day as needed for gas cramps furosemide mg tablet sig one tablet po daily daily dronabinol mg capsule sig one capsule po bid times a day bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation regular insulin sliding scale mg dl units units units mg dl units units units mg dl units units units mg dl units units units mg dl units units units mg dl units units units mg dl units units units mg dl units units units heparin flush units ml ml iv prn line flush picc heparin dependent flush with ml normal saline followed by heparin as above daily and prn per lumen dextrose gm iv prn hypoglycemia protocol discharge disposition extended care facility discharge diagnosis persistent air leak following wedge resection of right upper lobe pulmonary fibrosis boop organizing pneumonia in lul copd chronic mediastinal lymph node sarcoidosis gerd etoh abuse iron deficiency adhd osteopenia l inguinal hernia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions call dr office if you experience fevers or chills increased shortness of breath cough or chest pain right thoracotomy incision develops drainage chest tube to water seal via pneumostat assess every shift drain if drainage and record if acute shortness of breath get a stat cxr and if worse ptx change to pneumovac with wall suction change dressing daily activity shower daily wash incision with mild soap and water rinse pat dry no tub bathing swimming or hot tubs until incision healed pt and treat picc line per protocol daily weight with adjustment of lasix monitor daily lytes and replace as needed check blood sugars q ac and q hs and use insulin sliding scale followup instructions follow up with dr am on the clinical center chest x ray radiology minutes before your appointment completed by,"[
""admission_date"",
""discharge_date"",
""date_of_birth"",
""sex"",
""service"",
""allergies"",
""sulfa"",
""sulfonamide"",
""antibiotics"",
""attending_chief_complaint"",
""chief_complaint"",
""further_treatment_of_alveolopleural_fistula"",
""major_surgical_or_invasive_procedure"",
""right_thoracotomy"",
""excision_of_th_rib"",
""repair_of_alveolar_pleural_fistula_with_glue_and_pleural_tent"",
""bronchoscopy_right"",
""bronchoscopy_with_ibv_valves_deployed_"
17149,admission date discharge date date of birth sex m service surgery allergies plavix simvastatin tape hydrochlorothiazide attending chief complaint esrd here for living related kidney transplant major surgical or invasive procedure living related kidney transplant kidney biopsy donor disease no rejection history of present illness esrd secondary to wegeners that was diagnosed in with recent progression of kidney disease he recently started on hemodialysis in he has had no significant complications of dialysis although he does note that he feels fatigued for several hours after the treatments he was felt to be a good candidate for transplant and will receive a kidney from his sister past medical history atrial fibrillation recently diagnosed noted to be back in sinus on discharge dced on acute on crf chronic proteinuria baseline cr until last week when cr acutely increased at that time rbc casts on sediment renal ultrasound negative for hydronephrosis fe urea c w pre renal anca negative c wnl c wnl spep with igg other igg s wnl upep multiple protein bands seen no monoclonal bands renal consulted and felt most confident this reflected progression of wegener s cad multiple stent most recent stent in chronic angina hypertension hypercholesterolemia wegener s granulomatosis renal pulmonary involvement diagnosed s p cytoxan prednisone x y initially anca neg since chronic proteinuria baseline cr idiopathic pericarditis gerd depression anxiety gout umbilical hernia repair social history married with children lives w wife and youngest daughter two other children who live in quit smoking years ago rare etoh denies illicit drugs family history mother cva at myasthenia father cad died at six siblings one sister died of melanoma a sister has scleroderma and another sister has physical exam vs gen nad card nl s s lungs cta bilaterally abd midline incision with dressing in place extr no edema r tunneleed hemodialysos catheter pertinent results on admission wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap calcium phos mg on discharge wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap alt ast alkphos totbili calcium phos mg fk biopsy results from there is no evidence of humoral rejection in this sample there is significant chronic donor vascular disease particularly in larger arteries while the infarct may relate to the ligated artery clinical correlation is indicated to determine its significance the medullary changes are insufficient for a definite diagnosis of acute cellular rejection brief hospital course patient admitted following living related kidney transplant from his sister this is reported as a perfect match hla transplant please see the operative note for the surgical details there was a large hernia defect just above the umbilicus that was included in the incision also the kidney was a little sluggish to reperfuse and remained soggy and somewhat purplish in appearance but as hemostasis was maintained in the retroperitoneum it eventually pinked up and began making urine he received intra op immunosuppression to include simulect doses total day and cellcept and solumedrol prograf was started on the evening of pod due to cardiac history with presence of stent the ticlid was restarted on pod dressing over incision required frequent changes due to bloody dressings in addition he was becoming increasingly bloated and uncomfortable an abdominal ct done on pod showed no evidence of dilated loops of bowel no ct finding to explain abdominal pain on this limited non contrast evaluation unremarkable non contrast appearance of transplant kidney in the right lower quadrant on pod his creatinine was noted to be rising highest value on pod of transplant u s showed minimal simple appearing perinephric fluid collection with otherwise normal transplant ultrasound with appropriate arterial and venous waveforms and resistive indices patient was still continuing with distention and abdominal pain kub on pod showed persistent air distention of the cecum and transverse colon with less distention of the distal colon and sigmoid compared to a day prior this was concerning for ogilvies syndrome seen by gi service who felt the ileus was improving and initially recommended conservative management however on it was decided to attempt neostigmine treatment which was successful in alleviating the bowel distention biopsy also performed on for the rising creatinine it was determined that the kidney disfunction was a result of donor problems and was not rejection or tma received units prbc s for slowly downward trending hct patient transferred back to following the neostigmine by pod his bowel function returned abdominal incision was opened in two areas which will rewuire dressing changes upon discharge creatinine has improved to on day of discharge with urine output of about cc day patient was never dialyzed his hd catheter will remain in place for removal at future time in clinic medications on admission labetalol isosorbide mononitrate imdur norvasc cozaar asa ticlopidine allopurinol furosemide protonix colace zoloft requip phoslo tid lisinopril crestor tricor discharge medications trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours nystatin unit ml suspension sig five ml po qid times a day docusate sodium mg capsule sig one capsule po bid times a day mycophenolate mofetil mg tablet sig two tablet po bid times a day oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills senna mg tablet sig one tablet po bid times a day disp tablet s refills sertraline mg tablet sig one tablet po daily daily isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily valganciclovir mg tablet sig one tablet po qod ropinirole mg tablet sig three tablet po qpm once a day in the evening aspirin mg tablet sig one tablet po daily daily ticlopidine mg tablet sig one tablet po bid times a day labetalol mg tablet sig two tablet po bid times a day potassium sodium phosphates mg packet sig one packet po tid times a day disp packet s refills discharge disposition home with service facility vna of greater discharge diagnosis esrd s p kidney transplant discharge condition good discharge instructions please call the transplant office at if you experience fever chills nausea vomiting diarrhea or constipation monitor incision for redness drainage or foul smelling discharge dressing change to abdominal incision twice a day pack two open areas very lightly with a single x and cover with gauze and paper tape do not use occlusive dressings or silk tape have labs drawn every monday and thursday and faxed to clinic at cbc chem ca phos ast t bili u a trough prograf level hold on showering until incisions are more well healed do not drive if taking narcotic pain medications continue colace and senna as long as on pain medication or as long as needed followup instructions md phone date time md phone date time md phone date time completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies plavix simvastatin tape hydrochlorothiazide eptifibatide attending chief complaint chest pain angina shortness of breath major surgical or invasive procedure intubated extubated history of present illness yo gentleman with h o cad s p mis renal transplant for wegener s granulomatosis htn dyslipidemia and paroxysmal afib p w accelerating angina he c o pain in his jaw which then moves to his throat and then the middle of his chest feels like pressure symptoms are provoked by activity and associated with dyspnea patient states that symptoms began a few months ago and have been worsening in the sense that they come on with less stimulus now just with walking across the room and only resolve with nitro he also reports feeling exhausted he has had a cough productive of large amounts of white sputum x week sinus congestion which he reports feeling like it is dripping down the back of his throat and collecting in his lungs he also notes subjective fevers at home and nausea with episode of non bloody emesis in the ed he has had diarrhea about times a day like minestrone soup he denies sore throat abdominal pain or dysuria and he only gets headaches when he takes the nitroglycerin of note he does endorse pnd and orthopnea as well as ankle edema he reports pounds of weight gain in the last week in the ed his vs were tmax ra he was given asa mg and tylenol mg as well as metoprolol mg iv levaquin mg po was administered at for concern of pneumonia ekg showed st depression in v v as well as i and avl and upsloping st elevation in v and v troponin was last trop in patient was evaluated by the cardiology fellow and a heparin gtt was ordered but not started per nursing notes patient was also seen by transplant nephrology fellow past medical history paroxysmal atrial fibrillation not on coumadin esrd s p living donor sister renal transplant in cad s p acute mi with palmaz lad and rca stents s p rotablation and hepacoat stent to the d in treated with brachytherapy for instent restenosis in s p taxus stent in rpl in s p two cypher stents placed in the rca cath in with ostial stenosis of lad moderate diffuse disease of lcx proximal of rca with in stent restenosis with a in the pl branch taxus stent for latest cath see pertinent results denies h o dm however sugars have been elevated in past chronic angina hypertension hypercholesterolemia wegener s granulomatosis renal pulmonary involvement diagnosed s p cytoxan prednisone x y initially anca neg since chronic proteinuria now s p renal transplant in idiopathic pericarditis gerd anxiety endorses dysthymic symptoms but not depression gout umbilical hernia repair restless leg syndrome outpatient cardiologist nephrologist dr transplant nephrologist pcp allergies plavix rash simvastatin myalgia tape rash hctz unkown reaction social history social history is significant for the absence of current tobacco use quit years ago there is no history of alcohol abuse he endorses rare etoh no illicit drugs married with children lives w wife and youngest daughter family history there is no family history of premature coronary artery disease or sudden death mother had cva at sister with scleroderma and another sister with physical exam vs ra pounds gen pale appearing middle aged male in nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink with some pallor but no cyanosis of the oral mucosa no xanthalesma neck supple jvp of cm cv pmi located in th intercostal space midclavicular line rr normal s s no m r g no thrills lifts no s or s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use crackles l r with good air entry b l abd soft nt mildly distended no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits ext no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas somewhat diaphoretic pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results laboratory data ck troponin ck mb hct cr ekg demonstrated nsr with old q wave in v but new st depressions in v v and i avl as well as st elevations in v and v as compared with prior dated cxr two views of the chest there are slight increased patchy opacities in the right lower lobe which is seen to project posteriorly on the lateral view this may represent an early developing pneumonia the left lung is clear the aorta is tortuous small kerley b lines suggest mild interstitial edema the bony thorax is normal impression possible early developing right lower lobe pneumonia mild interstitial edema echo the left atrium and right atrium is moderately dilated a left to right shunt across the interatrial septum is seen at rest c w a small secundum atrial septal defect left ventricular wall thicknesses and cavity size are normal there is moderate regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferior and inferolateral walls and distal lateral and anterior walls the remaining segments contract normally lvef no masses or thrombi are seen in the left ventricle right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are structurally normal there is no mitral valve prolapse moderate mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression regional left ventricular systolic dysfunction c w cad moderate mitral regurgitation most likely due to papillary muscle dysfunction secundum type atrial septal defect mild pulmonary artery systolic hyertension compared with the prior study images reviewed of regional left ventricular systolic dysfunction is more extensive now involving the basal inferior and inferolateral walls the severity of mitral regurgitation has increased and pulmonary artery systolic hypertension is now identified the secundum type atrial septal defect is now better defined portable abdominal ultrasound findings limited grayscale images of the abdomen do not detect ascites and limited views of the liver suggest normal echotexture impression no ascites cxr increased airspace disease is evident by progressive increasing density of the bilateral consolidations the left now clearly expressing itself as such there is a subtle motion degradation though lateral costophrenic sulci are still reasonably delineated heart size is enlarged impression worsening airspace disease bilaterally for which bilateral pneumonias most fitting abdominal film on indication abdominal distention increased dyspnea and difficulty breathing a single view of the abdomen shows nonspecific non obstructed bowel gas pattern with predominantly gas filled large bowel visualized the appearance is quite similar to a remote prior abdominal film from on the current study there are surgical clips overlying the sacrum and there is no evidence for pneumatosis no ascites cxr increased airspace disease is evident by progressive increasing density of the bilateral consolidations the left now clearly expressing itself as such there is a subtle motion degradation though lateral costophrenic sulci are still reasonably delineated heart size is enlarged impression worsening airspace disease bilaterally for which bilateral pneumonias most fitting echo the left atrium is elongated the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is moderate regional left ventricular systolic dysfunction with inferior inferolateral and apical hypokinesis with mild hypokinesis elsewhere right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated the aortic valve leaflets appear structurally normal with good leaflet excursion trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion agitated saline contrast study is suggestive of intracardiac shunt with valsalva release consistent with the presence of a patent foramen ovale or asd compared with the prior study images reviewed of ventricular function appears similar brief hospital course hospital course admitted to with nstemi with positive enzymes peak trop ck ck mb and ekg with inferolateral mm st depressions mm st depressions in avl and mm ste in avr has baseline mm ste in v v had tte here after admission on confirming the ef of as well as focal hk of basal inferior and inferolateral walls and distal lateral and anterior walls was started on heparin gtt integrillin gtt the latter of which was d c d on the day of transfer to the ccu was treated with abx for pna and pulm also had plan for bronch ibal but course was complicated by intermittent hypotension and hct drop to for which he was transfused units of prbc s and l of ns after receiving the blood transfusion pt started to experience acute sob this am at around am patient was given furosemide mg iv with urine output of cc in hours he was also given morphine mg iv x and lorazepam mg iv x no associated fevers with transfusion although he did spike to the day prior he does have perihilar consolidation and hemoptysis and was followed by pulmonary and ent surgery who at this point recommended no steroids since they did not beleive this to be wegener s flare he was also followed by renal team for worsening acute renal failure that was though to be pre renal in etiology hospital course pna pt arrived to the ccu in respiratory distress with rr of abg bipap was tried but pt was eventually intubated since the ccu teamed feared he was becoming fatigued pt was found to have bilateral pulmonary infiltrates r l and hypoxia in the setting of a pneumonia and hemoptysis starting after integrillin dah was suspected pulm bronched pt showing minimal blood and hemoptysis resolved quickly after intergrillin had been stopped anca was negative making wegener s very unlikely the thinking was that pulm hemorrhage was inflammation due to pna pt was afebrile without a cough off oxygen ambulating well with good o sats on disccharge chf with ef pt also arrived fluid overloaded and in acute on chronic systolic heart failure after the transfusions he was given iv lasix over the next couple of days with great results days into the stay in the ccu pt started autodiuresing for a total of about l for the duration of the ccu stay repeat echo on was unchaged from cad s p mulitple stents pt likely had a minor nstemi on admission and definitely had interval inferolateral wall motion abnormalities from prior to admission the decision was made to continue to medical management and do a stress mibi as an outpatient for risk startification since this all happened in the setting of an acute illness patients creatinine was also presenting another argument to hold off on doing a cath plan was for f u with cards in weeks which was communicated with pt atrial fibrillation on the evening of extubation pt entered afib with a ventricular resonse rate of s lopressor mg iv x and diltiazem was both tried but unsucessful therefore cardioversion was performed with pt returning into sinus rhyhtm pt stayed in sinus for the remainder of hosp stay until d c metabolic acidosis diarrhea hypokalemia pt had an anion gap of when arriving to the floor likely uremia the ag corrected failry quickly however pt still had an acidosis with a low bicarb since he continued to have diarrhea with loose stools per day pt was therefore given bicarb per renal recommendation with good effect the cause of the diarrhea was not found in hosp and was negative for c diff x o p shigella salm legionella among other things immodium was prescibed with some effect and mycophenolate preparation was changed since the different preparations have different gi side effects hypokamlemia to was repleted agressively pt was given mg daily of k to take at home and to eat banana s especially if diarrhea continued pt was instructed to follow up closely with his pcp to have potassium checked on and wegener s disease patient is s p match donor transplant in with basline cr since meds were renally dosed bactrim for pcp while on immunosupression lisinopril was held due to raised creatinine sirolimus and cellcept initially continued sirolimus level was normal elevated then sirolimus was d c d due to concern over pulm toxicity renal recommended stopping sirolimus and starting tacrolimus once the sirolimus was tacrolimus was in therpeutic range at the time of d c anemia to with recent baseline hct as mentioned above was given units of prbc s prior to ccu transfer blood counts in the ccu improved with hct in range and no further transfusions were needed pt was guaiac negative and no other source of bleeding was identified other than the dah pancytopenia of unknown origin anemia as above also with platelets to high s but stable white count intially low to during the acute illness then recovered to normal range perhaps a medication effect although bone marrow biopsy may be indicated if persists and other causes are ruled out as an outpt medications on admission confirmed with patient and wife at time of admission amlodipine mg daily actos mg daily ambien mg po qhs prn sleep asa ec mg daily bactrim ss tab daily cellcept mg colace mg po daily ferrous sulfate mg daily not taking labetalol mg po bid lipitor mg daily lisinopril mg po bid nitroglycerin tablets mg sl prn chest pain nitroglycerin mg hr td patch daily with hour patch free interval at night protonix mg daily sirolimus rapamune mg daily ropinirole requip mg for restless leg zoloft mg po qam discharge medications amlodipine mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills ezetimibe mg tablet sig one tablet po daily daily disp tablet s refills trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily sertraline mg tablet sig one tablet po daily daily actos mg tablet sig one tablet po once a day zolpidem mg tablet sig one tablet po hs at bedtime as needed labetalol mg tablet sig five tablet po bid times a day disp tablet s refills mycophenolate sodium mg tablet delayed release e c sig four tablet delayed release e c po bid times a day disp tablet delayed release e c s refills ropinirole mg tablet sig three tablet po bid times a day lisinopril mg tablet sig one tablet po once a day nitroglycerin mg tablet sublingual sig one sublingual once a day take if experience chest pain may take on tab q minutes for a total of three doses if chest pain persists please call disp tabs refills protonix mg tablet delayed release e c sig one tablet delayed release e c po once a day diphenoxylate atropine mg tablet sig one tablet po q h every hours as needed for diarrhea for days disp tablet s refills tacrolimus mg capsule sig two capsule po q h every hours disp capsule s refills potassium chloride meq tab sust rel particle crystal sig two tab sust rel particle crystal po twice a day disp tab sust rel particle crystal s refills sodium bicarbonate mg tablet sig two tablet po three times a day disp tablet s refills outpatient lab work chem and tacrolimus level on and again on discharge disposition home discharge diagnosis pneumonia nstemi atrial fibrillation diffuse alveolar hemorrhage due to pneumonia and anticoagulaion acute on chronic systolic heart failure acute on chronic renal failure discharge condition stable discharge instructions stemi d c summ you were admitted to with a pneumonia acute on chronic systolic heart failure acute on chronic renal failure atrial fibrillation diffuse alveolar hemorrhage due to pneumonia and anticoagulaion and a small non st elevation myocardial infarction please take your previous medications as prescribed with the following changes please stop taking sirolimus please stop taking the nitroglycerin patch unless stable angina please increase labetalol to mg twice daily from mg please start taking myfortic instead of cellcept please start taking amlodopine mg instead of mg please do not take your evening dose of prograf on and restart in the am at mg twice daily on if you develop chest pain jaw pain or chest pressure with pain radiating into arm or if you for any reason become concerned about your medical condition please call or present to nearest ed we also gave you nitroglycerin tablets to take if you experience chest pain please call or your doctor if chest pain recurs even if it dissapears with nitroglycerine followup instructions provider lpn phone date time provider md phone date time provider md phone date time [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies plavix simvastatin tape hydrochlorothiazide eptifibatide cellcept attending chief complaint chest pain major surgical or invasive procedure cabgx left internal mammary artery to left anterior descending artery vein diagonal artery vein obtuse marginal artery vein posterior descending artery sequential to posterior left ventricular artery pfo closure cardiac catheterization history of present illness this is a yo m w extensive h o cad s p multiple pci last cath with ostial lad mod diffuse left circ prox rca medically managed recently admitted for a fib pna requiring intubation who presents with chest pain x h pt reports that x over the past couple of wks he has awoken from sleep w anginal pain which he describes as starting w upper jaw and teeth tingling sometimes radiating to throat and shoulders arms bl he reports that when it is very severe it also radiates to substernal chest he notes that prior to last night the angina lasted several minutes resolving w nitro radiating only to his throat not to shoulders arms chest he reports that last night pm he awoke w the anginal pain he took nitro at home w improvement but no resolution of pain it was associated w nausea which was especially concerning to pt b c he usually does not have associated sx he called the ambulance and was brought to osh where his pain was at the osh vitals upon presentation to osh ed were bp hr sat ra troponin i at osh was nl ekg was unchanged from baseline dated he received sl ntiro and heparin iv per weight based protocol was started pt was transferred to for further w u he notes that the cp resolved en route here after he received morphine iv he has been cp free since he notes that at baseline he is able to climb a flight of stairs w o cp or sob if he climbs flights which he has at home he does get some sob but does not have anginal pain sob resolves w rest he has only had his anginal pain while asleep he reports that he has otherwise felt well since discharge from his prior admission he does note fatigue but no f c no le edema intermittent palps which are his baseline no orthopnea pnd at pt s vitals were stable ekg showed mm st depressions v v troponins came back at his baseline he received asa and heparin iv was continued cardiology was notified pt has been chest pain free since arrival on review of systems he denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools he denies recent fevers chills or rigors he denies exertional buttock or calf pain all of the other review of systems were negative cardiac review of systems is as in hpi syncope or presyncope past medical history paroxysmal atrial fibrillation not on coumadin esrd s p living donor sister renal transplant in cad s p acute mi with palmaz lad and rca stents s p rotablation and hepacoat stent to the d in treated with brachytherapy for instent restenosis in s p taxus stent in rpl in s p two cypher stents placed in the rca cath in with ostial stenosis of lad moderate diffuse disease of lcx proximal of rca with in stent restenosis with a in the pl branch taxus stent for latest cath see pertinent results denies h o dm however sugars have been elevated in past chronic angina hypertension hypercholesterolemia wegener s granulomatosis renal pulmonary involvement diagnosed s p cytoxan prednisone x y initially anca neg since chronic proteinuria now s p renal transplant in idiopathic pericarditis gerd anxiety endorses dysthymic symptoms but not depression gout umbilical hernia repair restless leg syndrome outpatient cardiologist nephrologist dr transplant nephrologist pcp allergies plavix rash simvastatin myalgia tape rash hctz unkown reaction social history social history is significant for the absence of current tobacco use quit years ago there is no history of alcohol abuse he endorses rare etoh no illicit drugs married with children lives w wife and youngest daughter family history there is no family history of premature coronary artery disease or sudden death mother had cva at sister with scleroderma and another sister with physical exam vs ra pain gen middle aged male in nad oriented x heent ncat sclera anicteric perrl eomi no xanthalesma neck supple jvp of cm cv pmi located in th intercostal space midclavicular line rr normal s s systolic murmur no r g no thrills lifts no s or s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use clear bl no rrw abd soft nt mildly distended no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits transplanted kidney noted rectal guiac ext no c c e no femoral bruits skin no stasis dermatitis ulcers or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results admission labs am wbc rbc hgb hct mcv mch mchc rdw neuts lymphs monos eos basos pt ptt inr pt glucose urea n creat sodium potassium chloride total co anion gap am ck mb ctropnt ck cpk am ck mb mb indx ctropnt ck cpk pm ck mb mb indx ctropnt ekg demonstrated nsr at with subtle ste in iii avf also possibly in v v compared with prior dated cath coronary angiography in this right dominant system revealed three vessel coronary artery disease the lmca had mild diffuse disease the lad had diffuse disease in stent and within gap between stents d had an stenosis at its origin before the stent unchanged from prior cath the lcx was a small vessel with mild diffuse disease the rca had a severe proximal and mid in stent restenosis with focal proximal and diffuse mid with possible filling defects there was a distal rca de stenosis and mid pda limited resting hemodynamics revealed mild systemic systolic hypertension with sbp of mmhg and dbp of mmhg left ventriculography was deferred final diagnosis three vessel coronary artery disease systemic systolic arterial hypertension cabg recommended ideally with lima to lad svg to ramus high d svg to distal rca and distal pda echo pre bypass a patent foramen ovale is present a left to right shunt across the interatrial septum is seen at rest there is moderate symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is severe global left ventricular hypokinesis lvef there is noted hypokinesis of the inferior inferior lateral anterior and anterior septal walls for the mid to apical segments thereafter the walls appear akinetic right ventricular chamber size is normal there is mild global right ventricular free wall hypokinesis there are simple atheroma in the aortic arch there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen post bypass pt was removed from cardiopulmonary bypass on epinephrine and phenylephrine infusions and was av paced pfo has dramatically reduced in size minimal left to right flow across the septum biventricular function remains unchanged lvef regional wall motion abnormalities are unchanged aortic contours are intact post decannulation cxr findings ap single view of the chest has been obtained with patient in sitting semi upright position and analysis is performed in direct comparison with a preceding similar study dated there is status post sternotomy and multiple external wires are overlying the thorax on the frontal view no pneumothorax has developed during the latest examination interval nor is there any pulmonary vascular congestion the previously described left lower lobe atelectasis obscuring partially the diaphragmatic contour and that of the descending thoracic aorta persists there appears to be a somewhat improved inspiration with lower positioned diaphragms in comparison with the previous study no new parenchymal infiltrates have developed no pneumothorax identified impression slight improvement of postoperative atelectasis and pleural effusion on the left base otherwise stable findings brief hospital course mr was admitted to the on for further management of his chest pain heparin aspirin beta blockade and a statin were started he was taken to the cardiac catheterization lab and underwent a catheterization which revealed severe three vessel coronary artery disease given the severity of his disease the cardiac surgical service was consulted and mr was worked up in the usual preoperative manner the renal service was consulted to assist in his care given his history of end stage renal failure and a left renal transplant on mr was taken to the operating room where he underwent coronary artery bypass grafting to five vessels and a pfo closure please see operative note for details postoperatively he was taken to the the intensive care unit for monitoring by postoperative day one mr had awoke neurologically intact and was extubated beta blockade statin therapy and aspirin were resumed later on postoperative day one mr was transferred to the step down unit for further recovery he was gently diuresed towards his preoperative weight the physical therapy service was consulted for assistance with his postoperative strength and mobility he was transfused with packed red blood cells for postoperative anemia he developed atrial fibrillation which was treated with an increase in his beta blockade and amiodarone he is in nsr on dc pt to taper amiodarone pt tacrolimus level was adjusted to mg po bid he will have this followed as an outpt with he will see him early next week he is on concurrent medications that can affect tacrolimus level pt did see the pt he is stable from there standpoint pt also developed oglivies syndrome this resolved with conservative treatment npo rectal tube transplant surgery was consulted on dc pt is atking po medications on admission actos mg daily aspirin e c mg daily amlodipine mg daily bactrim ds daily lipitor mg daily lisinopril mg once a day labetalol mg twice a day myfortic mg nitroglycerin mg tablet s sublingually as needed for chest pain prograf mg protonix mg once a day requip mg twice a day zetia mg daily fluticasone mcg sprays each nostril qd zoloft mg once a day discharge medications oxycodone acetaminophen mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills cephalexin mg capsule sig one capsule po q h every hours for days disp capsule s refills ezetimibe mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily mycophenolate sodium mg tablet delayed release e c sig four tablet delayed release e c po bid ropinirole mg tablet sig three tablet po bid times a day tacrolimus mg capsule sig one capsule po q h every hours sertraline mg tablet sig one tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day acetaminophen mg tablet sig two tablet po q h every hours as needed amiodarone mg tablet sig two tablet po bid times a day take x days then qd x days then qd disp tablet s refills lisinopril mg tablet sig one tablet po twice a day pioglitazone mg tablet sig one tablet po once a day discharge disposition home with service facility vna of greater discharge diagnosis cad s p cabg afib ogivies syndrome paf pericarditis acute mi esrd wegners glomerulomatosis restless leg syndrome htn hyperlipidemia gerd discharge condition stable discharge instructions monitor wounds for signs of infection these include redness drainage or increased pain in the event that you have drainage from your sternal wound please contact the at report any fever greater then report any weight gain of pounds in hours or pounds in week no lotions creams or powders to incision until it has healed you may shower and wash incision gently pat the wound dry please shower daily no bathing or swimming for month use sunscreen on incision if exposed to sun no lifting greater then pounds for weeks no driving for month call with any questions or concerns followup instructions please follow up with dr in month please follow up with cardiologist dr in weeks please call all providers for appointments already scheduled appointments provider m d date time provider m d phone date time you are to hve your tacrolimus level drawn on your routine schedule this should be done early next week md completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies simvastatin tape hydrochlorothiazide eptifibatide cellcept attending chief complaint transfered from hospital for inferior myocardial infarction major surgical or invasive procedure cardiac catheterization rca stent history of present illness this is a year old man with a past medical history of cabg and pfo closure in s p renal transplant secondary to wegeners vasculitis who was transferred from an outside hospital for an inferior myocardial infarction pt was having chest pain and an electrocardiogram showed st segment changes in the inferior leads which was consistent with an inferior mi patinet underwent cardiac catheterization with stenting for an inferior mi he had some vagal symptoms towards the end of the procedure and was treated with zophrin and atropine pt was then transerred to the ccu past medical history paroxysmal atrial fibrillation not on coumadin esrd s p living donor sister renal transplant in cad s p acute mi with palmaz lad and rca stents s p rotablation and hepacoat stent to the d in treated with brachytherapy for instent restenosis in s p taxus stent in rpl in s p two cypher stents placed in the rca cath in with ostial stenosis of lad moderate diffuse disease of lcx proximal of rca with in stent restenosis with a in the pl branch taxus stent for latest cath see pertinent results denies h o dm however sugars have been elevated in past chronic angina hypertension hypercholesterolemia wegener s granulomatosis renal pulmonary involvement diagnosed s p cytoxan prednisone x y initially anca neg since chronic proteinuria now s p renal transplant in idiopathic pericarditis gerd anxiety endorses dysthymic symptoms but not depression gout umbilical hernia repair restless leg syndrome outpatient cardiologist nephrologist dr transplant nephrologist pcp allergies rash simvastatin myalgia tape rash hctz unkown reaction social history social history is significant for the absence of current tobacco use quit years ago there is no history of alcohol abuse he endorses rare etoh no illicit drugs married with children lives w wife and youngest daughter family history there is no family history of premature coronary artery disease or sudden death mother had cva at sister with scleroderma and another sister with physical exam vitals vital signs stable patient afebrile gen no acute distress heent mmm perrl neck no jvd heart s s no murmurs lungs clear to auscultation bilaterlly abd soft non tender non distended bowel sounds present ex no edema distal pulses present bilarerally neuro aaox pertinent results blood am blood wbc rbc hgb hct mcv mch mchc rdw plt ct electrolytes am blood glucose urean creat na k cl hco angap cardiac enzymes am blood ck cpk pm blood ck cpk am blood ck cpk am blood ck cpk am blood ck mb mb indx ctropnt am blood ck mb mb indx am blood calcium phos mg transplant meds am blood tacrofk am blood tacrofk am blood tacrofk blood gas pm blood type art po pco ph caltco base xs intubat not intuba brief hospital course patient was admitted to ccu for medical management post myocardial infarction and stent placement he remained stable he did develop an eight centimeter pseudoaneurysm and a v fistula on his left groin site surgery was consulted and said it was to small to intervene he will follow up with surgery for another ultrasound to assess the size he was seen by transplant team for management of his transplant medications renal was consulted for management of his wegeners granulomatosa as patient had a stent placed and had a history of an allergy to he was desensitized to the desensitization was successful without any adverse events ent was consulted for epistaxis prophylaxis while on patient started on saline nasal spray he was transferred out of the ccu to the floor and discharged on problem cad ischemia history of cad cabg in pt had st elevations on ecg in inferior leads with st elevation in v r which are sensitive for rv infarct cath complicated by vagal symptoms towards end of procedure treated with zofran and atropine pt desensitized to on continue statin patient monitored on telemetry as pt had rv infarct by ekg no right heart cath performed avoid nitroglycerin for chest pain as rv infarct patients are preload dependent pump current echo lvef lv apical dyskinesis and lv inferior inferior lateral hypokinesis pt with some orthopnea fluid status closely monitored pt started on lasix po rhythm pt having runs of nsvt on telemetry likely secondary to hypokalemia also possibly due to reperfusion history of paroxysmal a fib has cardioversion monitor on telemetry on metoprolol for rate control titrate up to home dose as bp tolerates will stop amiodarone as nsvt was peri mi and did not recur hypertension it was noted in a prior note on omr that pt s blood pressure should be managed with beta blocker a small dose of acei and nifedipine if necessary nifedipine should be titrated up as it is safe in the renal transplant setting c w bb and acei as bp tolerates nitrates were held as blood pressure stable can be re assessed as outpatient pt should have bp check by pcp or np within weeks of d c valves mr mitral valve leaf thickening mild aortic valve thickening left femoral bruit bruit over left groin where venous and arterial access lines were pulled systolic and diastolic bruit likely due to av fistula l groin u s showing mm pseudoaneurysm per surgery pseudoaneurysm is to small to treat cm f u with dr in clinic wegeners granulomatosis has been in remission for yrs stable monitor respiratory status monitor hct follow ent recs re epistaxis prevention saline nasal flushes three times a day renal transplant end stage renal disease secondary to wegener s granulomatosis received a living related renal transplant from his sister on baseline cr pt back to baseline cr continue tacrolimus and myfortic dose meds for crcl of dm sliding scale insulin fen cardiac heart healthy low salt diabetic diet prophylaxis code full medications on admission allopurinol mg tablet daily atorvastatin mg daily astelin mcg ns fluticasone mcg ns lisinopril mg daily metoprolol mg sr tabs daily myfortic mg tabs daily nifedipine mg daily protonix mg daily actos mg daily prednisone taper requip mg daily zoloft mg daily prograf mg daily bactrim mg daily aspirin mg daily discharge medications pioglitazone mg tablet sig one tablet po twice a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily atorvastatin mg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig sprays nasal daily daily trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily sertraline mg tablet sig one tablet po daily daily mycophenolate sodium mg tablet delayed release e c sig two tablet delayed release e c po twice a day ropinirole mg tablet sig one tablet po twice a day sodium chloride aerosol spray sig sprays nasal tid times a day as needed pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours clopidogrel mg tablet sig one tablet po daily daily please do not miss a dose take for at least year do not stop taking unless your cardiologist tells you to disp tablet s refills astelin mcg aerosol spray sig two puffs nasal twice a day toprol xl mg tablet sustained release hr sig tablet sustained release hrs po once a day disp tablet sustained release hr s refills furosemide mg tablet sig one tablet po daily daily tacrolimus mg capsule sig capsules po bid times a day lisinopril mg tablet sig one tablet po once a day discharge disposition home discharge diagnosis non st elevation myocardial infarction acute on chronic systolic congestive heart failure secondary diagnosis chronic renal insufficiency wegenner s vasculitis epistaxis discharge condition stable discharge instructions weigh yourself every morning before breakfast call doctor if weight lbs in day or pounds in days adhere to gm sodium heart healthy diet you had an inferior myocardial infarction with drug eluting stents placed in your right coronary artery you need to take every day for one year do not miss unless dr tells you to you were seen by pt who gave you a activity prescription until you see dr stop taking your nifedipine while you were inpatient you had desensitization you were started on a daily dose of after the desensitization this medication should be taken daily if at any time hours lapses between of the desensitization process will have to be repeated you need repeat angiogram in weeks you should speak to your cardiologist regarding this you should also have a holter monitor in weeks that will monitor your heart rhythm and track any irregular heart beats followup instructions primary care provider m d phone date time at pm provider m d phone date time cardiologist provider md phone date time at am clinical center follow up for left femoral pseudoaneurysm provider lmob nhb phone date time provider md phone date time [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies simvastatin tape x yd hydrochlorothiazide eptifibatide cellcept attending chief complaint shortness of breath major surgical or invasive procedure intubation mechanical ventilation arterial line placement internal jugular venous line placement ultrasound guided renal biopsy bronchoscopy with bronchoalveolar lavage history of present illness m w esrd wegener s granulomatosis s p kidney transplant on tacro cellcept severe cad s p five vessel cabg with pfo closure and s p multiple previous pcis most recently in schf ef copd paf htn hld p w cough productive of whitish sputum sinus tightness and muscle pain he was recently discharged after a day stay for evaluation of dyspnea and productive cough when he was found to have positive influenza a dfa and was treated w day course of osetalmavir in the ed vs exam was notable for elevated jvd tachypnea and bibiasilar rales he required l o and sao was cxr revealed a new retrocardiac opacity and labs were notable for a leukocytosis to and bnp of o was increased to l and pt was satting he had a bnp of double what it was last month and was given mg iv lasix with cc uop he was empirically tx w vanc levo for pna per cxr he was also found to be in af w rate in s as high as s so was given mg metoprolol he was also given iv potassium for a k in the ed initial vs l in the icu pt states his breathing is very difficult and feels like when he had flu except doesn t have the same fatigue myalgias he had at that time also endorses diarrhea nonbloody nonmelenotic x day denies cp palpitations lower extremity edema or orthopena has not increased pillows baseline denies dietary or medication noncompliance ros denies night sweats vision changes sore throat chest pain abdominal pain nausea vomiting constipation brbpr melena hematochezia dysuria hematuria past medical history major depression chf ef paroxysmal atrial fibrillation not on coumadin esrd s p living donor sister renal transplant in cad s p cabg cabg x lima lad svg d svg om svg r pl r plv and pfo closure occluded om and rca grafts s p acute mi with palmaz lad and rca stents s p rotablation and hepacoat stent to the d in treated with brachytherapy for instent restenosis in s p taxus stent in rpl in s p two cypher stents placed in the rca cath in with ostial stenosis of lad moderate diffuse disease of lcx proximal of rca with in stent restenosis with a in the pl branch taxus stent denies h o dm however sugars have been elevated in past chronic angina hypertension hypercholesterolemia wegener s granulomatosis renal pulmonary involvement diagnosed s p cytoxan prednisone x y initially anca neg since chronic proteinuria now s p renal transplant in idiopathic pericarditis gerd anxiety gout umbilical hernia repair restless leg syndrome basal cell carcinoma social history married for years with very recent separation from spouse adult children whith whom he is very close and put them all through college bachelor s degree in finance was a teacher for numerous years which he loved and then used to work in computer sales until his disease progressed on ss ssdi loves to play music and write except cannot motivate himself to do so currently remote history of smoking quit years ago no alcohol or ilicits family history there is no family history of premature coronary artery disease or sudden death mother had cva at sister with scleroderma and another sister with physical exam admission physical exam vs af sao high s low s on face tent l nc gen pleasant man speaking full sentences w o heent normocephalic atraumatic no conjunctival pallor no scleral icterus perrla eomi mmm op clear no throat erythema no sinus tenderness neck supple no lad no thyromegaly cv irregularly irregular faint no rubs or gallops jvp cm lungs b l bases with decreased bs rhonchi wheezes b l no rales good air movement biaterally abdomen nabs soft nt nd no hsm ext trace edema dorsalis pedis posterior tibial pulses skin no rashes lesions ecchymoses neuro a ox appropriate cn grossly intact preserved sensation throughout strength throughout reflexes equal bl normal coordination gait assessment deferred psych listens and responds to questions appropriately pleasant transfer physical exam gen nad very sleepy and difficult to arouse heent sclera anicteric op clear mmm cv irregularly irregular lungs clear anteriorly abd soft patient reports diffuse tenderness on palpation non distended ext no edema neuro cn ii xii intact full strength in all extremities although requires significant prompting to lift right lower extremity alert to person and place odd affect pertinent results admission labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh ck cpk alkphos totbili am blood albumin calcium phos mg discharge labs microbiology bal no bacterial growth no no pcp afb no cmv all blood urine and sputum cultures were negative imaging ct sinus bilateral sphenoid sinus frontal sinuses and ethmoidal air cell mucosal thickening bilateral mucus retention cysts or polyps in the maxillary sinuses ct chest progression of bibasilar consolidations and pleural effusions concerning for progression of pneumonia opacities previously noted in the right middle lobe however have resolved cardiomegaly but no evidence for chf increased mediastinal lymphadenopathy likely reactive in the setting of a progressive pneumonia distended gallbladder renal txp us no hydronephrosis resistive indices ranging from to slightly increased as compared to the previous study patent main renal artery and renal vein ct head left middle cerebral artery distribution infarction without evidence of mass effect or hemorrhage tte no atrial septal defect or patent foramen ovale is seen by d color doppler or saline contrast with maneuvers lv systolic function appears depressed the apex is akinetic no masses or thrombi are seen in the left ventricle definity contrast used the aortic valve leaflets are mildly thickened but aortic stenosis is not present the mitral valve leaflets are mildly thickened there is no mitral valve prolapse moderate mitral regurgitation is seen there is no pericardial effusion carotid us no evidence of stenosis on the right the left system was not visualized due to presence of a central line brief hospital course m w esrd wegener s granulomatosis s p kidney transplant on tacro cellcept severe cad s p five vessel cabg w pfo closure in and s p multiple previous pcis most recently in schf ef paf htn hld gout and depression anxiety p w weeks of productive cough and sob hypoxic respiratory distress mr was admitted from the ed in respiratory distress w increasing o requirement likely post infectious bacterial pna given recent admission for influenza he was covered broadly for hcap with vanc zosyn levofloxacin there was also likely a component of volume overload that contributed to his respiratory dysfunction given ivf and antibiotics given in ed in the setting of pt s poor forward flow chf w ef due to increasing work of breathing patient was intubated later on the admission day chest ct on demonstrated bibasilar consolidations and pleural effusions concerning for progression of pneumonia as anca returned moderately positive see below patient underwent bedside bronchoscopy on to rule out bronchial or alveolar hemorrhage bronchoscopy revealed erythematous airways but no obvious hemorrhages bal was negative for pcp afb cmv fungus or micro organisms patient s vent settings continued to be weaned and he was extubated on unfortunately during a speech and swallow evaluation the following day he had a significant aspiration event which shortly required reintubation secondary to respiratory distress he was liberated from the ventilator on following the placement of a large bore ng tube he did well following extubation he completed a day course of levofloxacin for aspiration pneumonia he was diuresed with lasix as needed and received nebs mucolytics as needed he underwent another speech and swallow evaluation and was able to tolerate pos he was stable on room air at discharge recommend continuation of incentive spirometry and ambulation with pt acute on chronic renal insufficiency mr baseline cr was as he is s p renal transplant and his creatinine slowly increased during his admission with cr peak at this was thought to be atn from poor perfusion due to hypotension and hypoxemia the renal transplant team followed the patient closely during his hopsital course monitoring his renal function and immunosuppression with tacrolimus and mycophenolate tacro levels were checked daily and adjusted accordingly pt s urine sediment was consistent w atn showing muddy brown casts but no acanthocytes indiciative of glomerular injury due to a reported moderately positive anca sent from there was concern for recrudescence of wegener s granulomatosis and patient underwent urgent bedside renal biopsy on he was given ddvap hr prior to biopsy given uremic platelets as well as units of platelets cardiology was consulted to determine whether patient could safely go off for biopsy but given pt s multiple cardiac risk factors and severe cad he was kept on with only sc heparin being held for the biopsy biopsy was consistent with atn without evidence of wegener s or rejection but final pathology is pending creatinine started to trend down after peak of on and was at discharge all medications were renally dosed he should continue sodium bicarbonate supplementation he should continue to have creatinine monitored as well as tacrolimus trough weekly and should follow up with renal as an outpatient atrial fibrillation pt has hx paroxysmal atrial fibrillation prior records show that he was initially anticoagulated on coumadin until when it was discontinued due to severe epistaxis requiring transfusions as well as difficulty controlling his inr pt s rate was initially controlled on home metoprolol mg but he frequently was tachycardic in atrial fibrillation and required some additional iv lopressor on he was changed to mg metoprolol q h which helped somewhat and he was also loaded with amiodarone on with a significant improvement in his rate control his cardiologist dr was contact for advice on continuing the amiodarone and a formal cardiology consult was initated additionally he was started on a heparin drip for bridge to coumadin given stroke see below he will be discharged on amiodarone mg daily and metoprolol mg q he should follow up with cardiology as an outpatient lmca infarct on while examining patient to determine mental status for potential extubation it was noted that patient s affect was abnormal he did not track past midline and was not following commands his right side was noted to be weaker than the left and he seemed to have some right sided neglect but this was difficult to assess given sedation a stat head ct revealed an infarct in the left middle cerebral artery territory that was likely several days old per radiology without mass effect midline shift or hemorrhage neurology was consulted who felt the patient s exam was out of proportion to the size of the infarct and that his mental status changes could be secondary to toxic metabolic encephalopathy neurology also recommended repeat tte w bubble study which showed no lv or atrial thrombus and no clear pfo although this was a limited study neurology felt that the source of the infarct was likely embolic and he was started on a heparin gtt coumadin pt ot worked with patient and he will be discharged to rehab facility he will be discharged on coumadin with inr goal and should continue to have coag panel monitored diarrhea mr suffered from significant diarrhea while hospitalized he had several negative stool cultures and cdiff tests it was felt that this diarrhea was attributable to his immunosuppressant mycophenolate he has had this issue in the past and was successfully switched to a different formula however this formulation was not available in a form that could be given while he was intubated a flexiseal was placed to help protect his skin from breakdown given his volume of stool after passing the speech and swallow evaluation the diet was advanced and his normal formulation of mycophenolate was restarted the rectal tube was removed he should follow up with the renal team as an outpatient abdominal wall hematoma on transfer from the unit to the medical floor it was observed that the patient complained of significant pain on palpation of his rlq location of renal graft a kub was unremarkable renal us was performed and was initially read as a renal hematoma w concern for renal aneursym transplant surgery recommended a ct scan which revealed that the hematoma was actually an abdominal wall hematoma with concern for active bleeding from r inferior epigastric artery due to a drop in hct the patient was taken for ir embolization on he tolerated the procedure well without complication he was transfused prbc and his hcts remained stable his heparin gtt coumadin was held for the procedure and was restarted hours after the procedure per ir recs chronic sinus congestion mr main concern on admission was his chronic debilitating sinus congestion which has been evaluated extensively as an outpatient he underwent ct sinus on revealed sinus air cell tickening was not consulted in the icu given patient s multiple pressing issues it is recommended that he follow up with as an outpatient cad chf patient has extensive cardiac history including vessel cabg and multiple pci as well as a history of chf and aspirin were continued throughout his hospital stay he received iv lasix for diuresis while in the unit and was transitioned to his home dose of lasix lisinopril was held given his renal issues described above nifedipine was initially held and was gradually re introduced at a low dose he should be seen by cardiology for further medication adjustments and consideration of cardiac rehab in the future depression his home zoloft was continued he was evaluated by psychiatry as an inpatient in the contect of agitation delirium haldol was started and will be continued at discharge per recommendatino of the accepting facility we recommend weaning it off over the next week as the patient continues to improve the patient has an extensive history of depression in the past and is at risk for post stroke depression he should have follow up with neurology social work medications on admission aspirin mg daily atorvastatin lipitor mg daily azelastine astelin mcg aerosol puffs clopidogrel mg daily fluticasone mcg spray sprays qdaily furosemide lasix mg daily ipratropium bromide not taking as prescribed mcg spray lisinopril mg tablet tablet s by mouth once a day dose per patient metoprolol succinate mg metronidazole metrolotion lotion mycophenolate sodium myfortic mg tablet tabs nifedipine mg daily pantoprazole protonix mg pioglitazone actos mg sertraline mg daily tacrolimus mg cholecalciferol vitamin d unit daily generix t tablet tablet s by mouth daily guaifenesin mucinex senna discharge medications aspirin mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily astelin mcg aerosol spray sig two nasal twice a day clopidogrel mg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig sprays nasal times a day lasix mg tablet sig one tablet po once a day ipratropium bromide nasal metronidazole lotion sig one application topical twice a day as needed for as needed mycophenolate sodium mg tablet delayed release e c sig two tablet delayed release e c po twice a day protonix mg tablet delayed release e c sig one tablet delayed release e c po twice a day sertraline mg tablet sig three tablet po daily daily cholecalciferol vitamin d unit capsule sig one capsule po once a day generix sig one once a day mucinex oral senna oral nifedipine mg tablet extended release sig one tablet extended release po daily daily disp tablet extended release s refills warfarin mg tablet sig one tablet po once daily at pm monitor inr weekly and adjust dose accordingly disp tablet s refills amiodarone mg tablet sig one tablet po once a day disp tablet s refills metoprolol tartrate mg tablet sig two tablet po q h every hours hold for heart rate or sbp disp tablet s refills tacrolimus mg capsule sig one capsule po q h every hours renally adjust dose disp capsule s refills insulin lispro unit ml solution sig as directed subcutaneous asdir as directed disp ml refills haloperidol mg tablet sig one tablet po bid times a day for weeks disp tablet s refills sodium bicarbonate mg tablet sig one tablet po bid times a day disp tablet s refills calcium acetate mg tablet sig one tablet po three times a day disp tablet s refills discharge disposition extended care facility discharge diagnosis primary atrial fibrillation with rvr stroke acute tubular necrosis pneumonia post infections bacterial pneumonia aspiration secondary end stage renal disease s p transplant congestive heart failure coronary artery disease s p cagb and multiple pci depression discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions it was a pleasure taking care of you mr you were admitted to the hospital with difficulty breathing which was likely due to a post infectious bacterial pneumonia given your recent bout of influenza because it was so difficult to breathe you required mechanical ventilation breathing machine and were treated with antibiotics you also had a stroke while you were in the hospital and you were started on anticoagulation medications your renal function worsened and you had a renal biopsy which showed acute tubular necrosis your renal function gradually improved you were found to have an abdominal wall hematoma and you underwent an interventional radiology procedure to stop the bleeding the following changes were made to your medications start amiodarone mg once a day start warfarin mg once a day this dose may be adjusted based on your inr you should have your inr checked weekly stop metoprolol succinate start metoprolol tartrate mg every hours stop lisinopril decrease nifedipine to mg once a day stop pioglitazone start insulin according to sliding scale decrease tacrolimus to mg twice a day start sodium bicarbonate mg twice a day stop sevelamer start calcium acetate mg three times a day start haloperidol mg twice a day the duration of this medication will be determined by your primary physician please continue your other home medications followup instructions the following appointments have been made for you department cardiac services when tuesday at am with md building campus east best parking garage department neurology when tuesday at pm with m d building campus east best parking garage you have been placed on a cancellation list for this appointment department west clinic nephrology when wednesday at pm with m d building de building complex campus west best parking garage [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies simvastatin tape x yd hydrochlorothiazide eptifibatide cellcept attending chief complaint shortness of breath major surgical or invasive procedure left mini thoracotomy and placement of epicardial left ventricular pacing lead x the lead leads are the following number is medical reference number serial number this was the one that was hooked up to the device the capped second lead in an medical lead reference number serial number removal of old single chamber pacemaker placement of new biventricular dual chamber pacing system it is a st medical model number pm serial number item number history of present illness mr is a year old gentleman with a history of systolic congestive heart failure moderate to severe mitral regurgitation coronary artery disease s p multiple angioplasties with recurrent in stent restenoses s p coronary artery bypass grafting and patent foramen ovale closure in recurrent atrial fibrillation s p atrioventricular nodal ablation and permanent pacemaker hypertension wegener s granulomatosis chronic kidney disea s p renal transplant and prior stroke who presented with shortness of breath for the past two days the patient has been experiencing progressively worsening shortness of breath paroxysmal nocturnal dyspnea and orthopnea along with increasing abdominal girth and weight gain of four pounds of note he ran out of his daily lasix mg prescription which he receives by mail order so he was only able to take mg on and nothing on he believes that his difficulty breathing began at the time of taking the decreaed dose of lasix he saw his cardiologist dr in clinic on friday at which time his weight was pounds and he noted dyspnea on exertion of one flight of stairs friday was also his birthday and the patient thinks that he may have taken in a bit more fluid that day than usual he was formerly evaluated by dr on for biventricularpacemaker placement but the left ventricular lead was unable to be placed the patient subsequently underwent atrioventicular nodal ablation with a ventricular lead placed on the right ventricular apex afterwards from he was readmitted with congestive heart failure exacerbation but improved with adjustment of his diuretics past medical history chronic systolic heart failure mitral regurgitation s p multiple angioplasties with recurrent in stent re stenosis recurrent atrial fibrillation s p atrioventricular node ablation permanent pacemaker hypertension hyperlipidemia chronic renal failure wegener s granulomatosis remission for years cerebral accident gastric reflux anxiety depression obstructive sleep apnea coronary artery bypass grafting closure of patent foramen ovale left renal transplant in secondary to wegener s granulomatosis umbilical hernia repair in and s p st medical accent rf pm s n implanted social history mr is divorced and is a retired teacher he has a remote smoking history he drinks socially and denies illicit drug use family history non contributory physical exam admission physical exam vs t bp hr rr o sat cpap general very pleasant comfrotable nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck unable to appreciate jvp cardiac rrr normal s s no m r g no s or s lungs breathing comfortably minimal end inspiratory crackles at left lung base otherwise ctab abdomen soft ntnd no hsm or tenderness normoactive bowel sounds extremities trace pedal edema bilaterally skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt pertinent results echocardiography report complete done at am final referring physician information c status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication abnormal ecg cerebrovascular event tia chest pain congestive heart failure coronary artery disease dilated cardiomyopathy h o cardiac surgery hypertension left ventricular function mitral valve disease pericarditis pulmonary hypertension shortness of breath icd codes test information date time at interpret md md test type tee complete son md doppler full doppler and color doppler test location anesthesia west or cardiac contrast none tech quality adequate tape aw machine echocardiographic measurements results measurements normal range left ventricle ejection fraction to findings left atrium mild la enlargement no spontaneous echo contrast is seen in the laa good cm s laa ejection velocity right atrium interatrial septum a catheter or pacing wire is seen in the ra and extending into the rv no asd by d or color doppler left ventricle normal lv wall thickness moderately dilated lv cavity right ventricle normal rv chamber size and free wall motion aorta normal ascending transverse and descending thoracic aorta with no atherosclerotic plaque normal descending aorta diameter simple atheroma in descending aorta aortic valve three aortic valve leaflets mildly thickened aortic valve leaflets no as trace ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification mild thickening of mitral valve chordae moderate mr tricuspid valve mild tr pulmonic valve pulmonary artery normal pulmonic valve leaflet no ps physiologic pr pericardium trivial physiologic pericardial effusion general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the patient was under general anesthesia throughout the procedure the patient received antibiotic prophylaxis the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope no tee related complications patient regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions thoracotomy for mlv lead placement the left atrium is mildly dilated no spontaneous echo contrast is seen in the left atrial appendage no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated right ventricular chamber size and free wall motion are normal the ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are mildly thickened there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen there is a trivial physiologic pericardial effusion there was no significant pericardial effusion after lead placement dr was notified in person of the results fa a pm chest pa lat clip reason interval change wet read shsf sat pm unchanged right base atelectasis or scarring left base is better aerated cardiomegaly as before final report pa and lateral chest history post thoracotomy comparison findings right ij line has been removed heart remains mildly enlarged there is no pulmonary congestion or pneumothorax minimal bibasilar atelectasis not significantly changed pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood plt ct am blood pt inr pt am blood plt ct am blood pt inr pt am blood plt ct pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood urean creat na k cl am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood na k cl am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood probnp pm blood ctropnt am blood ck mb ctropnt am blood hba c eag am blood triglyc hdl chol hd ldlcalc am blood tacrofk brief hospital course mr is a year old gentleman who presented with dyspnea weight gain elevated probnp and pulmonary congestion consistent with exacerbation of his congestive heart failure he diuresed well after receiving lasix he underwent an attempt to place a biventricular pacemaker but it was unsuccessful due to an inability to place the left ventricular lead cardiac surgery was consulted transplant nephrology were also consulted to follow him given his history of left renal transplant on he underwent a left thoracotomy left ventricular lead placement pacemaker replacement performed by dr please see operative report for details he tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit he soon extubated left paravertebral blocks were administered as were intravenous opioids pod he was transferred to the floor physical therapy was consulted for strength and mobility and cleared him for home when medically ready warfarin for atrial fibrillation and lasix were restarted on pod pod found him afebrile voiding adequate amounts tolerating a regular diet with pain well controlled he was discharged on pod in stable condition to home with vna all follow up appointments were advised medications on admission mg po daily atorvastatin mg po daily azelastine mcg aerosol spray puffs in nostrol calcium acetate mg capsulte po tid clopidogrel mg po daily eplerenone mg po daily fluticasone mcg spray suspension sprays each nostril furosemide mg po daily lisinopril mg po daily metoprolol succinate mg po daily metronidazole lotion apply to face mycophenolate sodium delayed release mg tablets nifedipine er mg po daily oxycodone acetaminophen mg mg tablets po q prn pain sertraline mg po daily tacrolimus mg po q trazodone mg po qhs prn insomnia warfarin mg tablet tablets po daily adjust per clinic cholecalciferol units po daily famotidine mg po daily sennosides mg po prn constipation discharge medications aspirin mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po hs at bedtime clopidogrel mg tablet sig one tablet po daily daily eplerenone mg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig sprays nasal times a day lisinopril mg tablet sig tablets po daily daily disp tablet s refills metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po daily daily metronidazole gel sig one appl topical times a day as needed for rosacea nifedipine mg tablet extended release sig one tablet extended release po daily daily sertraline mg tablet sig tablets po once a day trazodone mg tablet sig one tablet po hs at bedtime as needed for insomnia warfarin mg tablet sig one tablet po once a day check pt inr on tues disp tablet s refills cholecalciferol vitamin d unit tablet sig one tablet po daily daily senna mg tablet sig one tablet po once a day as needed for constipation disp tablet s refills mycophenolate sodium mg tablet delayed release e c sig two tablet delayed release e c po twice a day azelastine mcg aerosol spray sig two puffs nasal docusate sodium mg capsule sig one capsule po twice a day hold for loose stools disp capsule s refills calcium acetate mg capsule sig one capsule po tid w meals times a day with meals oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain for days no driving drinking alcohol or operating machinery while taking this medication disp tablet s refills famotidine mg tablet sig one tablet po once a day tacrolimus mg capsule sig one capsule po q h every hours furosemide mg tablet sig tablets po daily daily disp tablet s refills discharge disposition home with service facility vna and hospice of greater discharge diagnosis acute on chronic systolic heart failure discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with incisions sternal healing well no erythema or drainage leg right left healing well no erythema or drainage edema discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns females please wear bra to reduce pulling on incision avoid rubbing on lower edge please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments dr cardiologist dr please call to schedule appointments with your primary care dr w in weeks please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours labs pt inr for coumadin indication goal inr first draw results to phone fax department when tuesday at pm with m d building sc clinical ctr campus east best parking garage department cardiac services when friday at am with md building campus east best parking garage department west clinic when wednesday at am with m d building de building complex campus west best parking garage completed by,"[
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9258,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint stemi cardiogenic shock major surgical or invasive procedure cardiac catheterization arterial line placement intra aortic balloon pump placement history of present illness yo m with h o dm seizure disorder htn and remote history of mi years ago s p angioplasty who was brought in by ems with cc of cp pt was reported to be in his normal state of health until this afternoon when he was noted to be unable to descend or ascend his stairs after being able to do so twice before as he left his house to go to the store he was complaining of severe left sided chest pain without radiation he never lost consciousness denied any sob n v and had no accompanying diaphoresis his sister thought he looked weak and checked a finger stick which was elevated to ems was called and the patient was brought to on arrival per the ems report the patient was in sr with ste in i v v and std in ii iii f and had bg of he was given ns bolus started on dopamine and given asa in the ed he was intubated started on heparin and taken emergently to cath lab in cath lab given atropine for hr in s he had a des placed in lcx he had vt vf in cath lab with restoration of flow and had cpr and dccv lad was attempted but appeared to be chronic iabp was also placed he was also started on levophed past medical history cad s p remote mi years ago dm type htn hyperlipidemia chf a fib ckd bph per pt s sister the patient cannot urinate herpes encephalitis with resultant seizure disorder asthma schizophrenia cholecystectomy social history per daughter patient has never used tobacco alcohol or illicit drugs family history two sisters died of ca there is a family history of dm and heart disease physical exam vitals t hr bp rr o ac general intubated nad heent nc at pupils equally round and minimally reactive to light intubated neck supple no appreciable jvd chest cv could not appreciate heart sounds to iabp pt went into cardiac arrest with stopping iabp in lab for this reason did not attempt to stop machine lungs ctab b l anteriorly abd soft nt nd decreased bs hematoma of right groin soft no bruits outlined in marker ext no c c e dopplerable pulses skin warm dry no lesions pertinent results admission labs pm type art temp po pco ph total co base xs pm lactate pm o sat pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm asa neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm type art temp po pco ph total co base xs pm hct pm type art po pco ph total co base xs pm glucose lactate na k cl pm freeca pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot ld ldh ck cpk alk phos tot bili pm ck mb mb indx ctropnt pm calcium phosphate magnesium cholest pm triglycer hdl chol chol hdl ldl calc pm type art rates tidal vol peep o po pco ph total co base xs aado req o assist con intubated intubated pm glucose k pm hgb calchct o sat pm type art peep o po pco ph total co base xs aado req o assist con intubated intubated pm glucose lactate na k cl pm hgb calchct o sat pm alt sgpt ast sgot ck cpk alk phos amylase tot bili pm ck mb mb indx ctropnt pm albumin pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm ptt pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb mb indx ctropnt pm calcium phosphate magnesium pm digoxin pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos pm hypochrom normal anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal pm plt smr normal plt count pm pt ptt inr pt pm fibrinoge labs at time of death pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso pm blood plt ct pm blood glucose urean creat na k cl hco angap am blood ck cpk am blood ck mb greater th pm blood calcium phos mg am blood digoxin am blood ethanol neg pm blood type art temp rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated pm blood lactate am blood o sat pm blood freeca microbiology blood and urine cultures no growth to date imaging cardiac cath comments selective coronary angiography revealed a right dominant system with patent short lmca the lad was chronically totally occluded with modest l l collaterals the lcx was thrombotic with slow flow and was the culprit vessel rca had no significant obstructive disease left ventriculography was deferred hemodynamic assessment showed low systemic aortic pressures consistent with hemodynamic collapse right sided filling pressures were elevated final diagnosis two vessel coronary artery disease severe systolic ventricular dysfunction acute inferior myocardial infarction managed by acute ptca and iabp placement ptca of vessel echo conclusions overall left ventricular systolic function is severely depressed there is focal hypokinesis of the apical free wall of the right ventricle the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened the supporting structures of the tricuspid valve are thickened fibrotic there is an anterior space which most likely represents a fat pad though a loculated anterior pericardial effusion cannot be excluded compared with the findings of the prior study images reviewed of the left ventricular ejection fraction remains severely reduced brief hospital course stemi the patient was urgently brought to the cath lab from the ed given his clinical picture and ekg findings he was intubated and on heparin given low bps he was also bolused normal saline and started on dopamine in the cath lab he was bradycardic and was given atropine he also went into vt vf and was cardioverted cpr was performed an iabp was placed a stent was placed to the left circumflex artery he was also started on levophed vasopressin and lidocaine drips cath findings are described above he was transported to the ccu and put on asa statin acei plavix integrillin he continued to have hypotension despite being on three pressors and an iabp attempts at weaning the pressors failed attempts at weaning the iabp were unsuccessful his groin also ad a hematoma his hct dropped and the patient was given units prbcs an echo was performed which showed severe rv lv dysfunction with an ef of on the night of the patient went into afib with nsvt per the family s request the decision was made not to start amiodarone in fact after numerous discussions with the family regarding prognosis of the patient as well as his condition the decision was made to make the patient cmo the patient was kept comfortable and all pressors were sequentially stopped for hour the patient maintained his tachycardic rhythm however the patient eventually became bradycardic and hypotensive at am the patient went into asystole and passed away the family was present the spouse denied an autopsy the ccu attending and pcp were aspiration during his cardiac arrest the patient was thought to have aspirated and was started on flagyl he was maintained on the ventilator in the ccu and was unable to be weaned anemia the patient was anemic during the admission likely secondary to groin oozing and hematoma formation given anticoagulation he was transfused units prbcs during his admission acidosis the patient was acidotic with an elevated lactate his hemodynamics were optimized with pressors and an iabp code the patient was dnr initially the family was very involved in the patients care after thoughtful discussion of the patients condition and wishes the family decided to make the patient cmo on the night of his death the medical team supported them in their decision after all efforts were taken to stabilize the patient the patient was made cmo pressors were withdrawn and the patient expired at am on the appropriate steps were made to support the patient and family medications on admission toprol xl lisinopril mg increased two weeks prior to admission from mg digoxin mg benzotropine nph units lipitor aspirin mg haldol mg qhs cogentin mg qhs dilantin mg qam discharge medications expired discharge disposition expired discharge diagnosis primary diagnoses st elevation myocardial infarction cardiac arrest secondary diagnoses respiratory failure acidosis anemia discharge condition expired discharge instructions expired followup instructions expired,"[
""admission_date"" : ""2019-1-29"",
""discharge_date"" : ""2019-2-1"",
""date_of_birth"" : ""2043-10-15"",
""sex"" : ""Male"",
""service"" : ""Medicine"",
""allergies"" : ""Patient recorded as having no known allergies to drugs"",
""attending_chief_complaint"" : ""STEMI, cardiogenic shock, major surgical or invasive procedure, cardiac catheterization, arterial line placement, intra aortic balloon pump placement"",
""history_of_present_illness"" : ""YO M with H/O DM, seizure disorder, HTN and remote history of MI years ago"
32141,admission date discharge date date of birth sex f service cardiothoracic allergies augmentin morphine sulfate attending chief complaint positive exercise stress test admission for elective cardiac catheterization major surgical or invasive procedure cardiac catherization coronary artery bypass graft x left internal mammary left anterior descending saphenous vein graft obtuse marginal saphenous vein graft right coronary artery saphenous vein graft plv history of present illness this is a year old female with a history of htn hc hyperthyroidism who presented to the ed following a positive exercise stress test the patient reports that she has had teeth pain especially with exertion for several months but she did not attribute this to a cardiac issues she describes over past weeks episodes of chest heaviness with pain radiating to her jaw teeth the first episode occured while pushing her grandchildren uphill in a stroller she also reports mild dyspnea with this episode her pain was relieved by rest a second episode occurred post prandial with similar characteristics lasting about hour while the patient was cleaning dishes and relieved by falling asleep the patient s husband was very concerned by these episodes and encouraged his wife to seek care an ecg last week prompted an admission to the serum cks were negative and the highest troponin was lab normal work up including dobutamine echo stress test on indicated old but no new defects the patient increased her atenolol to mg daily the patient was referred for ett but put it off by one week during which time she had an additional episode of exertional angina relieved with rest without jaw pain this additional episode of pain prompted the patient to have her ett done today which was grossly abnormal and highly suggestive for ischemia patient has had no nausea diaphoresis pnd orthopnea presyncope syncope or palpitations past medical history dyslipidemia hypertension hyperthyroidism osteoarthritis s p femur fracture s p hysterectomy s p bladder suspension s p tonsillectomy social history her social history is significant for the absence of current tobacco use remote pack yr smoking history there is no history of alcohol abuse lives with spouse family history father sudden death at physical exam vs bp hr rr o sat lnc gen wdwn middle aged female in nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp of cm cv pmi located in th intercostal space midclavicular line rr normal s s no m r g no thrills lifts no s or s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abd soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits ext no c c e skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap brief hospital course admitted for cardiac catherization that revealed coronary artery disease and she was referred to cardiac surgery for surgical evaluation she underwent preoperative workup and was brought to the operating she underwent coronary artery bypass graft surgery see operative report for further details she received vancomycin for perioperative antibiotic due to augmentin allergy and in hospitalization she was transferred to the intensive care unit for hemodynamic monitoring she was weaned from sedation awoke neurologically intact and was extubated without complications she continued to progress and was transferred to the floor pod physical therapy worked with her for strength and mobility pod following chest tubes removal cxr revealed a right pneumothorax a ct was reinserted and the right lung fully reexpanded after hours on suction the ct was placed on water seal the lung remained fully expanded and the ct was dc d a follow up cxr revealed a lessening of both the right and left pneumothoraces she was asymptomatic on room air saturating on room air she was discharged to home with instructions to return on the following tuesday to clinic with a chest x ray medications on admission atenolol mg daily atorvastatin mg daily asa mg daily multivitamin daily discharge medications lipitor mg tablet sig one tablet po once a day disp tablet s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills tramadol mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills acetaminophen mg tablet sig two tablet po q h every hours disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig tablets po tid times a day disp tablet s refills potassium chloride meq tab sust rel particle crystal sig two tab sust rel particle crystal po once once for days disp tab sust rel particle crystal s refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p cabg hypertension osteoarthritis hyperthyroidism elevated lipids discharge condition good discharge instructions please shower daily including washing incisions no baths or swimming monitor wounds for infection redness drainage or increased pain report any fever greater than report any weight gain of greater than pounds in hours or pounds in a week no creams lotions powders or ointments to incisions no driving for approximately one month no lifting more than pounds for weeks please call with any questions or concerns followup instructions please call to schedule all appointments dr for next tuesday with cxr in am cxr already ordered dr for week dr for weeks completed by,"{
""date"": ""2019-1-29"",
""type"": ""Pt Adm/Discharge Note"",
""reasons"": [
""Hypertensive emergency""
],
""service"": ""Cardiothoracic Surgery""
}"
11819,admission date discharge date date of birth sex m service medicine allergies imipramine attending chief complaint this is a yo male with pmh of hep b c and etoh abuse induced cirrhosis transferred to from osh for hepatic transplant work up and implantable defibrillator evaluation major surgical or invasive procedure thoracentesis central venous access history of present illness this is a yo male with pmh of hep b c and etoh abuse induced cirrhosis transferred to from osh for hepatic transplant work up and implantable defibrillator evaluation initially the patient was admitted to the osh s p fall x with loss of consciousness and bladder function following an episode of chest pain and dizziness after the second fall he was found by his son and brought to the hospital in the ed he was found to be dyspneic and hypoxic and a cxr showed a right sided pleural effusion he underwent a l thoracentesis on which was consistent with a transudate with a diff showing polys lymphs eos and monos total protein of and ldh cultures were negative following the procedure his sats improved his hospitalization was complicated by an episode of tdp on attributed to hypomagnesemia and prolonged qt which required cpr and shocks amiodarone loading drip and magnesium bolus although he did rule out for mi by ce repeat surface echo indicated a hyperdynamic lvef from to additionally the patient had blood cultures for gpc s and was started on vancomycin on transfer the patient is stable and complains of pain over his chest in the location of rib fractures secondary to cpr he denies n v d abd pain chest pressure palpitations and although he feels mildly dyspneic he notes that he feels much improved past medical history long qt syndrome h o tdp hepatitis b hepatitis c h o hepatitis a etoh abuse sober yrs viral alc cirrhosis thrombocytopenia with coagulopathy dm gerd h o cholelithiasis anxiety depression social history admits to ivdu sober for years etoh abuse sober for years and is a current tobacco smoker at ppd patient has children lives at home with his teenage son divorced patient is on habit management and stable to take day take home doses worked for as a repairman for the electrical poles is currently on disability for his anxiety and depression family history non contributory physical exam vs high flow general yo m appearing older than his stated age arousable but sedated skin mildly jaundiced warm and well perfused with venous stasis changes in the lower extremities and multiple tattoos over upper extremities spider angiomata on chest heent normocephalic perrl eomi but sluggish mild scleral icterus op clear ecchymosis over chin on left side no jvd chest gynecomastia ecchymosis over sternum with significant ttp cardiac rrr iii vi sem heard best at rusb radiating to right carotid and across the precordium louder with inspiration no rubs gallops lungs diffuse expiratory wheeze mild rhonchi abd distended with faint fluid wave hepatomegaly to cm below costal margin bs nontender negative ext venous stasis changes dp pulses no edema neuro psych strength follows commands asterixis pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot ld ldh alk phos amylase tot bili pm lipase pm albumin calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm anisocyt macrocyt pm plt smr very low plt count pm pt ptt inr pt brief hospital course yo m with mmp including viral and alcoholic cirrhosis transferred s p thoracentesis for hydrothorax complicated by decompensated tdp requiring cpr shock resuscitation viral etoh cirrhosis and ards gastroenterologist at osh dr evaluated the patient and felt that he may be a candidate for liver transplant there was no evidence of ascites on ct or us but patient s presentation was consistent with hepatic encephalopathy hepatology was on board throughout the patient s course in the micu but did not feel that he was a candidate for liver transplant secondary to his septic picture the patient continued to decompensate requiring intubation for hypoxic respiratory failure and pressors for what was believed to be possible ards sepsis and ended up going into fulminant hepatic failure despite maximum supportive measures and antibiotics his coagulopathy was unable to be controlled even with receiving maximum blood products and support with pressors his family decided to withdraw blood products and the patient passed away on medications on admission protonix mg po bid amiodarone mg po bid spironolactone mg po daily methadone mg po qam clonazepam mg tid clonazepam mg qhs neutraphos packet with meals tid lactulose ml po qid vancomycin g iv q h lasix mg po bid riss discharge medications none discharge disposition expired discharge diagnosis liver failure discharge condition deceased discharge instructions none followup instructions none,"[
""date"": ""2022-10-10"",
""type"": ""SICU NPN""
]

73 yo male with PMH of hep b c and etoh abuse induced cirrhosis transferred to from osh for hepatic transplant work up and implantable defibrillator evaluation.

Major Surgical or Invasive Procedure:
- thoracentesis
- central venous access

History of Present Illness:
This is a yo male with pmh of hep b c and etoh abuse induced cirrhosis transferred to from osh for hepatic transplant work up and implantable defibrillator evaluation.

This is a yo male with pmh of hep b c and etoh abuse induced cirrhosis transferred to from osh for hepatic transplant work up and impl"
24235,admission date discharge date date of birth sex f service history of present illness this is a year old female with a history of seizure disorder cva severe tracheobronchiomalacia status post stenting of trachea and left main stem bronchus in presenting from for stent removals the patient had a bronchoscopy with therapeutic aspiration of retained secretions in per the patient she had a bronchoscopy at subsequently which showed partial obstruction of one stent in the patient with chronic cough since stents placed unable to cough up secretions the patient feels shortness of breath at rest and with exertion worsened since last hospitalization in aspiration pneumonia and seizures no fevers or chills she has had decreased mobility secondary to dyspnea no chest pain no chest tightness no orthopnea pnd or leg swelling appetite good except over the past days no abdominal pain no changes in urination or bowel movements past medical history tracheobronchiomalacia status post stents of trachea and left main stem in status post bronchoscopy with therapeutic aspirations of secretions in seizure disorder for more than years history of paralysis status post right cva of motor strip pfo versus asd with interatrial septal aneurysm asthma depression osteomalacia fibromyalgia gerd status post bilateral pneumonia in social history lives at used to live with her sister history pack years occasional alcohol quit years ago family history significant for allergies and eczema allergies penicillin and tetracycline medications colace vioxx q d cyclobenzaprine mg p r n tegretol mg b i d neurontin mg q a m and mg q h s topiramate mg q a m and mg q h s valproic acid mg b i d singulair mg q d protonix mg b i d aspirin mg q d plavix mg q d zocor mg q h s flovent salmeterol albuterol atrovent guaifenesin mg b i d tranxene mg t i d physical examination vital signs temperature pulse blood pressure breathing at oxygen saturation percent on liters nasal cannula general alert and oriented times in no acute distress able to speak in complete sentences heent pupils equal round and reactive to light sclerae anicteric positive neck retractions dry mucous membranes cardiovascular regular rate and rhythm distant s s no murmurs rubs or gallops appreciated lungs transmission of coarse upper respiratory sounds scant expiratory wheezing questionable decreased breath sounds right more than left no egophony increased fremitus on the right abdomen soft nontender nondistended no hepatosplenomegaly bowel sounds present extremities no edema plus dps and extremities are warm swallowing evaluation in no signs of aspiration laboratory data hematocrit of sodium potassium chloride glucose abg on room air chest x ray persistent left lower lobe infiltrate with effusion questionable worse consistent with prior concise summary of hospital course tracheobronchomalacia it is very likely that the patient s presenting symptoms are secondary to plugging of the stents that the patient had placed this year the patient was scheduled to go to the or for visualization and probable therapeutic procedure on the patient underwent a bronchoscopy with stent removal times bronchial washes were sent for culture and the patient was placed on levofloxacin and flagyl for two days then was taken off her medication formulary since the patient had continued to be afebrile with normal white cell count her symptoms improved postprocedure and remained stable long term plan tracheoplasty hypoxia the patient had been on mild oxygen supplementation postprocedure the patient had percent oxygen saturations on room air anemia borderline iron deficiency hematocrit was stable vitamin b and folate were normal further workup as an outpatient asthma continue with mdis nebulizers and seizure disorder continue with valproate topiramate and neurontin as well as carbamazepine the patient remained stable as an inpatient with no evidence of seizure activity the patient was needed to follow up with dr as an outpatient history of cva the patient was continued on her aspirin and plavix without any complications hypercholesterolemia continued with zocor gerd continued with protonix stable depression and anxiety continued with tranxene the patient was stable on this regimen prophylaxis the patient was maintained on proton pump inhibitors heparin subcutaneous and bowel regimen throughout the entire hospital stay eosinophilia the patient had multiple reasons to have eosinophilia the patient was taking carbamazepine has history of asthma and also taking valproate no further workup was done as an inpatient follow up full code condition on discharge stable discharge status to home the patient did not want to go to rehabilitation discharge diagnoses hypoxia hyponatremia tracheobronchiomalacia anemia asthma seizure disorder history of cva hypercholesterolemia gerd depression anxiety eosinophilia discharge medications ferrous sulfate mg tablet p o q d aspirin mg tablet p o q d topiramate mg tablets p o q h s topiramate mg tablets p o q a m colace mg capsule p o b i d simvastatin mg tablets p o q d pantoprazole mg tablet p o q d gabapentin mg capsules p o q h s gabapentin mg capsule p o q a m carbamazepine mg tablet p o b i d valproate mg at ml one p o q hours plavix mg tablet p o q d rofecoxib mg tablets p o q d cyclobenzaprine mg tablet tablet p o q h s fluticasone propionate puffs inhaled b i d ipratropium bromide mcg puffs inhaled q i d albuterol mcg inhalations times a day salmeterol xinafoate mcg disk with the device inhalation q hours clorazepate potassium mg tablet p o t i d dextromethorphan guaifenesin mg per ml ml p o q hours montelukast sodium mg tablet tablet p o q d followup plans the patient is to follow up with me and dr in the center in neurology on at p m phone number for question the patient is to follow up with dr at the ba complex on at p m phone number is the patient is to schedule an appointment with pulmonary clinic within weeks please call to schedule an appointment with dr within weeks she is to call and schedule an appointment at the patient is to call and schedule an appointment with dr for follow up of stroke she is to call and schedule an appointment within week dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins tetracycline analogues attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness y o female pmh asthma tbm presented to ed with weeks of shortness of breath and cough patient reports going downhill weeks ago which she explains as increasing shortness of breath at rest cough and generally feeling unwell patient began taking mg prednisone and spoke to dr reported feeling better and was to re start taking prednisone mg every other day but patient continued taking mg prednisone every day this past friday patient s cough began to be productive of green sputum associated with rhinorrhea and congestion she reports fever and chills for the last weeks but her temperature is patient denies recent triggers but did clean her house early over the last weeks patient never increased her albuterol and continued to take only once a day additionally she does not take singulair she denies sick contacts she denies recent travel leg swelling or pain she has never been intubated for her asthma patient followed by pulmonary clinic for asthma and requires mg prednisone every other day she received her flu vaccine this year she has frequent asthma flares reveiw of omr on arrival to ed vs bp hr rr o sat ra tachycardia improved to s with l ns patient given combivent nebs mg methylpred gram magnesium levofloxacin l ns tylenol and asa during her ed stay o ranged l nc labs notable for abg on l o lactate negative troponin hct wbc with neutrophils no bands patient continued to tachypneic up to s consequently is being admitted to icu for close monitoring vs on transfer t hr bp rr o sat l nc past medical history asthma patient chronically on steroids mg qod followed by dr history of tracheomalacia s p tracheoplasty history of multiple strokes patent pfo according to problem list right mca seizure disorder no clear documentation of seizure disorder history of body jerking followed by neurology depression osteomalacia fibromyalgia gastroesophageal reflux disease subacute cutaneous lupus no evidence of systemic lupus followed by dr ibs social history the patient currently lives in she is divorced with adult children her son lives in the patient was previously employed in advertising but is not currently working secondary to illness tobacco quit years ago ppd x years etoh once per month illicits none family history noncontributory physical exam on admission vs temp bp hr rr s o sat l gen pleasant comfortable mildy tachypneic but able to complete full sentances no respiratory distress heent mmm no supraclavicular or cervical lymphadenopathy no jvd resp wheezes throughout cv rr s and s wnl no m r g abd nd b s soft nt no masses or hepatosplenomegaly ext no c c e pertinent results admission am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood ctropnt other labs am blood type art o flow po pco ph caltco base xs intubat not intuba am blood lactate microbiology mrsa screen mrsa screen pending sputum gram stain final respiratory culture final blood culture blood culture routine pending blood culture blood culture routine pending radiology cxr chest pa and lateral the lungs are hyperexpanded with flattening of the hemidiaphragms widening of the anteroposterior diameter apical hyperlucency and pleural parenchymal scarring there is no focal consolidation there is a stable x cm calcified granuloma in the left upper lobe the cardiomediastinal and hilar contours are normal there are no pleural effusions or pneumothorax the trachea is normal in caliber again noted is partial resection of the right posterior fifth rib from prior tracheoplasty procedure the bones are diffusely demineralized with multilevel degenerative changes impression chronic obstructive airways disease no evidence of pneumonia brief hospital course year old f pmh asthma tbm who presents with shortness of breath and cough shortness of breath and cough probable copd exacerbation in setting of viral or environmental trigger cxr without infiltrate the patient was initially admitted to the icu where she was started on methylprednisolone mg iv q hours and nebulizer treatement she had improvement back to her recent baseline which is with persistent severe sob with minimal activity she will complete a very slow taper of prednisone eventually back to her chronic home dose for lupus of mg every other day she will complete total days of azithromycin and have ongoing nebulizer therapy she will go to rehab for ongoing physical therapy she was started on bactrim prophylaxis dosing because of the ongoing steroid use the patient has a very poor prognosis she requires ongoing counselling as an outpatient regarding code status and expectations going forward she will follow up with her pcp and pulmonologist all other medical issues were stable and she was continued on her home medicatin regimen medications on admission albuterol sulfate mg ml solution for nebulization vial nebulizer four times a day as needed does not use albuterol sulfate proair hfa mcg hfa aerosol inhaler puffs inh four times a day prn only takes once a day alendronate mg tablet tablet s by mouth weekly calcitonin salmon unit dose aerosol spray spray in alternating nostrils daily celecoxib celebrex mg capsule capsule s by mouth twice a day as needed for pain clopidogrel mg tablet tablet s by mouth once a day clorazepate dipotassium mg tablet tablet s by mouth or times per day as needed for seizures anxiety cyclobenzaprine mg tablet tablet s by mouth up to four times a day as needed for prn for neck pain ergocalciferol vitamin d vitamin d unit capsule capsule s by mouth weekly fluticasone salmeterol advair diskus mcg mcg dose disk with device puff inhaled daily rinse mouth after use furosemide mg tablet one half tablet s by mouth once a day as needed for swelling typically does not take hydrocodone acetaminophen mg mg tablet tablet s by mouth three times daily hydroxychloroquine mg tablet tablet s by mouth twice a day is taking once a day lisinopril mg tablet tablet s by mouth once a day mirtazapine mg tablet tablet s by mouth at bedtime montelukast singulair mg tablet tablet s by mouth once a day not taking omeprazole mg capsule delayed release e c capsule s by mouth twice daily prn pravastatin mg tablet tablet s by mouth once a day prednisone mg tablet prescribed as every other day pregabalin lyrica mg capsule capsule s by mouth once a day no substitution tiotropium bromide spiriva with handihaler mcg capsule w inhalation device one capsule inhaled daily not taking zolpidem mg tablet tablet s by mouth at bedtime only as needed medications otc aspirin aspirin prescribed by other provider mg tablet chewable tablet s by mouth once a day diphenhydramine hcl benadryl otc mg capsule tabs at bedtime discharge medications albuterol sulfate mg ml solution for nebulization sig one inhalation every four hours as needed for shortness of breath or wheezing albuterol sulfate mcg actuation hfa aerosol inhaler sig two inhalation four times a day as needed for shortness of breath or wheezing alendronate mg tablet sig one tablet po once a week calcitonin salmon unit actuation aerosol spray sig one nasal once a day celecoxib mg capsule sig one capsule po twice a day as needed for pain clopidogrel mg tablet sig one tablet po daily daily clorazepate dipotassium mg tablet sig two tablet po daily daily as needed for seizures mood for time period until rehab pharmacy has in stock then ongoing use disp tablet s refills furosemide mg tablet sig tablet po once a day as needed for swelling hydrocodone acetaminophen mg tablet sig one tablet po q h every hours as needed for fibromyalgia pain hydroxychloroquine mg tablet sig one tablet po twice a day lisinopril mg tablet sig one tablet po daily daily mirtazapine mg tablet sig one tablet po hs at bedtime omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily pravastatin mg tablet sig one tablet po daily daily pregabalin mg capsule sig one capsule po daily daily for time period until rehab pharmacy has in stock then ongoing use disp capsule s refills ipratropium bromide solution sig one inhalation q h every hours disp neb refills aspirin mg tablet chewable sig one tablet chewable po daily daily phenytoin sodium extended mg capsule sig one capsule po daily daily for time period until rehab pharmacy has in stock then ongoing use disp capsule s refills guaifenesin mg ml syrup sig mls po q h every hours disp ml s refills nebulizer machine for copd dispense nebulizer machine zero refills advair diskus mcg dose disk with device sig one inhalation once a day azithromycin mg tablet sig one tablet po q h every hours for days bactrim mg tablet sig one tablet po once a day prednisone mg tablet sig per description tablet po daily daily mg daily for days then mg for days then mg for days then mg for days then mg for days then mg every other day ongoing docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po bid times a day as needed for constipation discharge disposition extended care discharge diagnosis copd exacerbation prior stroke fibromyalgia depression hypertension discharge condition stable discharge instructions you were admitted with shortness of breath due to a copd exacerbation please continue all breathing treatments and the steroid taper with prednisone as prescribed please follow up with your outpatient pulmonologist and primary care doctor stop using ambien and flexeril due to the risk of sedation contributing to your shortness of breath followup instructions department when thursday at am with m d building sc clinical ctr campus east best parking garage department pulmonary function lab when monday at pm with pulmonary function lab building campus east best parking garage department pft when monday at pm department medical specialties when monday at pm with dr dr building campus east best parking garage,"{
""date"": ""2022-10-10"",
""discharge_date"": ""2022-10-11"",
""service"": ""MICU"",
""admission_date"": ""2022-10-10"",
""date_of_birth"": ""2001-10-10"",
""sex"": ""F"",
""service_history"": [
""This is a year old female with a history of seizure disorder cva severe tracheobronchiomalacia status post stenting of trachea and left main stem bronchus in presenting from for stent removals the patient had a bronchoscopy with therapeutic aspiration of retained secretions in per the patient she had a bronchoscopy at subsequently which showed partial obstruction of one stent in the patient with chronic c"
57161,admission date discharge date date of birth sex f service obstetrics gynecology allergies no known allergies adverse drug reactions attending chief complaint vaginal bleeding fever chills major surgical or invasive procedure none history of present illness ms is a year old g p s p ltcs on with postpartum course complicated by vaginal bleeding requiring blood transfusion immediately post op with subsequent identification of pelvic hematoma requiring readmission for additional blood transfusion who presents to ed today with recurrent heavy vaginal bleeding fatigue and shaking chills from the patient was amditted to the hospital with acute vaginal bleeding and sympotmatic anemia requiring transfusion her hematocrit went from following transufsion hct increased to she was also treated for endometritis given fundal tenderness noted on examination since her discharge from the hospital on she reports that she has had continued vaginal bleeding which waxes and wanes with periods of heavy flow and light flow however today she experienced very heavy vaginal bleeding when she went to the bathroom with passage of large clots in addition she has experienced fatigue chills vomiting and diarrhea today she states that she has felt feverish today but has not taken her temperature she denies any intercourse since delivery dysuria or urinary frequency past medical history ob gyn hx g p sab weeks in ltcs for nrfht pap ascus negative hr hpv pmh seizures low body weight psh ltcs as noted social history lives with fiancee and child denies t e d family history non contributory physical exam on admission t bp hr rr o ra general fatigued appears dry cv tachycardic with regular rhythm pulm ctab abd thin soft bs diffusely ttp but exquisitely ttp over suprapubic region no guarding and no rebound sse cc clot evacuated from vagina and os no active bleeding from cervix bimanual exquisitely tender on exam with inserion of finger and throughout exam cmt and ttp over suprapubic area no masses appreciated in adnexa but limited discomfort ext nt ne on discharge brief hospital course ms is a year old s p c section c b blood loss anemia requiring blood transfusion with readmission for heavy vaginal bleeding and identification of pelvic hematoma requiring additional blood transfusion who presents to the ed again with vaginal bleeding and fever chills in the ed she was tachycardia and hypotensive concerning for sepsis vs blood loss anemia however she remained afebrile she was initially admitted to the icu for close monitoring but did not require pressors and vitals improved to normal range her hematocrit was from discharge and she was transfused units prbcs with an increase to and was subsequently stable her wbc was without bands and trended down to a urine culture was negative and blood cultures had no growth to date at time of discharge she was started on vancomycin zosyn as her initial presentation was concerning for sepsis flagyl was added on hd she was seen by the id service who recommended discontinuation of antibiotics unless chronic endometritis was suspected however given her course concerning for sepsis antibiotics were continued until discharge on admission a ct scan showed a persistent x cm hematoma between the posterior uterine wall and the bladder slightly decreased in size as compared to preceding exam dated with faint peripheral enhancement superinfection of the hematoma could not be excluded there was a small amount of complex fluid in the pelvis no retained products of conception were identified she remained stable in the icu and was transferred to the floor on hd she was started on methergine for control of vaginal bleeding as there was suspicion for chronic endometritis prompting lower uterine segment atony ms was discharged home with a course of flagyl and levofloxacin per id recommendations on day of discharge ms heavy vaginal bleeding dizziness and abdominal pain medications on admission keppra mg vitamin d units every wks folic acid daily prenatal vit iron daily discharge medications levofloxacin mg tablet sig one tablet po once a day for days disp tablet s refills flagyl mg tablet sig one tablet po every eight hours for weeks disp tablet s refills methergine mg tablet sig one tablet po every six hours for days disp tablet s refills discharge disposition home discharge diagnosis pelvic hematoma vaginal bleeding possible endometritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms you were admitted for further evaluation and management of vaginal bleeding and concern for infection please take the two antibiotics levofloxacin and metronidazole as prescribed for the next week you have also been prescribed methergine to help with vaginal bleeding followup instructions provider md phone date time clinical center completed by,"{
""name"": ""Ms. [**Known lastname 1081**]"",
""date of birth"": ""2017-1-1"",
""sex"": ""Female"",
""service"": ""Obstetrics/Gynecology"",
""allergies"": [
""Penicillins""
],
""no known allergies"": [
""Penicillins""
],
""adverse drug reactions"": [
""Hypotension""
],
""chief complaint"": ""Vaginal bleeding, fever, chills"",
""history of present illness"": ""Ms. [**Known lastname 1081**] is a year old G P S P LTCS on with postpartum course complicated by vaginal bleeding requiring blood transfusion immediately post op with subsequent identification of pel"
80914,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint sharp abdominal pain major surgical or invasive procedure ex lap sigcolectomy end colostomy ileocecotomy history of present illness m pmh sig for crohn s disease presents with sharp stabbing abdominal pain since mn woke up diaphoretic extremely painful abdomen with movement called ems was taken to osh at osh was tachycardic and hypotensive with an acute abdomen he was fluid resuscitated and ct demonstrated inflamed colon with fluid collections and free air he was started on zosyn and transferred here wbc was with bands hct was at the ed here he has continued to receive fluids he was initially hypotensive to but with fluid resus has been is getting iv vanc and iv pain meds is still diaphoretic abdomen tender denies flatus or bm today denies n v denies cp sob of note he has been having symptoms of a uti for the last month his urine has been cloudy to rusty on and off he was seen by a urologist dr who treated him with antibiotics initially he felt better for about weeks then did not follow up any further he was told that he would need cystoscopy and that there was a concern for fistula past medical history pmh crohn s disease primarily affecting terminal ileum has been stable on no medications followed by a gastroenterologist whom he has not seen in about months also has depression and anxiety psh bilateral inguinal hernia repair as child social history social etoh denies t d family history father with inflammatory bowel disease died of complications from ileostomy reversal physical exam on admission t hr bp o sat on l rr gen diaphoretic but a o x sick appearing cor tachy but no m r g pulm ctab abdomen distended but not tense absent bs ttp diffusely but in particular epigastric area and rlq has rebound and guarding umbilical hernia palpated rectal no masses normal tone guiaic negative gu normal male genitalia no discharge brief hospital course m pmh significant for crohn s disease presents with sharp stabbing abdominal pain since mn of admission at osh was tachycardic and hypotensive with an acute abdomen he was fluid resuscitated and ct demonstrated inflamed colon with fluid collections and free air he was started on zosyn and transferred here wbc was with bands hct was at the ed here he has continued to receive fluids he was initially hypotensive to but with fluid resus has been continued on iv vanc zosyn pain meds to or on am of for exlap colon abscess in comunnication with bladder identified pt with sigcolectomy end colostomy and ileocectotomy crystaloid urine ebl persistent hypotension and transferred to sicu from or on phenylephrine drip and remained intubated admitted to sicu persistent mild hypotension overnight on phenylephrine drip given lr vent weaned febrile extubated bedside tte with slight hypovolemia albumin x crystalloing per team increased ivf to uop good kvo iv lasix x given for goal l negative fluid balance ng tube placed intermittent hypertension treated with metoprolol febrile cultured ms self d c d cvl replaced with piv no transfer to floor confusion tachycardia and htn flagyl added started on clears with home anxiety meds diuresed during the day jp d c d regular diet repeat lasix mg transferred to the floor on the floor he did well and antibiotics were stopped on he did require metoprolol and will be discharged with this and is to follow up with his pcp was tolerating regular diet and a wound vac was placed he recieved ostomy teaching with the ostomy nurse team he did have increased ostomy output and was started on imodium and cdif was checked and was negative his ostomy output was apporopriate by the time of discharge and he was off imodium on he had a positive ua and he was treated with ciprofloxacin the wound vac was removed on and the wound was stapled closed and he had dry dressing changes by the time of discharge he was tolerating regular diet and his pain was well controlled with po meds he will be discharged with vna for wound and ostomy care medications on admission seroquel paxil discharge medications paroxetine hcl mg tablet sig two tablet po daily daily quetiapine mg tablet sig one tablet po qhs once a day at bedtime oxycodone mg tablet sig tablets po every six hours as needed for pain disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain metoprolol tartrate mg tablet sig tablets po tid times a day disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills discharge disposition home with service facility discharge diagnosis perforated viscus crohn s disease urinary tract infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions call if fever f call if signs of wound infection including increased redness and foul smelling discharge call with any questions or concerns you have staples closing your abdominal wound they will be removed at one of your follow up appointments in surgery clinic you may place a dry dressing over the wound and this should be changed daily ostomy care per instruction teaching you recieved in the hospital followup instructions please call dr office to schedule follow up appointment in weeks phone please call your primary care physician to schedule follow up appointment in weeks pcp md,"[
""admission_date"" : ""2132-10-10"",
""discharge_date"" : ""2132-10-11"",
""date_of_birth"" : ""2109-10-10"",
""sex"" : ""Male"",
""service"" : ""Surgery"",
""allergies"" : ""Patient recorded as having no known allergies to drugs"",
""attending_chief_complaint"" : ""Sharp abdominal pain"",
""chief_complaint"" : ""Sharp abdominal pain"",
""history_of_present_illness"" : ""Major surgical or invasive procedure (ex Lap Sigcolectomy, End Colostomy, Ileocecotomy)
History of Present Illness:
This is a 2"
95294,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint chest pain major surgical or invasive procedure none history of present illness y o m with cad s p ptca of om in new paf on coumadin htn hld monoclonal gammopathy ra on leflunomide and bronchogenic cyst s p fna presenting with pleuritic substernal chest pain x day was seen for similar complaint by pcp at which time paf was diagnosed and he was started on coumadin several interchanges with pcp recently including appt yesterday due to supratherapeutic inr which resulted in coumadin being held his chest pain is nonradiating not associated with shortness of breath or nausea he does state that it is worsened by deep inspiration however he notes that he also has had exertional chest pain over the past months or so that has progressed and occurs every time he climbs a or walks up a flight of stairs he denies any associated symptoms with this exertional chest pain and states that it resolves with rest denies orthopnea pnd leg edema chest pain at rest in the ed initial vs were t hr bp rr o sat l cxr was notable for b l pleural effusions but no focal opacities ekg showed labs were notable for trop cr baseline lactate d dimer wbc pmns and inr blood cultures were drawn he was given nitro s l morphine mg mg vit k and ffp with a fever to after ffp that resolved with tylenol tte was done showing a moderate sized pericardial effusion with signs of early tamponade he was hemodynamically stable and transferred to the ccu for further monitoring on arrival to the ccu he was in sinus rhythm at a rate of with systolics in the s his pulsus was he was comfortable stating that he did not want to take a deep breath due to pleuritic pain early after arriving on the floor he went into rapid atrial fibrillation without hemodynamic compromise past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history percutaneous coronary interventions ptca of om in of other past medical history nonsustained supraventricular tachycardia with exercise rheumatoid arthritis bronchogenic cyst anemia monoclonal gammopathy social history denies smoking infrequent etoh widowed there are also three unmarried daughters living out at home family history son has had depression and is now living with mr physical exam on admission vs afebrile p bp ra general nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp at mid neck at degrees collapses with inspiration cardiac pmi located in th intercostal space midclavicular line tachycardic normal s s no m r g lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities no c c e at discharge pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso atyps metas myelos pm blood neuts lymphs monos eos baso am blood neuts lymphs monos eos baso am blood hypochr occasional anisocy normal poiklo macrocy normal microcy normal polychr normal ovalocy am blood pt ptt inr pt am blood plt smr normal plt ct pm blood pt ptt inr pt pm blood pt ptt inr pt pm blood plt ct am blood pt ptt inr pt am blood plt ct pm blood ptt am blood pt ptt inr pt am blood plt ct am blood ptt pm blood ptt am blood pt ptt inr pt am blood plt ct pm blood ptt pm blood ptt pm blood ptt am blood pt ptt inr pt am blood pt ptt inr pt am blood plt ct am blood esr am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood estgfr using this am blood alt ast ld ldh alkphos totbili am blood alt ast am blood alt ast alkphos totbili am blood ctropnt am blood ck mb am blood calcium phos mg pm blood calcium phos mg am blood totprot calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood d dimer am blood crp greater th am blood pep abnormal b igg iga igm am blood glucose lactate na k am blood hgb calchct am blood free kappa and lambda with k l ratio pnd echocardiogram the left atrium is moderately dilated the left atrium is elongated left ventricular wall thickness cavity size and regional global systolic function are normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is a moderate sized pericardial effusion the effusion appears circumferential no right ventricular diastolic collapse is seen there is sustained right atrial collapse consistent with low filling pressures or early tamponade echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures impression moderate circumferential pericardial effusion with evidence of right atrial collapse but no frank tamponade preserved biventricular regional and global systolic function echocardiogram due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef there is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats right ventricular chamber size and free wall motion are normal the mitral valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is a small to moderate sized pericardial effusion the effusion appears circumferential echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures impression mild to moderate circumferential pericardial effusion there are no definitive signs of tamponade however the presence of atrial fibrillation and pulmonary hypertension may mean that echo signs of tamponade are absent compared with the prior study images reviewed of the right atrium does not appear to have sustained collapse on the current study brief hospital course m hx cad s p ptca htn hlp mgus who presented with pleuritic chest pain found to have pericardial effusion with early tamponade physiology pericardial effusion differential diagnosis included hemopericardium with elevated inr vs viral vs malignant history of mgus vs rheumatologic hx of ra on leflunomide tte showed signs of early tamponade vs hypovolemia with ra collapse repeat tte on was stable he was hemodynamically stable without signs of tamponade hypertensive hr was stable prior to rapid afib no kussmaul s sign pulsus consistently we did not perform a pericardiocentesis due to hemodynamic stability and high risk of procedure we held his lisinopril and imdur regarding the etiology of his effusion we found no evidence of uri rendering a viral etiology unlikely we discussed his case with his outpatient rheumatologist and oncologist to consider ra and mgus with possible progression myseloma as etiologies spep and upep were sent and were stable from prior a serum free ligth chain assay was sent and was pending at the time of discharge esr was and crp was the upper limit measurable by the assay the patient also reported recently changing his ra medications following consultation with rheumatology it was thought that the pericardial and pleural effusions most likely represented rheumatoid serositis he was treated with empiric mg prednisone with a taper and will be followed by rheumatology following discharge pleural effusions likely related to rheumatoid serositis as discussed above acute kidney injury creatinine peaked at may be secondary to ra or due to poor renal perfusion due to atrial fibrillation spep and upep were unremarkable as above creatinine trended down prior to discharge abnormal lfts transaminitis new for this patient bilirubin and alkaline phosphatase normal likely due to poor hepatic perfusion in the setting of atrial fibrillation atrial fibrillation with rvr he was recently diagnosed with atrial fibrillation per pcp during his hospitalization he was tachycardic with rvr but when given diltiazem or amiodarone flipped into a bradycardic junctional rhythm with occasional superimposed atrial fibrillation on one occasion he had a second pause when flipping fromt achycardia to bradycardia he was started on amiodarone and metoprolol with good rate control although he continued to have occasional episodes of tachycardia to the s he was also restarted on coumadin starting and will require close inr monitoring as an outpatient he will also need outapatient followup with cardiology for further management of his arrhythmia cad hx of ptca in history concerning for stable angina over the past months we held imdur in the setting of pericardial effusion but continued aspirin metoprolol atorvastatin he will followup with caerdiology as an outpatient and may benefit from repeat stress imaging following resolution of his current medical problems elevated inr resolved we restarted coumadin prior to discharge have restarted coumadin htn permissive at the moment till pericardial effusion is proven to be stabilized we held lisinopril and imdur in the setting of pericardial effusion hld continued atorvastatin transitional issues he will need outpatient followup with rheumatolgoy regarding his prednisone taper and further managemtn of his rheumatoid arthritis at the time of discharge serum free light chains were pending please followup as on outpatient of note spep and upep were unchanged from prior please repeat lfts as an outpatient to ensure that theyare not trending up he will need to followup with cardiolgoy regarding further management of arrhythmia medications on admission atenolol mg po qday atorvastatin mg po qday benzoonatate mg po q h prn cough isosorbide mononitrate xr mg po qday leflunomide mg po qday lisinopril mg po qday niacin xr mg po qday warfarin mg po qday asa mg po qday feso mg po qday discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily atorvastatin mg tablet sig one tablet po once a day amiodarone mg tablet sig two tablet po bid times a day for days then decrease to mg daily thereafter disp tablet s refills amiodarone mg tablet sig one tablet po once a day to start after mg twice daily for days is complete disp tablet s refills prednisone mg tablet sig tablets po daily daily for days disp tablet s refills prednisone mg tablet sig one tablet po once a day for days prednisone mg tablet sig tablet po once a day for days prednisone mg tablet sig tablet po once a day for days until you see dr warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills hydroxychloroquine mg tablet sig one tablet po bid times a day isosorbide mononitrate mg tablet extended release hr sig tablet extended release hrs po daily daily discharge disposition home with service facility vna discharge diagnosis pericardial effusion atrial fibrillation with rapid ventricular response acute kidney injury supratherapeutic inr discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you had a collection of fluid around your heart that we think was because of your rheumatoid arthritis you were started on medicine to help treat the rheumatoid arthritis prednisone and you will need to decrease this medicine slowly we have spoken to dr about your treatment your heart rate was also fast and you needed to increase your metoprolol and was started on amiodarone a medicine that will decrease your heart rate and also may convert the atrial fibrillation back to a regular rhythm your kidney function is mildly worse it will need to be checked again once you go home your coumadin level was very high when you were admitted and you were given vitamin k to lower it now your coumadin level is on a lower dose of coumadin mg because the amiodarone will make the coumadin level higher you will need to have your coumadin level checked on we made the following changes to your medicines start taking amiodarone to slow your heart rate decrease your warfarin to mg daily decrease your atorvastatin to mg daily discontinue atenolol take metoprolol twice daily instead to slow your heart rate disontinue your lisinopril for now you will be restarted on this medicine once your kidney function improves stop taking leflunomide for your arthritis take prednisone to treat your arthritis instead and taper down the dose according to directions you will be on mg daily by the time you see dr followup instructions department cardiac services when tuesday at am with md building campus east best parking garage department medical group when wednesday at am with dr building ma campus off campus best parking on street parking name location arthritis center at address phone appt at am completed by,"{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
},
{
""date"": ""2022-12-14"",
""type"": ""PFI""
}"
23145,admission date discharge date date of birth sex m history of present illness mr is a year old male who is a resident of who had been traveling to to visit his daughter reports a week to week history of a progressive onset of jaundice he also denied any pruritus he also had lower abdominal discomfort but denied any significant upper abdominal pain he denies any nausea or vomiting he states that his appetite has been poor over the past few weeks the patient was initially seen at hospital for these symptoms and was found to have a bilirubin level of and he subsequently underwent an abdominal ultrasound which was consistent with distal common bile duct obstruction and pancreatic ductal obstruction though no definite lesion was seen he also was noted to have a distended gallbladder with evidence of gallstones the patient also underwent an endoscopic retrograde cholangiopancreatography at the outside hospital which demonstrated a markedly dilated bile duct with a distal stricture attempts were also made to introduce a biliary stent however one could not be successfully placed he was then transferred to the for further evaluation of his obstructive jaundice and possible surgical intervention past medical history past medical history was unremarkable past surgical history no past surgical history social history the patient is married and has three children he lives in he is a former smoker who quit years ago he states that he does drink two to three beers per day and at least two cocktails per day medications on admission none allergies no known drug allergies physical examination on presentation weight was pounds blood pressure was heart rate was in general the patient was a middle aged male in no acute distress head eyes ears nose and throat revealed normocephalic and atraumatic scleral were icteric pupils were equal round and reactive to light and accommodation extraocular movements were intact neck was supple no jugular venous distention lungs were clear to auscultation bilaterally cardiovascular revealed a respiratory rate no murmurs rubs or gallops abdomen was mildly distended soft nontender no hepatosplenomegaly mild ascites extremities revealed no clubbing cyanosis or edema neurologically alert and oriented times three no asterixis skin was notable for jaundice pertinent laboratory data on presentation hematocrit was white blood cell count was sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was blood glucose was ast was alt was alkaline phosphatase was total bilirubin was pt was inr was ptt was ca from the outside hospital was hepatitis a hepatitis b and hepatitis c serologies were negative radiology imaging electrocardiogram revealed a normal sinus rhythm at beats per minute and no evidence of st changes a ct of the abdomen with intravenous contrast revealed pancreatic head mass measuring cm x cm with minimal small peripancreatic lymph nodes and minimal stranding of the mesentery grade involvement of the superior mesenteric artery and probable grade or involvement of the superior mesenteric vein normal celiac access ascites findings suggestive of mild cirrhosis endoscopic retrograde cholangiopancreatography revealed ampullary mass biliary dilatation compatible with distal obstruction stent placement in the common bile duct gastric mucosal changes consistent with portal hypertensive gastropathy hospital course by system hepatobiliary the patient initially presented to an outside hospital with signs and symptoms consistent with obstructive jaundice an endoscopic retrograde cholangiopancreatography and ct scan demonstrated a mass in the head of the pancreas consistent with adenocarcinoma he was also noted to have mild ascites following the patient s ct scan he developed an elevated creatinine to he was therefore managed as an inpatient with rehydration and total parenteral nutrition until he was deemed suitable for surgery on he was taken to the operating room for exploration possible whipple and possible biliary bypass intraoperatively the patient s liver was noted to be cirrhotic in nature and approximately liters of straw colored ascites fluid was also noted in light of the patient s liver disease the patient was deemed not to be suitable for a whipple and therefore a roux en y choledochal jejunostomy was performed in addition he also underwent a cholecystectomy wedge liver biopsy and transduodenal biopsy of the pancreas the liver wedge biopsy revealed chronic obstruction with marked bile stasis and active cholangiolitis as well as mild steatosis with prominent regeneration also noted was marked portal and sinusoidal fibrosis the pancreatic biopsy revealed invasive adenocarcinoma which was moderately differentiated the patient continued to do well postoperatively his total bilirubin levels came down dramatically from to on the patient s day of discharge in addition the patient s alkaline phosphatase levels also improved he was evaluated by the medical oncology and radiology oncology teams for his pancreatic cancer he was to follow up with them as an outpatient the patient s liver disease was likely secondary to chronic alcohol use he was noted to have ascites both intraoperatively and on his ct scan of the abdomen he was started on aldactone mg by mouth daily for management of his fluid status urinary sodium levels were followed to assess for adequate diuresis he was to continue this medication as an outpatient on postoperative day eight fluid from the drain was sent for cell count cytology and cultures the patient was found to have a white blood cell count of and polymorphonuclear leukocytes his absolute neutrophil count was determined to be which was consistent with spontaneous bacterial peritonitis he was started on intravenous unasyn for treatment of spontaneous bacterial peritonitis the culture from the drain fluid also grew out alpha streptococcus and staphylococcus epidermidis the patient was then started on vancomycin intravenously which was subsequently dosed by levels infectious disease as noted above the patient was found to have spontaneous bacterial peritonitis as suggested by the cell count and culture from the drain fluid he underwent a diagnostic paracentesis on for further evaluation of his ascites fluid the gram stain revealed no evidence of polymorphonuclear leukocytes or microorganisms however his white blood cell count was found to be with polymorphonuclear leukocytes this also confirmed the diagnosis of spontaneous bacterial peritonitis since the patient s absolute neutrophil count was he was continued on intravenous antibiotics until the day of discharge he has remained afebrile and has not complained of any abdominal pain since that time renal on admission the patient s creatinine was within normal limits at however following the patient s ct scan with intravenous contrast the patient developed an increase in his creatinine to since that time his creatinine has remained stable and on the day of discharge his creatinine was wound care the patient s incision was healing well and there was no evidence of a wound infection the drain was removed on postoperative day eight a stitch was placed at the drain site and there was no evidence of leakage for the next one to two days however on postoperative day the patient noted leakage of straw colored fluid from the drain site despite the stitch that was placed previously on the day of discharge an additional two stitches were placed at the drain site however there were still amounts of fluid coming out from the site he was discharged home with an ostomy bag for fluid collection he was instructed to remove the bag if he noticed that the fluid leakage had minimized discharge diagnoses pancreatic adenocarcinoma cirrhosis status post cholecystectomy roux en y hepaticojejunostomy liver biopsy and pancreatic biopsy chronic renal insufficiency spontaneous bacterial peritonitis medications on discharge augmentin mg p o b i d times days ciprofloxacin mg p o b i d times days aldactone mg p o q d protonix mg p o q d condition at discharge condition on discharge was good discharge status discharge status was good discharge followup the patient will be followed up at dr clinic he was instructed to call dr office for a follow up appointment the patient also had an appointment with dr on at p m at the medical clinic he was instructed to return should he develop any fevers or persistent abdominal pain m d ph d dictated by medquist d t job,"{
""name"": ""Mr. [**Known lastname 1051**]"",
""date of birth"": ""2013-1-1"",
""sex"": ""M"",
""history of present illness"": ""admission date discharge date date of birth sex m history of present illness mr is a year old male who is a resident of who had been traveling to to visit his daughter reports a week to week history of a progressive onset of jaundice he also denied any pruritus he also had lower abdominal discomfort but denied any significant upper abdominal pain he denies any nausea or vomiting he states that his appetite has been poor over the past few weeks the patient was initially seen at hospital for these symptoms and was found to have a bilirubin level of and he subsequently underwent an abdominal ultrasound which was consistent"
30948,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint rectal bleeding major surgical or invasive procedure selective angiography the latter with embolization history of present illness yr male had colonoscopy in nedeham on mm polyp in cecum with ooze after polypectomy s p local cauterization comes back with profuse post polypectomy bleeding hct of hypotension past medical history atrial fibrillation status post pacer hypertension s p hernia repair coronary artery disease status post coronary artery bypass graft in three vessels unknown anatomy h o inferior myocardial infarction history of echoin with ejection fraction percent with moderate tricuspid regurgitation biatrial enlargement mild left ventricular hypertrophy moderate mitral regurgitation moderate pulmonary artery systolic hypertension and aortic sclerosis nuclear stress test in with a moderate to large fixed inferior defect without reversibility hyperlipidemia history of first degree av delay and right bundle branch block symptomatic bradycardia and complete heart block necessitating guidant pacemaker history of cardioversion in atrial fibrillation to normal sinus rhythm cri history of anemia with hematocrit and mcv also in social history the patient is married retired and worked for the town of sewer department he drinks alcohol occasionally but does not smoke family history no known history of coronary artery disease or blood disease physical exam ra gen nad aaox cv s s pulm cta b l abd mildly distended nontender ext no c c e pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct am blood hct am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast alkphos amylase totbili am blood lipase am blood albumin calcium phos mg angiography no evidence of active contrast extravasation in the superior or inferior mesenteric artery territories no evidence of other vascular malformations angiography active arterial bleeding in the proximal right colon at the level consistent with the patient s recent polypectomy site site embolized am blood hct brief hospital course the patient was admitted and was transfused throughout the night to maintain hemodynamic stability he also received concomitant fresh frozen plasma when appropriate neuro no issues acetaminophen for pain control cv the patient came to with massive lower gi bleeding for which he received over units initially in the ed the patient was admitted to the icu for serial hematocrit checks and constant vital sign monitoring the patient was taken to angiography to localize the bleeding site which was not initially localized for details please see report on the patient was taken back to angiography where the site of bleeding near the prior polypectomy site and was embolized for more details please see report the patient s hematocrit stabilized after a total of units it was felt that the patient would not tolerate an operation given his extensive cardiac history his hematocrit was monitored every hours and remained stable until when his hematocrit dropped from to the patient was transfused units and his hematocrit rose to the patient was having no more bloody or melenic stools pulm stable the patient had one episode of wheezing during which his vital signs were stable the patient had not received any respiratory treatments and could not remember his medication at home gi gu the patient was initially made npo and received famotidine once the patient s hematocrit had stabilized he was given clear liquids his diet was advanced as his hematocrit continued to remain stable which he tolerated well his urine output was routinely monitored with a foley catheter in place heme as previously mentioned serial hematocrits were performed and the patient was transfused when necessary he also received concomitant ffp when appropriate the patient was constantly monitored endo the patient was initially put on an insulin drip for close blood sugar monitoring he was changed to a sliding scale once they were controlled proph the patient received famotidine for gi prophylaxis and had pneumoboots as anticoagulation was not an immediate option on discharge the patient s hematocrit was stable and the patient was no longer having any bloody bowel movements or bright red blood per rectum the patient was afebrile vital signs stable ambulating tolerating regular diet urinating and doing well medications on admission asa coumadin gemfibrozil atorvastatin famotidine metoprolol lisinopril albuteral atrovent discharge medications famotidine mg tablet sig one tablet po q h every hours acetaminophen mg tablet sig tablets po q h every hours as needed omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day lisinopril mg tablet sig one tablet po daily daily pravastatin mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po bid times a day furosemide mg tablet sig one tablet po once a day niacin mg tablet sig one tablet po tid times a day amlodipine mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po once a day discharge disposition home discharge diagnosis profuse post polypectomy bleeding lower gi bleed discharge condition stable discharge instructions you may have several dark or marroon bowel movements following your discharge which is normal please call your doctor or return to the er for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough or wheezing if you are vomiting and cannot keep in fluids or your medications you are getting dehydrated due to continued vomiting diarrhea or other reasons signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing you may see dark black material when you have a bowel movement please seek medical attention if you have a large bright red bowel movement not dark marroon however your skin or the whites of your eyes become yellow your pain is not improving within hours or not gone within hours call or return immediately if your pain is getting worse or is changing location or moving to your chest or back you have shaking chills or a fever greater than f degrees or c degrees any serious change in your symptoms or any new symptoms that concern you please resume all regular home medications except coumadin you may restart your coumadin and aspirin on saturday continue to ambulate several times per day followup instructions you should follow up with your primary care doctor weeks after discharge follow up with your pcp regarding your coumadin and monitoring your inr have your inr cheched on wednesday please follow up with dr as needed call to schedule an appointment if necessary md completed by,"[
""date"": ""2019-1-15"",
""type"": ""SICU NPN""
]

73 yo male with h/o atrial fibrillation status post pacer, hypertension, s/p coronary artery bypass graft in three vessels, unknown anatomy, h/o inferior myocardial infarction, history of echoin with ejection fraction percent with moderate tricuspid regurgitation, biatrial enlargement, mild left ventricular hypertrophy, moderate mitral regurgitation, moderate pulmonary artery systolic hypertension and aortic sclerosis, nuclear stress test in with a moderate to large fixed inferior defect without reversibility, hyperlipidemia, history of first degree av delay and right bundle branch block symptomatic bradycardia and complete heart block necessit"
18654,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint fever neutropenia major surgical or invasive procedure bronchoscopy unsucessful due to hypoxia history of present illness year old man with cml transformed to all s p hypercvad starting with second course currently day he presented to outpatient clinic on with fever to degrees at home and was admitted to the bmt service he was put on empiric vanco cefepime on he deveoped increaasing shortness of breath and tachycardia with t o sat to ra improved to on l nc abc was on l fm ekg showed v v st depressions he had negative troponins x cxr showed bilateral lower lobe infiltrate and consolidations and cta showed rll consolidation diffuse ground glass opacities with no pe he was evaluated by the pulmonary service who performed bronch on which he did not tolerate well desaturating and having to be put on nonrebreather he was noted to be increasingly tachypnic so he was transferred to the micu past medical history no significant pmh he had a negative stress echo in after having sob and arm pain social history mr lives in with his wife and children he works at a restaraunt in town he denies tobacco use and drink alcohol only rarely family history no significant family history with no known family history of hematologic malignancy physical exam pe tm tc bp p r o l nrb gen nad sitting in chair slightly tachypnic without retractions heent left eye with nonactive hemorrhage inferior lateral of pupil pupils reactive eomi op clear resp poor inspiratory effort reduced bs right base cv rrr nl s s no mgr abd soft ntnd bs ext dp s pertinent results micro blood cultures viridans streptococci sensitive to vanco ceftriaxone bottles blcx negative sputum cx only positive for oropharyngeal flora echo worse mr and worse lv systolic function and new wall motion abnormality compared with chest xray consistent with pneumonia chest ct diffuse bilateral nodular and ground glass opacities with more confluent regions of bibasilar consolidation brief hospital course a p year old man with cml transformed to all s p hypercvad with respiratory distress resp patient developed a cough with decreased breath sounds on hd and that day he had an episode of respiratory distress desating to the low s his chest xray showed pneumonia chest cta done originally for pe was neg for pe but did show ground glass opacities and bilobar consolidation pulmonary was consulted and patient was taken for bronchoscopy during the bronchcoscopy the patient had an episode of desaturation into the s and it was aborted over the rest of the day the patient had increasing sob and was sent to the icu for one night due to tachypnea and desating to on nrb he did well in the icu on only l oxygen and was transferred back in a m patient was initially treated with vanco levo flagyl and then was switched to just levo and ceftriaxone after id consult he was also placed on pcp prophylaxis and maintained on acyclovir and fluconazole on discharge he was feeling much better and able to remain on room air patient was discharged on po levaquin and will come every day to get gm of ceftriaxone until cardiac status during the episode of respiratory distress on hd patient had reversible st segment depression patient with echo with wall motion abnormalities negative troponins after that day patient did not have any ekg changes he will see a cardiologist as an outpatient to consider stress test we started a low dose beta blocker but because of his low bp did not start ace and because of low platelets did not start asa opth on hd patient reported a spot in this right eye the ophthamology team was consulted this monocular defect was determined to be thrombocytopenic retinopathy l eye hemorrhage r eye he was just given supportive treatment with platelet transfusions and hob degrees he was discharged with ophthal follow up all on hypercvad chemo held proph acyclovir fluconazole bactrim discharge medications fluconazole mg tablet sig one tablet po q h every hours disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills trimethoprim sulfamethoxazole mg tablet sig one tablet po bid times a day double strength disp tablet s refills acyclovir mg capsule sig two capsule po q h every hours disp capsule s refills ceftriaxone sodium in d w mg ml piggyback sig two gm intravenous once a day levofloxacin mg tablet sig one tablet po once a day for days disp tablet s refills discharge disposition home discharge diagnosis febrile neutropenia pneumonia ischemia preretinal hemorrhage discharge condition stable discharge instructions please call dr if you have any symptoms such as fever cough nausea vomiting or any concerning symptoms if you have any chest pain or shortness of breath go directly to the ed followup instructions please follow up with dr within weeks please follow up with dr tomorrow provider md where hematology oncology phone date time please follow up with dr in cardiology clinic provider m d where cardiac services phone date time please follow up at center provider m d where center phone date time completed by,"[
""admission_date"" : ""2019-12-10"",
""discharge_date"" : ""2019-12-12"",
""date_of_birth"" : "" him 1959-12-10"",
""sex"" : ""Male"",
""service"" : ""Medicine"",
""allergies"" : ""Patient recorded as having no known allergies to drugs"",
""attending_chief_complaint"" : ""Fever, neutropenia"",
""chief_complaint"" : ""Fever, neutropenia"",
""history_of_present_illness"" : ""Year old man with CML transformed to all s/p hypercvad starting with second course currently day he presented to outpatient clinic on with fever to degrees at home and was admitted"
98024,admission date discharge date date of birth sex m service ccu chief complaint chest pain history of present illness this is a year old male with a history of nephrolithiasis admitted to ccu from catheterization laboratory after complaining of chest pain described as burning substernal radiating to the left and right upper extremities and back the patient was in class at the time of the onset at a m on the day of admission the patient went to unit health where he reports received three nitroglycerin sublingual and chewed on an aspirin the patient was brought in by ambulance to at his heart rate was blood pressure with a respiratory rate of his electrocardiogram was consistent with an inferior myocardial infarction with elevations in leads ii iii avf v the patient was treated with aspirin nitroglycerin oxygen heparin intravenous nitroglycerin drip mcg the patient was taken to the catheterization laboratory where he was found to have a patent right coronary artery patent left anterior descending and the left circumflex with a subtotal occlusion wire across the lesion percutaneous transluminal coronary angioplasty was performed the stent was placed where upon the patient complained of some chest pain and treated with fentanyl after the procedure the patient s chest pain abated right heart catheterization was performed with right atrial mean pressure of right ventricular pressure of with a wedge pressure of the patient received cc of contrast during the procedure review of systems no shortness of breath no nausea no vomiting no diaphoresis no light headedness no abdominal pain some difficulty with urination status post fentanyl past medical history no past medical history other than nephrolithiasis the patient reports a past surgical history for kidney stone allergies no known drug allergies medications no medications at admission social history the patient moved to from rio de janiero two years ago he has a nine pack year history of tobacco use he quit two years ago and then recently restarted family history significant for coronary artery disease father passed away from myocardial infarction at age physical examination vital signs on admission revealed temperature heart rate systolic blood pressure diastolic blood pressure on mcg nitroglycerin mean atrial pressure the patient is on examination revealed the patient pleasant no apparent distress alert and oriented to person place and date no pallor no jaundice no anasarca extraocular movements are intact sclera anicteric no jugular venous distention no carotid bruit normal s and s bradycardic in the s no murmurs rubs or gallops the lungs are clear to auscultation anteriorly the abdomen is soft nontender nondistended bowel sounds auscultated the patient with angio to right femoral artery with no evidence of hematoma or bruit the right femoral vein sheath is in place no lower extremity edema laboratory data white blood count with a differential of neutrophils lymphocytes bands monocytes platelets red blood cell morphology within normal limits prothrombin time inr partial thromboplastin time biochemical profile as follows sodium potassium chloride bicarbonate blood urea nitrogen creatinine glucose ck from a m with a troponin less than assessment this is a year old male with a family history of coronary artery disease and positive tobacco use status post percutaneous transluminal coronary angioplasty and stent of left circumflex artery with decrease in chest pain following catheterization the patient with negative ck at a m the pain beginning at a m the patient hemodynamically stable on reopro drip and nitroglycerin drip on admission hospital course coronary artery disease the patient s cks were cycled during hospital course the patient had a peak ck mb of with an index of at p m on the patient s troponin was measured to be greater than the patient was treated with aspirin plavix lopressor captopril bedrest reopro drip for twelve hours and then discontinued nitroglycerin drip was titrated and discontinued the patient was maintained on telemetry the patient had episodes of nonsustained supraventricular tachycardia on telemetry as well as bradycardia after lopressor treatment began ldl was checked which was the patient was started on lipitor milligrams p o q d during the hospital course the patient was adequately beta blocked to a heart rate of with a systolic blood pressure of to on milligrams b i d lopressor the patient was also treated with captopril milligrams p o t i d his blood pressure tolerated this treatment the patient was provided nutritional counseling for cardiac diet the patient s urine output was within normal limits during hospital course after contrast during cardiac catheterization blood urea nitrogen and creatinine were within normal limits after reopro drip and heparin treatment the patient s platelets were within normal limits during hospital course the patient complained of chest pain within the hour after arrival to the ccu serial electrocardiograms were obtained showing no electrocardiographic changes and no evidence of in stent restenosis stat transthoracic echocardiogram was obtained which showed normal left atrium mild symmetric left ventricular hypertrophy mild regional left ventricular systolic dysfunction with hypokinesis of the posterior wall and basal inferior wall aortic leaflets appeared within normal limits mitral leaflets were structurally normal no mitral valve prolapse and mitral regurgitation was noted no pericardial effusion for further workup of the patient s predisposition for myocardial infarction lipid protein a and homocystine laboratories were sent which are pending at the time of discharge the patient complained of gastric upset he was treated with prilosec milligrams p o q d as well as maalox p r n the patient was noted to have an elevated white count which decreased consistent with myocardial infarction the patient was noted to have a low grade temperature to which abated which was consistent with recent myocardial infarction amylase and lipase were sent when the patient complained of epigastric pain with back pain amylase and lipase were both noted to be within normal limits the patient was discharged on with the following medications atenolol milligrams p o q d zestril milligrams p o q d nitroglycerin milligrams sublingual q minutes p r n chest pain prilosec milligrams p o q d lipitor milligrams p o q d aspirin milligrams p o q d plavix milligrams p o q d times twenty eight days follow up the patient will follow up with and on at p m and with on at p m discharge diagnosis acute myocardial infarction left circumflex artery thrombosis with percutaneous transluminal coronary angioplasty and stent condition on discharge stable m d dictated by medquist d t job cc [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint left main coronary artery disease major surgical or invasive procedure coronary artery bypass graft x left internal mammary artery to left anterior descending saphenous vein graft to diagonal saphenous vein graft to ramus saphenous vein graft to obtuse marginal history of present illness this year old hispanic male with history coronary artery disease and multiple interventions to the circumflex and a nstemi in who had recurrent chest pain with minimal exertion and a positive exercise mibi he underwent cardiac catheterization in which revealed left main disease and he was referred for surgery he was discharged after catheterization to allow plavix washout and to stop smoking past medical history coronary artery disease s p myocardial infarction nstemi and multiple pcis to lcx hypercholesterolemia gastroesophageal reflux disease anxiety depression kidney stones s p laser surgery social history race hispanic last dental exam months ago lives with partner occupation flight attendant tobacco ppd x years etoh glasses of wine week rec drug denies family history father died of mi age brother with age physical exam admission pulse resp o sat ra b p right left height weight lbs general skin dry x intact heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema varicosities none x neuro grossly intact pulses femoral right left dp right left pt left radial right left carotid bruit right none left none pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am hgb calchct am glucose lactate na k cl pm glucose lactate na k cl pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm urea n creat chloride total co echo pre bypass the left atrium is moderately dilated no mass thrombus is seen in the left atrium or left atrial appendage no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses and cavity size are normal overall left ventricular systolic function is normal lvef the right ventricular cavity is mildly dilated there are simple atheroma in the aortic arch there are simple atheroma in the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal mild to moderate central mitral regurgitation is seen worse at pressures of s systolic vena contracta for mitral jet ranged from cm there is mild partial anterior prolapse and borderline annular dilation of the mitral valve there is no pericardial effusion cxr there again is noted bilateral areas of consolidation throughout both lung fields which are stable findings are worse within the lung bases cardiac silhouette is upper limits of normal but stable brief hospital course mr was a same day admit for coronary bypass grafting he had previously undergone pre operative work up and cardiac catheterization on which revealed severe left main coronary artery disease on he was brought to the operating room where he underwent coronary artery bypass graft x please see operative report for surgical details in summary he had coronary artery bypass grafting x with left internal mammary artery grafted to the left anterior descending reverse saphenous vein graft to the first marginal branch ramus intermedius and first diagonal branch his bypass time was minutes with a crossclamp of minutes he tolerated the surgery well following surgery he was transferred to the cvicu for invasive monitoring in stable condition he was hemodynamically stable in the immediate post operative period and later that day he weaned from sedation awoke neurologically intact and was extubated on pod he was transfered to the floor for further recovery beta blockers were resumed and diuresis was initiated with a goal of matching his pre operative weight all tubes lines and drains were removed according to cardiac surgery protocol on pod he was noted to be febrile a white blood cell couont was checked and found to be elevated a chest xray at that time revealed bilateral opacities sputum cultures were sent the eventually grew gram positive rod s and he was begun on appropriate antibiotics his fever and elevated white count resolved physical therapy worked with him for strengthening and mobilization his antidepressents and anxiolytics were resumed post operatively the remainder of his post operative course was uneventful and he was discharged home with visiting nurses on post operative day six all medications restrictions and follow up care was discussed with him prior to going home medications on admission plavix mg po daily amlodipine mg po daily lipitor mg po daily wellbutrin sr mg celexa mg daily folic acid zestril mg po daily trazodone mg po daily asa mg po daily omeprazole mg daily discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily disp capsule delayed release e c s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig three tablet po tid times a day disp tablet s refills bupropion hcl mg tablet sustained release sig one tablet sustained release po bid times a day disp tablet sustained release s refills citalopram mg tablet sig two tablet po daily daily disp tablet s refills hydromorphone mg tablet sig tablets po every hours as needed for pain disp tablet s refills furosemide mg tablet sig one tablet po daily daily for days disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po daily daily for days disp tab sust rel particle crystal s refills levofloxacin mg tablet sig two tablet po q h every hours for days disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis coronary artery disease s p coronary artery bypass graft x hypercholesterolemia s p multiple percutaneous interventions to circumflex gastroesophageal reflux disease anxiety depression kidney stones s p laser surgery discharge condition good discharge instructions monitor wounds for signs of infection these include redness drainage or increased pain report any fever greater then report any weight gain of pounds in hours or pounds in week shower daily wash incision with soap and water no lotions creams or powders to incision for weeks no driving for month and taking narcotics no lifting greater then pounds for weeks please call with any questions or concerns take all medications as directed followup instructions dr in weeks dr in weeks dr in weeks wound clinic in weeks please call for appointments completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2013-03-01"",
""sex"": ""Male"",
""service"": ""CCU"",
""chiefComplaint"": ""Chest pain"",
""historyOfPresentIllness"": ""This is a year old male with a history of nephrolithiasis admitted to ccu from catheterization laboratory after complaining of chest pain described as burning substernal radiating to the left and right upper extremities and back the patient was in class at the time of the onset at a m on the day of admission the patient went to unit health where he reports received three nitroglycerin sublingual and chewed on an aspirin the patient was brought in by ambulance to at his heart rate was blood pressure with a respiratory rate of his electrocardiogram was consistent with an"
58510,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint nausea vomiting abdominal pain major surgical or invasive procedure nasogastric tube placement diagnostic and therapeutic paracentesis colonoscopy diagnostic and therapeutic paracentesis colonoscopy picc line placement intestinal tube placement history of present illness mr is a year old male with alcoholic cirrhosis htn and pud who was recently discharged from the hepatology service on where he was treated for hepatic encephalopathy and sbp with ciprofloxacin after leaving the hospital he developed nausea vomiting and then abdominal pain he has mostly stayed in bed and has had difficulty tolerating pos vomiting has been bilious non bloody he vomited once yesterday he denies fevers or lightheadedness he had one headache that resolved no photophobia or neck stiffness he has a chronic cough that has become slightly more productive of yellow sputum he has some shortness of breath with exertion and ocassional lower chest discomfort upon arrival to the ed intial vitals were pain t hr bp rr o sat ra exam notable for a protuberant and diffusely tender abdomen labs notable for wbc count with bands on the diff lactate ct abdomen and pelvis was concerning for sbo with dilated loops of bowel transplant surgery was consulted and recommended serial abdominal exams ngt foley npo foley paracentesis pan culture and cxr ngt had l of output the patient underwent diagnostic paracentesis with cc of fluid removed fluid was unremarkable but patient received zosyn for concern for sbp he also received g of albumnin per recommendation from the hepatology fellow vitals prior to transfer to the floor hr bp rr o sat ra upon arrival to the floor the patient was comfortable and felt much better since insertion of the ngt review of systems per hpi denies fever chills night sweats denies rhinorrhea or congestion denies palpitations denies diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rashes or skin breakdown no numbness tingling in extremities no feelings of depression or anxiety all other review of systems negative past medical history etoh cirrhosis htn pud gerd social history lives at home with his wife and son in last drink about months ago per family pt denies tobacco use family history non contributory physical exam on discharge t hr bp gen comfortable nad ng tube in place temporal wasting cv rrr s s no murmurs rubs gallops respiratory clear to auscultation bilaterally no wheezes rales or rhonchi abd distended soft non tender tympanitic to percussion bowel sounds ext le edema to knees neuro a ox pertinent results on admissionl pm plt count pm hypochrom normal anisocyt poikilocy macrocyt microcyt normal polychrom normal ovalocyt occasional burr occasional bite occasional pm neuts bands lymphs monos eos basos atyps metas myelos pm wbc rbc hgb hct mcv mch mchc rdw pm albumin pm lipase pm alt sgpt ast sgot alk phos tot bili pm glucose urea n creat sodium potassium chloride total co anion gap pm pt ptt inr pt am ascites wbc rbc polys lymphs monos mesotheli macrophag other am lactate am comments green top am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am osmolal am calcium phosphate magnesium am lipase am alt sgpt ast sgot alk phos tot bili am glucose urea n creat sodium potassium chloride total co anion gap am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am urine color yellow appear clear sp am lactate am type comments green top am urine osmolal am urine hours random urea n creat sodium potassium chloride at discharge chemistry na k cl hco bun cr ca mg phos cbc wbc hct plts coag inr lft alt ast ap ldh tbili alb studies ct abdomen pelvis impression massive ascites small bowel is distened and large bowel is distended to the distal transverse colon where there is a relative transition point without obvious mass consistent with a large bowel obstruction a barium enema is recommended for further investigation nodule at the liver dome is concerning for a hepatama nodular densities along the left flank may be omental implants recommend mr m for further evaluation of the liver lesion dilated and fluid filled esophagus and stomach small left pleural effusion portal vein patent subacute left rib fracture perisistent bilateral subcentimeter hypodensities too small to characterize statistically likely to be benign cysts mri abdomen pelvis impression cirrhotic liver with enhancing lesion with washout characteristics in the dome of the liver in segment viii concerning for hepatocellular carcinoma massive ascites small left pleural effusion with adjacent atelectasis incompletely visualized gastrointestinal tract which demonstrates distention of the small bowel and large bowel as seen on recent ct colonoscopy no mass or obstructing lesion was noted preparation was noted to be poor therefore any smaller underlying lesions could not be completely excluded retroflexion was not performed due to large amount of stool in rectal vault decompression in icu colonic dilatation without overt mass lesion or external compression stool throughout colon decompression using colonoscope please insert rectal tube maintain in icu abdominal xray dilated loops of both small and large bowel are noted with air also seen within the ascending and transverse colons the overall degree of distention and appearance are not significantly changed from prior study and may reflect an ileus there is no free air or pneumatosis impression no interval change in persistent small bowel dilatation as well as dilated ascending and transverse colon abdominal xray dobhoff tube in standard location appears post pylroic brief hospital course mr is a y o m w esld etoh cirrhosis c b ascites sbp and pse who was admitted for nausea vomiting and abdominal pain due to bowel obstruction bowel obstruction mr was discharged from the hospital on on ciprofloxacin to treat sbp with last dose scheduled to be on admission his repeat diagnostic paracentesis was negative sbp the patient was found to have a large bowel obstruction with dilated large and small bowel loops he had a colonoscopy which showed no intraluminal mass but it was a poor prep the patient was given an ng tube to suction and was kept npo his symptoms did not improve and he was unable to tolerate po on hospital day the patient started to complain of increased abdominal pain there was concern for perforation versus obstruction kub showed no signs of free air and repeat paracentesis was negative for sbp in the afternoon the patient became more sleepy arousable to voice with asterixis and was noted to have small bright red blood clots in his ng tube fluid drainage he was transfered to the icu for closer monitoring and possible colonoscopy for decompression of ileus pt was admitted to micu for colonoscopy and possible decompression of his bowel he underwent colonoscopy with decompression using colonoscope following colonoscopy the patient passed flatus and had a bowel movement his condition improved and he was transferred out of the micu back to the floor mr continued to have bowel movements and pass gas his diet was gradually advanced to full diet which he tolerated his lactulose dose was decreased as he had discomfort from gas pains his ng tube to suction was removed and he denied nausea and vomiting esld alcoholic cirrhosis initially the patient s lasix and spironolactone were held and the patient was intravascularly dry they were re started after he was volume repleted lactulose and rifaximin were continued the patient had two paracentesis both were negative for sbp in the second paracentesis on l of fluid were removed after re starting diuretics the patient had persistent peripheral edema as well as ascites the patient s lasix dose was increased from to mg daily and his spironolactone dose was increased from to daily the patient s mri showed concern for hepatocellular carcinoma however his afp was normal no work up was initiated in the hospital because of the patient s acute issues acute renal failure the patient had acute renal failure at time of admission with creatinine up to from his baseline of it was thought to be pre renal in etiology from vomiting and poor po intake it resolved to during hospitalization with iv fluids and increased po intake malnutrition mr is very malnourished he presented with an albumin of he was unable to tolerate po to his ileus he started on tpn on and it was continued throughout the hospitalization he was discharged on both a full diet and tpn he also had a post pyloric intestinal tube placed to start enteric feeds as wll anemia thrombocytopenia during the hospitalization the patient s hematocrit trended down to the mid s from the low s on admission iron studies on consistent with anemia of chronic disease he had both normal folate and b levels egd in consistent with portal hypertensive gastropathy and ulceration platelets are low likely due to splenomegaly throughout the hospitalization the hematocrit remained stable in the mid s the patient had small amount of blood from ng on which resolved but no other bleeding during admission he was given a ppi twice a day medications on admission home medications per discharge summary furosemide mg tablet sig one tablet po daily daily disp tablet s refills folic acid mg tablet sig one tablet po daily daily disp tablet s refills multivitamin tablet sig one tablet po daily daily disp tablet s refills rifaximin mg tablet sig one tablet po tid times a day disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day spironolactone mg tablet sig one tablet po daily daily disp tablet s refills lactulose gram ml syrup sig thirty ml po twice a day titrate to bowel movements per day disp ml s refills prochlorperazine maleate mg tablet sig one tablet po q h every hours as needed for nausea disp tablet s refills phytonadione mg tablet sig one tablet po once a day discharge medications rifaximin mg tablet sig one tablet po bid times a day folic acid mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily lactulose gram ml syrup sig fifteen ml po daily daily ciprofloxacin mg tablet sig one tablet po q h every hours disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day furosemide mg tablet sig one tablet po daily daily disp tablet s refills spironolactone mg tablet sig two tablet po daily daily disp tablet s refills discharge disposition extended care facility northeast discharge diagnosis primary large bowel obstruction abdominal ascites malnutrition acute renal failure alcoholic cirrhosis secondary hypertension peptic ulcer disease discharge condition stable discharge instructions you were admitted to the hospital with abdominal pain and vomiting you were found to have a blockage in your large intestine you had a colonscopy that showed no large mass in your colon you also had a nodule on your liver that was concerning for cancer you had an iv placed to receive nutrition through your vein you also had fluid removed from your abdomen which did not show any infection or cancer cells you had an tube placed through your nose into your intestine so that you could get adequate nutrition please see below for your follow up appointments the following changes have been made to your medications added ciprofloxacin mg daily this medication will prevent infection recurrence please take it every day changed dose of lasix to mg po daily changed dose of spironolactone to mg po daily changed dose of lactulose to ml po once per day followup instructions md phone date time if he is unable to get appointment with his own gi i called dr office to get an appointment they will get back to both me and patient please call your pcp to make an appointment please call your gi doctor at to make an appointment,"{
""date"": ""2019-1-14"",
""type"": ""PFI""
},
{
""date"": ""2019-1-15"",
""type"": ""PFI""
},
{
""date"": ""2019-1-16"",
""type"": ""PFI""
},
{
""date"": ""2019-1-17"",
""type"": ""PFI""
},
{
""date"": ""2019-1-18"",
""type"": ""PFI""
},
{
""date"": ""2019-1-19"",
""type"": ""PFI""
},
{
""date"": ""2019-1-20"",
""type"": ""PFI""
}"
46816,admission date discharge date date of birth sex m service cardiothoracic allergies theophylline shellfish derived attending chief complaint dyspnea on exertion major surgical or invasive procedure aortic valve replacement mm st mechanical and two vessel coronary artery bypass grafting left internal mammary to left anterior descending with vein graft to diagonal history of present illness this is a year old male with known coronary artery disease and aortic stenosis the history of coronary disease dated back to when he had an inferior wall myocardial infarction at that time he received a bare metal stent to the rca he remained stable until when he developed chest pain cath at that time revealed stenosis of the lad and he received a des in he was hospitalized and treated for pulmonary edema cardiac cath on revealed lm and two vessel cad he is also found to have severe as on echo he was subsequently referred for avr cabg of note he recently completed a course of antibiotics for pneumonia currently breathing much better no fevers chills or rigors past medical history coronary artery disease s p iwmi s p bms of rca s p des to lad hodgkin s lymphoma s p radiation to chest and abdomen history of paroxysmal atrial fibrillation dx dyslipidemia diabetes mellitus type ii hypothyroidism reactive airway syndrome s p laparotomy splenectomy s p biopsy of left clavicular node s p tonsillectomy social history race caucasian last dental exam dr in lives with wife child occupation works in software quality assurance for tyco safety tobacco none etoh none family history no premature coronary artery disease physical exam preop exam pulse regular resp o sat b p right left height weight lb general nad appears older than stated age skin dry x intact x heent perrla x eomi x neck supple x full rom rom limited xrt kyphosis chest lungs clear bilaterally x heart rrr x irregular murmur systolic radiation markers on chest pectus excavatum noted abdomen soft x non distended x non tender x bowel sounds x well healed mid line abdominal scar extremities warm x well perfused x hair loss laterally and distally edema none varicosities none x neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit no bruit noted no significant murmur noted pertinent results intraop tee pre bypass the left atrium is mildly dilated the left atrium is elongated no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal regional left ventricular wall motion is normal right ventricular chamber size and free wall motion are normal there are simple atheroma in the ascending aorta there are complex mm atheroma in the aortic arch there are complex mm atheroma in the descending thoracic aorta the number of aortic valve leaflets cannot be determined there is severe aortic valve stenosis valve area cm moderate aortic regurgitation is seen there is mitral regurgitation with calcification of the anterior mitral leaflet jet appears central there is mild valvular mitral stenosis area cm due to co existing aortic regurgitation the pressure half time estimate of mitral valve area be an overestimation of true mitral valve area there is no pericardial effusion post bypass a mechanical prosthesis is seen in the aortic position st per surgeons on initial seperation from bypass a significant paravalvular leak is noted between and o clock position where the native non coronary cusp would have been surgeons notified immediately and bypass reiniatied on second bypass wean this jet is no longer present only symmetric washing type jets are seen peak gradients measure mm hg mean mm hg with cardiac output lpm and systemic pressures of systolic valve leaflets could not be visualized due to significant artifacts mr is now aortic contours intact remaining exam is unchanged all findings discussed with surgeons at the time of the exam pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood pt inr pt am blood pt inr pt pm blood urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood calcium phos mg am blood wbc rbc hgb hct mcv mch mchc rdw plt ct brief hospital course mr was admitted and underwent a mechanical aortic valve replacement and coronary artery bypass grafting surgery by dr for surgical details please see operative note following surgery he was brought to the cvicu for invasive monitoring in stable condition within hours he was weaned from sedation awoke neurologically intact and was extubated without incident he remained in the cvicu receiving aggressive pulmonary toilet for an additional day and was transferred to the step down for on post op day two beta blockers and diuretics were started and he was diuresed towards his pre op weight coumadin was initiated for mechanical aortic valve but inr quickly rose to be supra therapeutic at coumadin was held he received vitamin k and inr trended down coumadin was restarted the following day with a gentle titration on post op day four he was transferred back to the cvicu due to rapid atrial fibrillation with hypotension and no iv access picc line was placed and he was given initially given cardizem and then amiodarone rhythm converted back to sinus rhythm and later on the same day he was transferred back to step down floor but he did continue to have atrial fibrillation flutter which was appropriately treated along with ep consult chest tubes and epicardial pacing wires were removed per protocol he developed bilateral arm phlebitis with elevated white count and was started on iv antibiotics which was eventually changed to oral he will continue antibiotics for days in addition warm compresses and ace wraps were applied per vascular consult over the next several days he continued to slowly improve while working with physical therapy for strength and mobility in addition his inr slowly trended up and was therapeutic at discharge on post op day he was ready for discharge home with vna services and the appropriate medications and follow up mwhc will follow inr and adjust coumadin accordingly medications on admission sotalol mg digoxin mg daily lisinopril mg daily crestor mg daily aspirin mg daily metformin glipizide mg daily levothyroxine mcg daily ventolin inhaler prn vit c mg daily vit d iu daily vit b mcg daily mvi daily sl ntg prn discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills rosuvastatin mg tablet sig two tablet po daily daily disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills glipizide mg tablet sig one tablet po daily daily disp tablet s refills levothyroxine mcg tablet sig two tablet po daily daily disp tablet s refills tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime disp capsule ext release hr s refills metformin mg tablet sig two tablet po bid times a day disp tablet s refills amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for days disp tablet s refills amiodarone mg tablet sig one tablet po bid times a day take mg twice daily for days then mg daily until stopped by cardiologist disp tablet s refills outpatient lab work labs pt inr for coumadin indication mechanical aortic valve atrial fibrillation goal inr first draw day after discharge results to clinic phone fax metoprolol tartrate mg tablet sig tablet po tid times a day disp tablet s refills warfarin mg tablet sig three tablet po once once for doses dose will change daily for goal inr disp tablet s refills discharge disposition home with service facility discharge diagnosis aortic stenosis coronary artery disease s p aortic valve replacement and coronary artery bypass graft x past medical history hodgkins lymphoma paroxsymal atrial fibrillation dyslipidemia type ii diabetes mellitus hypothyroidism reactive airway syndrome s p laparotomy splenectomy s p biopsy of left clavicular node s p tonsillectomy discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with incisions sternal healing well no erythema or drainage leg right left healing well no erythema or drainage edema discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon look at your incisions daily for redness or drainage please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions you are scheduled for the following appointments wound care nurse phone date time at surgeon dr date time cardiologist at pm please call to schedule appointments with your primary care dr in weeks please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours labs pt inr for coumadin indication mechanical aortic valve atrial fibrillation goal inr first draw day after discharge results to clinic phone fax completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""dateOfDeath"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Cardiothoracic"",
""allergies"": [
""Theophylline"",
""Shellfish""
],
""attendingChiefComplaint"": ""Dyspnea on exertion"",
""chiefComplaint"": ""Dyspnea on exertion"",
""historyOfPresentIllness"": ""This is a year old male with known coronary artery disease and aortic stenosis. The history of coronary disease dated back to when he had an inferior wall myocardial infarction at that time he received a bare metal stent to the rca. He remained stable until when"
26645,admission date discharge date date of birth sex m service vascular chief complaint right toe ulceration history of present illness this year old black male who has a history of type diabetes and right toe ulceration since which is refractor to conservative treatment the patient was referred to dr by dr podiatrist he was seen in the office on of this year which the pulse exam shows the right foot was a pt of absent dp on the right and absent dp and pt on the left patient underwent arteriogram with right leg runoff on which demonstrated diffuse aortic magnus a right common iliac saccular aneurysm of cm with aneurysmal dilatation of the distal aorta the left common iliac artery hypogastric and common femoral profunda femoris are without stenosis the right superficial femoral arteries showed moderate disease the trifurcation occluded at its origin the distal peroneal was occluded the pt is the major runoff vessel which perfuses the plantar arch in dp review of systems the patient denies claudication or rest pain denies chest pain palpitations he does admit to three pillow orthopnea which is chronic over the last years with rare episodes of pnd does admit to dyspnea on exertion shortness of breath with walking patient underwent a stress on by dr results not available at time of dictation past medical history coronary artery disease with mi in and hypertension gerd type diabetes right shoulder dislocation pneumonia at the age of five or six years of age diminished hearing right sciatica hyperlipidemia past surgical history excision of cyst at l in the back right knee laceration repair excision of penile growth lumbar laminectomy allergies sulfa and penicillin which causes hives medications on admission aspirin enteric coated mg b i d enalapril mg q d in the a m enalapril mg q d in the p m isosorbide mg b i d lopressor mg b i d lipitor mg at h s metformin mg q a m and mg q p m glipizide er mg q d social history the patient lives alone ambulates independently he is a former pack year smoker alcohol intake is a half a pint of brandy per day or beers q d physical exam vital signs blood pressure pulse respirations and o saturation on room air heent exam is unremarkable there is no jvd or carotid bruits the lung exam shows increased a p diameter with diminished lung sounds in all lung fields there are no adventitious sounds heart is regular rate and rhythm and is distant in sounding abdominal examination was obese soft nontender and nondistended bowel sounds were present x there were no abdominal bruits the peripheral vascular examination shows right first second and third toes with ruborous changes and superficial skin ulcerations there were no femoral bruits the neurological exam was unremarkable preoperative pulse exam femorals were bilaterally popliteals on the right was biphasic signal dp and pt were monophasic signals on the left the popliteal was palpable with monophasic dp and pt hospital course patient was admitted to the preoperative holding area on he underwent an aortobifem and ligation of multiple iliac aneurysms the patient tolerated the procedure well was transfused unit of packed red blood cells intraoperatively and was transferred to the pacu in stable condition an epidural was placed intraoperatively for anesthesia and analgesia control immediate postoperatively the patient was afebrile he required fluid boluses x to improve his urinary output his physical exam was remarkable for some extremity edema his white count was hematocrit bun and creatinine of patient remained npo and was transferred to the vicu for continued hemodynamic monitoring postoperative day one patient had no overnight events he did require diminish fluid requirements secondary to elevated filling pressures his epidural remained in place and worsening he was afebrile his hematocrit was white count bun creatinine his abdominal incisions and groin incisions were clean dry and intact he had a palpable pt bilaterally with biphasic dopplerable dps bilaterally patient remained in the vicu for continued monitoring and care on postoperative day two the patient continued to require lasix for elevated filling pressures t max was to white count was hematocrit post transfusion unit of pack cells he was instituted on his preoperative medications his pulse exam remained unchanged incisions were clean dry and intact he continued to be diuresed and cardiopulmonary toilet and incentive spirometry was encouraged he maintained npo he was diuresed to maintain him liter regular insulin sliding scale was used for glycemic control and he remained in the vicu postoperative day three it was noted that he had a low platelet count but it was stable he was continued on his preoperative medications he required a total of of lasix over the preceding hours for diuresis his lung sounds improved with some diminished sounds at the bases incisions were clean dry and intact his pulse exam showed unchanged patient s epidural remained in place for analgesic control and patient remained in the vicu on postoperative day four the pa catheter was converted to triple lumen lasix diuresis was continued patient was begun on clears as tolerated epidural was discontinued his white count was hematocrit of bun of creatinine he was afebrile t max examination showed continued rales at the bases abdominal exam was minimal bowel sounds wounds were clean dry and intact and there was some ecchymosis at the inferior aspect of the wound pulse exam demonstrated palpable dp and pt on the left and right dp was biphasic with palpable right pt his lasix converted to b i d his foley was discontinued his electrolytes were repleted and a line was discontinued patient was transferred to the regular nursing floor for continued care postoperative day five he continued to remain afebrile he passed flatus podiatry was requested to see the patient for management of his foot ulcer and appropriate weightbearing status his diet was advanced as tolerated impression was that this was a gentleman status post aortobifem with diminished protective sensation and superficial x cm ulcer at the submedial right hallux with hyperkeratotic borders there was no drainage and the wound did not probe to bone patient had an epithelial base recommendations were that an x ray at this time was not indicated that this was a superficial tissue lesion that the patient should follow up in clinic one week after discharge for debridement of the hyperkeratotic ulcerations patient was evaluated by physical therapy on who felt that he would be able to be discharged to home on postoperative day six the patient did have a bowel movement associated with flatus at discharge he was afebrile wounds were clean dry and intact lung exam noted some mild expiratory wheezing in the upper lung fields patient was discharged to home in stable condition he should follow up with dr in two weeks time he should not drive a car until seen in followup he should shower only no tub baths prior to discharge it was noted that patient had developed a temperature cbc and blood cultures were obtained chest x ray was requested results are pending at the time of dictation urine c s and urinalysis were pending at the time of dictation discharge was deferred until situation discussed with attending and chest x ray and urinalysis were reviewed discharge medications aspirin mg q d metoprolol mg b i d hold for systolic blood pressure less than heart rate less than enalapril mg q a m enalapril mg q p m isosorbide dinitrate sa mg b i d glipizide mg q d oxycodone acetaminophen tablets q h prn pain discharge diagnoses right foot ischemic ulcerations with aortoiliac disease status post aortobifemoral bypass diabetes type controlled hypertension controlled m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service vascular surgery addendum this is a continuation of previous discharge summary the patient s anticipated discharge on was held secondary to elevated temperature the job number the patient s discharge was deferred secondary to a temperature and leukocytosis pan cultures were obtained a chest x ray was obtained the patient s chest showed a right lower lobe infiltrate the patient s stool was positive for c difficile and blood cultures were gram positive cocci which were mrsa the patient was continued on vancomycin levofloxacin and flagyl on the patient had an episode of weakness and short of breath arterial blood gases were and ekg with st depressions in v and v rule out was flat negative enzymes the patient was transferred to the vicu for continued monitoring the patient remained in the vicu for hours he continued to do well and was transferred back to the regular nursing floor on infectious disease was consulted on for persistent continued positive blood cultures and intermittent low grade temperatures tee was obtained which was negative for vegetations the patient was begun on gentamycin hep the vancomycin the levofloxacin was discontinued on also on the patient complained of right shoulder pain he has a history of a right rotator tear orthopedics was consulted and an intra articular steroid injection was done with improvement in the patient s pain a ct of the abdomen was obtained that day and it demonstrated questionable fluid collection around the left distal anastomosis and proximal aortic stenosis he continued on antibiotics and continued to be followed by infectious disease the service was consulted regarding the patient s diabetic management the patient had been on glipizide and metformin and the metformin was discontinued secondary to elevated lfts recommendations were made to start lantus insulin at bedtime this was instituted serial blood cultures taken every hours was continued to be positive dr was requested to see the patient in consultation by dr on he recommended a wbc tagged study and a repeat ct of the abdomen because the initial ct reported just usual perioperative reactive changes a wbc tagged white blood study was done which showed positive uptake in the left groin area and the right shoulder the vancomycin was discontinued on and daptomycin was instituted on on examination that morning a new murmur was auscultated and the patient underwent repeat tee with the results pending at the time of dictation repeat ct of the abdomen showed persistent bilateral femoral perigraft fluid left greater than right his white count remained stable at his creatinine was blood cultures from to grew mrsa and on to were no growth on cultures were pending the c difficile was pending at the time of dictation id recommended that we should consider draining the left femoral fluid collection and sending it for culture although dr and dr felt that this was a seroma and not necessarily an infection process they also recommended a rehabilitation evaluation for the right shoulder by orthopedics to exclude joint seeding secondary to increased uptake in the wbc tagged scan at the time of discharge the patient was ambulating independently a picc line will be placed for continued iv antibiotic therapy for a total of six weeks of antibiotics discharge summary dictation regarding discharge medications and instructions will be dictated on the day of discharge m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service addendum mr is now postoperative day no the date of this dictation is and since the previous discharge summary the hospital course continued to be one of slow and steady progress towards being discharged to a rehabilitation center however this morning the patient became in acute respiratory failure complicated by hemodynamic instability pulseless electrical activity and after minutes was pronounced dead at in the morning he had been receiving ongoing treatment with dr for staphylococcus pneumonia as well as graft infection and the last set of computerized tomography scans showed no worsening in the appearance of these prosthetic materials and their appearance on computerized axial tomography scan he had also been receiving coumadin and was a tracheostomy collar off the ventilator being diuresed with lasix and on a beta blocker three times a day his death was reported to his family and dr and this includes the final discharge summary for him discharge disposition death discharge diagnosis right foot ischemic ulcerations with aortoiliac disease status post aortobifemoral bypass type diabetes requiring insulin hypertension coronary artery disease with myocardial infarction in and gastroesophageal reflux disease decreased hearing right sided sciatica hyperlipidemia staphylococcus aureus bacteremia staphylococcus aureus pneumonia creation of a left axillo to superficial femoral artery bypass with ptfe secondary to a left femoral pseudoaneurysm after infection of a left limb of the aortobifemoral bypass graft the patient also had chest tubes placed and removed requiring a procedure in the operating room which just resulted in straw colored fluid evacuation for a loculated left sided effusion previously seen on computerized tomography scan on the patient underwent flexible bronchoscopy and laryngoscopy which resulted in a shiley tracheostomy tube placement hypernatremia treated with free water failure to thrive malnutrition requiring ventral tube feedings volume overload postoperatively atrial fibrillation postoperatively respiratory failure left lower lobe hematoma seen on computerized tomography scan severe deconditioning drug induced neutropenia resolved acute renal failure resolved condition on discharge deceased dictated by medquist d t job [NEW_RECORD] name w unit no admission date discharge date date of birth sex m service discharge medications aspirin mg once daily metoprolol mg twice a day isosorbide dinitrate mg twice a day rosuvastatin mg once daily oxycodone acetaminophen ml one to two q hours as needed for pain enalapril maleate mg qam and mg qpm protonix mg once daily daptomycin mg intravenous q hours for a total of weeks started on calcium carbonate mg three times a day ferrous sulfate mg once daily colace mg twice a day insulin dosing l arginine units qhs humalog scale as follows breakfast and lunch scale glucose if less than no insulin units units units units units units units greater than notify doctor dinner humalog scale glucose if less than no insulin units units units units units units units greater than notify doctor scale glucose if less than no insulin units units units units greater than notify doctor discharge instructions patient should follow up with podiatry for hyperkeratotic lesion you may follow up with our people or follow up with own podiatrist should follow up with dr in two weeks should call for an appointment should follow up with clinic as discussed by please call for an appointment should follow up with infectious disease clinic in two weeks should follow up with orthopedist post discharge m d dictated by medquist d t job,"[
""admission_date"" : ""2019-1-28"",
""discharge_date"" : ""2019-2-1"",
""date_of_birth"" : ""2048-10-28"",
""sex"" : ""M"",
""service"" : ""Vascular"",
""chief_complaint"" : ""right toe ulceration"",
""history_of_present_illness"" : ""this year old black male who has a history of type diabetes and right toe ulceration since which is refractor to conservative treatment the patient was referred to dr by dr podiatrist he was seen in the office on of this year which the pulse exam shows the right foot was a pt of absent dp on the right and absent dp and pt on the left patient underwent arteriogram with right leg run"
89292,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint shock major surgical or invasive procedure thoracentesis bronchoscopy history of present illness yo m who h o moderate as copd afib on coumadin schf who was transferred from ed to ed for further management of septic shock and respiratory failure per the patient s three sons he was noted to feel sob and tired for the past few days this morning he called his ex wife to drive him to the as he was feeling unwell at he was found to be hypotensive with sbp in the s s with hr in the s s due to concern for pna on cxr he was given ceftriaxone given liters ns started on dopamine and levophed with continued sbps in the s s femoral line placed labs notable for a wbc of with eosinophilia due to this finding he was given mg of hydrocortisone k was elevated at and cr elevated at bl bun inr lactate guaiac negative given cacl insulin with amp d also intubated for tachypnea and hypoxia and started on fentanyl and versed uop was cc in total vs prior to transfer bp hr in the ed initial vs were degrees c rectal on dopamine and levophed on ac he was given vancomycin and zosyn as well as liters of ns a line was placed also g ivs ct torso did not show any obvious catastrophy echo performed by cards did not show any wall motion abnormalities did suggest severe as renal was called for possibility of hd and felt he could be medically managed for now labs lactate k abg inr was given cacl amp of bicarb dopamine at and levophed at admitted for pna as he had evidence of bilateral basilar consolidation on ct he was treated with a course of levofloxacin and his lasix was doubled to mg daily notably ct at that time showed pleural effusion and multifocal pna thoracentesis at that time showed a transudate on arrival to the micu patient is intubated and sedated his dopamine was weaned down however became bradycardic to the s dopamine was increased and hr increased to the s maps well above past medical history bilateral pneumonia in early treated with levofloxacin systolic heart failure ejection fraction to chronic kidney disease stage iv coronary artery disease status post vessel coronary artery bypass in chronic atrial fibrillation on anticoagulation chronic obstructive pulmonary disease asthma gout hypertension peripheral vascular disease s p left fem bypass lt cea social history per sons he drinks glasses of wine daily and not a current smoker but h o heavy smoking was staying with his son since his hospitalization in early prior was ambulating and living independently family history unknown physical exam vitals t f bp p r o ac x at fio and peep general intubated and sedated heent sclera anicteric dry mm oropharynx with et tube neck supple jvp just below ear at degrees cv irregular normal s s harsh systolic murmur no rubs no gallops lungs rhonchi in anterior lung fields bilaterally decreased sounds at the bases right left abdomen soft non tender mildly distended bowel sounds hypoactive gu foley in place ext warm well perfused pulses no clubbing cyanosis or edema neuro left pupil and right pupil very sluggish not following commands sedated skin multiple diffuse excoriations on legs torso and old bruise on chest pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso pm blood pt ptt inr pt am blood cd done am blood ipt done pm blood alt ast ld ldh ck cpk alkphos totbili pm blood lipase pm blood ctropnt pm blood ck mb ctropnt pm blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood albumin calcium phos mg pm blood hapto pm blood hba c eag am blood tsh am blood vanco cbc with diff pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood neuts bands lymphs monos eos baso atyps metas myelos am blood neuts lymphs monos eos baso pm blood neuts bands lymphs monos eos baso atyps metas myelos am blood neuts lymphs monos eos baso am blood neuts lymphs monos eos baso am blood neuts lymphs monos eos baso am blood neuts lymphs monos eos baso am blood neuts lymphs monos eos baso am blood neuts bands lymphs monos eos baso atyps metas myelos am blood cd done cd done hla dr done kappa done cd done cd done cd done cd done cd done lambda done cd done coag labs am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt pm blood fibrino pm blood fibrino pm blood fibrino pm blood fibrino am blood fibrino pm blood hapto pm blood hapto pm blood hapto pm blood hapto lytes creatine trend pm blood urean creat pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood creat na k cl am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap lfts lipase pm blood alt ast ld ldh ck cpk alkphos totbili am blood alt ast ld ldh ck cpk alkphos amylase totbili am blood alt ast ld ldh alkphos totbili am blood alt ast ld ldh alkphos totbili am blood alt ast ld ldh alkphos totbili am blood lipase am blood lipase am blood lipase am blood lipase am blood lipase am blood lipase ce pm blood ck mb ctropnt pm blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb ctropnt am blood ck mb ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt flow cytometry the following tests antibodies were performed hla dr fmc kappa lambda and cd antigens and results three color gating is performed light scatter vs cd to optimize lymphocyte yield lymphoid cells comprise of total analyzed events b cells comprise of lymphoid gated events have nonspecific surface immunoglobulin staining and do not express aberrant antigens t cells comprise of lymphoid gated events express mature lineage antigens cd cd cd cd and have a normal helper cytotoxic ratio of usual range in blood cell marker analysis demonstrates an increased percentage of natural killer cells at usual range in blood but display an expected antigenic profile interpretation there is an atypical pattern of immunoglobulin staining in b cells while not diagnostic it raises the possibility of a b cell lymphoproliferative disorder please correlate with clinical radiologic and other laboratory findings flow cytometry immunophenotyping may not detect all lymphomas due to topography sampling or artifacts of sample preparation microbiology respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus respiratory viral antigen screen final less than columnar epithelial cells specimen inadequate for detecting respiratory viral infection by dfa testing interpret all negative results from this specimen with caution negative results should not be used to discontinue precautions refer to respiratory viral culture results recommend new sample be submitted for confirmation reported to and read back by am viral culture r o cytomegalovirus preliminary no cytomegalovirus cmv isolated cytomegalovirus early antigen test shell vial method final negative for cytomegalovirus early antigen by immunofluorescence images studies ct c a p large right pleural effusion with adjacent consolidation which likely represents atelectasis but underlying pneumonia cannot be excluded small focus of ground glass opacity in the left upper lobe which is nonspecific but could represent a small focus of infection trace ascites with possible peripancreatic and periduodenal stranding fluid and trace fluid anterior to the bilateral psoas muscles correlation with pancreatic enzymes is recommended this could also be secondary to hydration and ongoing capillary leak ruq ultrasound no gallstones or gallbladder sludge unremarkable gallbladder no intra or extra hepatic biliary dilatation sliver of perihepatic fluid along the inferior liver edge and in morison s pouch right pleural effusion derm biopsy l thigh mild spongiotic psoriasiform and superficial perivascular dermatitis with neutrophils and eosinophils occasional dyskeratotic cells and marked neutrophilic scale crust an eczematous dermatitis including nummular eczema is possible due to the finding of dyskeratosis the differential diagnosis includes a drug eruption the scale is not that of pityriasis rosea special stains gram gms and pas are negative for organisms pleural fluid negative for malignant cells bronchial washing negative for malignant cells peripheral smear mild microcytosis with central pallor eosinophil was seen and was morphologically normal pmns were also normal and there were no atypical lymphocytes platelets were slightly decreased in number and had normal morphology video swallow on indication suspected aspiration technique video oropharyngeal swallow study was performed in conjunction with the speech pathology department varying consistencies of barium were administered in the ap and lateral projections findings there is severe aspiration identified with thin liquids with nectar thickened liquids a single penetration event was noted though there was no aspiration identified moderate pharyngeal residue was noted please consult the speech and language pathology department note in the online medical record for further details echo on the left atrium is mildly dilated left ventricular wall thicknesses are normal the left ventricular cavity size is normal there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior wall and mild hypokinesis of the distal of the left ventricle the remaining segments contract normally lvef overall left ventricular systolic function is low normal lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg there is a mild resting left ventricular outflow tract obstruction right ventricular chamber size and free wall motion are normal the aortic valve leaflets are severely thickened deformed there is moderate aortic valve stenosis valve area cm the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of left ventricular ejection fraction is improved with improved regional function of the distal third of the left ventricle a mild left ventricular outflow gradient is now present there is less mitral and tricuspid regurgitation cxray on large right pleural effusion has increased mild pulmonary edema persists heart size top normal right sided central venous catheter ends in the upper svc et tube in standard placement nasogastric tube passes below the diaphragm and out of view no pneumothorax brief hospital course yo m h o moderate as copd chf and recent admission for multifocal pna presenting with weakness and hypotension and found to be in septic shock with respiratory failure respiratory failure on presentation to the osh ed the patient was felt to be in respiratory distress and intubated he recent underwent treatment in early for a multifocal pneumonia and underwent a r thoracentesis at that time which showed transudative pleural fluid imaging on this admission showed multifocal consolidations and large r sided pleural effusion unclear as to whether these are due to residual findings from the prior pneumonia or a new hcap he was covered with vanc zosyn for possible hcap and repeat right sided thoracentesis during this admission showed transudative pleural fluid with negative cultures he developed a new pneumothorax following the thoracentesis which was stable and resolved on serial cxrs in the setting of receiving ivf and prbc see below the patient became fluid overloaded in the setting of chronic heart failure he was diuresed with bumex as he did not respond to high doses of iv lasix see below he also was noted to have expiratory stridor wheezing at his trachea and also had a hoarse whispering voice following extubation ent was consulted for a bedside laryngoscopy and the patient was found to have right vocal cord paralysis he was to be maintained on strict npo he was called out to the medical floor and in the setting of pulling out his ng tube and having increased secretions he developed hypercapnic respiratory failure and was reintubated his antibiotics were broadened and treated aggressively for copd exacerbation however it was very difficult to wean the patient from the vent due to apnea in addition he was fluid overloaded with a total of approximately l for his length of stay he was given bumex and metolazone and he was initially not responding to diuretics he was also falling his multiple sbt trials due to apnea and increase secretions this was discussed with the family with the possibility of cvvh to attempt to remove fluid and improve respiratory status and the possibility of future tracheostomy the family decided to change his goals of care to cmo with the plan of extubation and do not reintubate he was then extubated on in the evening after several family members came by to see patient he initially did well and then had increase work of breathing with increase in secretions which he was unable to clear he was placed on morphine drip for comfort and on scopolamine patch his oxygen saturation remained low and he then passed way on rash multiple excoriations and history of profound itching dermatology was consulted for an extensive erythematous rash on his torso and extremities and was found to have eczematous dermatitis on biopsy he was treated with petroleum jelly for hydration of his skin as well as triamcinolone cream to be used for up to weeks with some improvement of the rash famotidine was also started and allopurinol was stopped for question of hypersensitive reaction in the setting of his elevated creatinine he continued to have some pruritus prior to extubation for which he was then given prednisone and low dose benadryl for comfort in addition to topical creams which seem to have helped bleeding patient with significant bleeding from multiple sites including significantly increased hematuria melena and profuse bleeding from lines earlier in his hospitalization which has now improved initially concern for dic vs ttp although lab work has been negative so far he cont to have increase in inr at even after having two doses of vit k uncertain etiology sent smear and flow cytology he was transfused units of prbc with only a minimal increase in his hematocrit he was started on iv ppi gi was contact with the plan of possible scope prior to discharge nstemi hypotension bradycardia h o chronic afib on metoprolol was initially bradycardic on presentation concern for decreased renal clearance of metoprolol also likely an element of sick sinus syndrome was found to have elevated cardiac enzymes ekg low voltages but did not show significant st changes consistent with nstemi given inr was on admission and at the time of nstemi started on aspirin and atorvastatin and held plavix or heparin gtt per cardiology recs cardiac enzymes subsequently stabilized and started to down trend he was transfused with goal hct for nstemi to increase coronary perfusion he was restarted on metoprolol mg iv q hours npo given aspiration for tachycardia likely rebound tachycardia given he is on nodal agents at home he subsequently developed bleeding from multiple sites see above and asa was discontinued eosinophilia initial significant peripheral eosinophilia at which had resolved on arrival to in the setting of stress dose hydrocortisone hydrocortisone was discontinued several days after transfer and several days after discontinuation the patient was noted to have recurrence of peripheral eosinophilia which derm did not feel was secondary to his rash he was also found to have eosinophils in his urine which was determined to be secondary to possible allergic reaction to medication allopurinol or lasix although the etiolgy was uncertain heme was consulted for evaluation of eosinophilia as well as elevated inr he had a peripheral smear which showed mild microcytosis with central pallor eosinophil was seen and was morphologically normal pmns were also normal and there were no atypical lymphocytes platelets were slightly decreased in number and had normal morphology he also had flow cytometry which was undeterminate heme thought that his eosinophilia could have been due to loafers syndrome or a reactive process secondary to asthma or eosinophilic pneumonia although this is unlikely given that pt had no eos on his bronchial lavage even though he had already been treated with steroids this should still be present allergic reaction to antibiotics or a vasculitic process possibly involving the lungs and skin were also a consideration the ct scan did not show definite evidence of lymphadenopathy or tumor to suggest lymphoma or other tumors the blood smear does not show evidence of leukemia in addition spep and upep were also negative acute on chronic ri thought to be due to atn but urine eos now suggest ain the patient was previously on lasix with presumed good response but now is not responding to mg iv lasix responded to mg iv but due to high doses transitioned to bumex after his second intubation he was not responding to high dose of bumex and metolazone with increase in his creatine which was thought to be due to atn we discussed possible cvvh with the family however they decided against it shock initially on two pressors for sbp in the s s gradually weaned off with fluid resuscitation and antibiotics likely septic shock from multifocal pna although hypovolemic shock from overdiuresis is also a possibility given his diuretics were increased as an outpatient at the time of his prior pna in he was also given stress dose hydrocortisone on initial presentation which was subsequently discontinued after pressors were weaned off cultures negative to date findings on cxr and ct chest may be residual findings from his recently treated pneumonia he was treated with vancomycin and zosyn for day course he had a second episode of respiratory failure and hypotension post intubation requiring pressors his cxray was consistent with aspiration pneumonia he was also hypothermic and there was concern for resistant bacteria so antibiotics were broaden to vanco and meropenem he was pan cultured with no growth in cultures as of today elevated inr initial inr in setting of coumadin use as an outpatient and acute renal failure likely poor renal clearance of coumadin as well as possible nutritional deficiency received vitamin k mg po x doses with improvement of inr however inr continues to remain elevated at off coumadin and after evaluation by heme pt had another dose of vit k which helped trend inr down so this was likely due to nutritional deficit elevated lipase ruq us was negative be medications lasix abx vs sepsis trending down and stabilizing his abd initially thought to be more distended on his second transfer to the icu on he had kub which was negative for obstruction or free air his lft were only mildly elevated w ast in the s aortic stenosis moderate with valve area cm on echo repeat echo showed valve are to be stable with peak gradient of mm hg as was also thought to played a significant role in his fluid status given that he had re accumulated of pleural fluid and hypotension he was very fluid overloaded possibly leading to over distension of ventricles and decrease co we had a repeat echo on which showed increased left ventricular filling pressure as noted above his renal function worse and he was only moderately responsive to diuretics family was against cvvh given changes in goal of care systolic diastolic chf no new wall motion abnormalities noted on echo hold ace i restarted on bb and diuretics cad s p cabg mi the patient had an acute mi as described above continue statin hold asa for now gout d c ed allopurinol due to concern for hypersensitive reaction htn hold losartan doxazosin continue diuresis fen ivfs prn replete electrolytes npo due to aspiration risk pt had a ng tube while intubated prophylaxis elevated inr pneumoboots access peripherals a line and femoral line wich was switched to lij and removed when he was off pressors communication sons hcp code initially full code then changed to dnr and he was changed to comfort measures only after discussion with the sons on medications on admission vitals t f bp p r o ac x at fio and peep general intubated and sedated heent sclera anicteric dry mm oropharynx with et tube neck supple jvp just below ear at degrees cv irregular normal s s harsh systolic murmur no rubs no gallops lungs rhonchi in anterior lung fields bilaterally decreased sounds at the bases right left abdomen soft non tender mildly distended bowel sounds hypoactive gu foley in place ext warm well perfused pulses no clubbing cyanosis or edema neuro left pupil and right pupil very sluggish not following commands sedated skin multiple diffuse excoriations on legs torso and old bruise on chest discharge medications none discharge disposition expired discharge diagnosis expired respiratory failure discharge condition expired,"{
""admission_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-12"",
""date_of_birth"": ""2034-10-10"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""No Known Allergies""
],
""adverse_drug_reactions"": [
""Attending Chief Complaint Shock Major Surgical or Invasive Procedure Thoracentesis Bronchoscopy History of Present Illness Yo M who H O Moderate as COPD AFib on Coumadin SCHF who was transferred from ED to ED for further management of Septic Shock and Respiratory Failure per the patient's three sons he was noted to feel sob and"
85725,admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint cc major surgical or invasive procedure cerebral angiogram with coiling of the l ica aneurysm right frontal external ventricular drain left hemicraniectomy diagnostic cerebral angiogram angioplasty right mca left mca right ica angioplasty of basilar artery vp shunt lap assisted history of present illness hpi this is a year old female with history of migranes who at am experienced headache and speech difficulties the headache had been gradual onset and had originally started at pm in the afternoon at approx am the patient s husband called and the patient was brought to where a head ct revealed extensive sah and left sided hemorhage the patient was given dilantin mg and decadron mg iv the patient was intubated and trasnferred here for further care the husband states that she took one aspirin mg po last night he states that the patient does not take any other blood thinning medications such as coumadin heparin plavix or lovenox she does not take aspirin on a daily bassis past medical history pmhx migraines chronic pain social history social hx lives with husband family history family hx unknown physical exam ros patient in intubated physical exam hunt and grade grade gcs e v motor t o bp hr r o sats assit control fio x peep gen intubated heent pupils mm eoms unable to test neck extrem warm and well perfused neuro mental status orientation gcs t intubated recall unable to assess language intubated non verbal cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields unable to test iii iv vi extraocular movements unable to test v vii facial strength and sensationunable to test viii hearing unable to test ix x palatal elevatin unale to test sternocleidomastoid and trapezius unable to test xii tongue unable to test motor normal bulk and tone bilaterally no abnormal movements tremors strength pronator drift unable to test sensation unable to test toes bilaterally up going coordination unable to test handedness right exam on discharge patient is trached and tolerating trach mask at times opens eyes spontaneously other times opens to nox stim perrl at mm to mm bilaterally moves upper extremities to stim and spontaneously flexing not purposeful minimally withdraws bilateral lower extremities pertinent results cxr impression ett in proximal trachea please advance cm ngt in distal esophagus please advance cm cta brain conclusion extensive left frontal intraparenchymal hemorrhage as well as subarachnoid and intraventricular hemorrhage demonstration of left supraclinoid internal carotid artery aneurysm intervention neuroradiology consultation advised if not already obtained ct brain there is interval development of a small amount of hyperdense material overlying the longus muscles in the nasopharynx the finding could represent a small amount of blood secondary to the intubated status of the patient ct head impression increase in the size of the large left frontal lobe hemorrhage worsening mass effect and shift of normally midline structures evolving left mca and pca infarcts ct head post op patient is status post left hemicraniectomy with mild relief of the mass effect shift of the midline structures is still significant at cm to the right unchanged extensive subarachnoid hemorrhage and large left frontal lobe hematoma echo the left atrium and right atrium are normal in cavity size left ventricular wall thicknesses are normal the left ventricular cavity is dilated there is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the distal two thirds of the left ventricle no masses or thrombi are seen in the left ventricle there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present a mass is present on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression regional lv systolic dysfunction suggestive of stress cardiomyopathy no significant valvular abnormality seen mild to moderate pulmonary artery hypertension cxr et tube left subclavian line and nasogastric tube are in standard placements respectively no consolidation heart size normal no pleural effusion lungs essentially clear cxr comparison is made with prior study performed on same day earlier in the morning there are low lung volumes cardiac size is top normal mediastinal widening is unchanged lines and tubes remain in place and unchanged in standard position there is no pneumothorax there are small bilateral pleural effusions there is new mild to moderate vascular congestion ble dopplers impression no evidence of deep vein thrombosis in either leg echo moderate to severe regional left ventricular systolic dysfunction c w cad differential diagnosis includes stress cardiomyopathy or neurogenic regional lv systolic dysfunction cxr lines and tubes are in unchanged standard position cardiac size is top normal there has been interval improvement in now mild pulmonary edema left lower lobe retrocardiac atelectasis has improved persistent opacities in the right upper lobe could be due to the pulmonary edema but attention in this area is recommended in followup studies to exclude a focus of infection cta head limited study due to venous contamination however there appears to be narrowing of the mid to distal basilar artery and narrowing of the bilateral m mca segments suggesting vasospasm increased midline shift and mass effect from the large intraparenchymal hemorrhage stable intraparenchymal subarachnoid intraventricular hemorrhage ct head findings there is overall little change in the extensive intraparenchymal bilateral subarachnoid and intraventricular hemorrhage right frontal approach ventriculostomy catheter terminates in the third ventricle ventricular size is unchanged there has also been no change in approximately mm rightward shift of normally midline structures the patient is status post left frontal craniectomy marked sulcal effacement bilaterally greater on the left is again seen metallic artifact from coil was seen in the region of the supraclinoid ica there is partial opacification of the left mastoid air cells as on the previous study with the remainder of the paranasal sinuses well aerated impression grossly stable widespread subarachnoid intraparenchymal and intraventricular hemorrhage with unchanged mm rightward subfalcine herniation hypodensity in left cerebral hemisphere extending to occipital cortex is also unchanged ct perfusion impression head ct shows no significant change since the ct of with left sided craniectomy and blood products in the left frontal lobe with surrounding edema and hypodensity in the left occipital lobe ct perfusion shows perfusion abnormality in the region of hemorrhage but no other perfusion abnormalities are seen diffuse perfusion abnormalities could not be excluded in absence of quantitative assessment ct angiography demonstrates diffuse vasospasm involving the arteries of anterior and posterior circulation bilat lower ext veins no evidence of deep vein thrombosis in either leg ct head w o contrast grossly stable widespread subarachnoid intraparenchymal and intraventricular hemorrhage with unchanged mm rightward subfalcine herniation cta head w w o c recons no significant change in widespread subarachnoid intraparenchymal and intraventricular hemorrhages with shift of midline structures to the right and rightward subfalcine herniation unchanged left hemispheric edema which likely is due to ischemia infarction improved caliber of bilateral middle cerebral arteries unchanged narrowing of the basilar artery bilateral posterior and anterior cerebral arteries assessment of patency of coiled aneurysm is limited due to the streak artifact ct chest abdomen pelvis impression no ct findings to explain patient s fever right lower lobe aspiration volume overload with small pleural effusions ascites and body wall edema left ovarian cystic lesion recommend correlation with patient s menstrual status as well as outpatient pelvic ultrasound in weeks cta head w w o c recons evolution of the known infarcts in the left cerebral hemisphere grossly stable widespread subarachnoid intraparenchymal and intraventricular hemorrhage with stable rightward subfalcine herniation diffuse vasospasm of the anterior and posterior circulation with the m segment of the left mca containing a stent in comparison with the study of the monitoring and support devices remain in place there is a new dense streak of opacification at the right base consistent with atelectasis otherwise little change with no evidence of vascular congestion or acute pneumonia lower extremity doppler ultrasound negative for dvt bilaterally stable right lower lobe infiltrate aspirate mri brain noncontrast impression extensive multifocal acute infarcts involving as detailed above involving the frontal cortex centra semiovale cingulate gyri bilaterally as well as the left posterior parietal cortex basal ganglia and occipital pole there is no specific evidence of hemorrhagic transformation of these infarcts extensive multifocal hemorrhage including diffuse subarachnoid hemorrhage layering intraventricular blood and left frontotemporal parenchymal hematoma as on recent studies status post extensive left frontotemporoparietal craniectomy with herniation of edematous brain through the craniectomy defect as before status post right transfrontal ventriculostomy catheter placement unchanged in position with no further ventricular dilatation to suggest ventriculostomy malfunction or obstructive hydrocephalus portable chest xray findings there is a newly placed left pic catheter with the tip positioned in the upper svc a right sided subclavian catheter tip is positioned within the mid svc the tip of a dobbhoff feeding tube is within the stomach the patient has been extubated and a tracheostomy catheter has been placed and the tip of the tracheostomy catheter is cm from the carina lung volumes are low with bibasilar atelectasis small bilateral effusions may be present ct head impression massive ventriculomegaly new from prior study suggesting that the ventriculostomy catheter may not be functioning properly no new foci of hemorrhage identified parenchymal and subarachnoid hemorrhage has largely resolved ct head impression status post right frontal approach vp shunt placement with tip terminating near the septum pellucidum and expected postoperative changes overall stable appearance of the brain with edematous and protuberant left hemisphere with similar distribution of hypodensity released by a left sided craniotomy stable degree of hydrocephalus stable trace intraventricular hemorrhage layering along the occipital horns no new hemorrhage or major vascular territorial infarct eeg to final read pending preliminary reports indicate some spikes but no active seizure activity brief hospital course ms was admitted to the icu under the care of dr neurosurgery after being transferred intubated from hospital she underwent cerebral angiogram and the left ica aneurysm was coiled an evd was placed a clot was noted proximal to the aneurysm and integrilin was given she was kept on a heparin drip through the night and her r femoral sheath remained in place she was brought to the angio suite to re evaluate this thrombus the following am on when on the angio table it was noted that her left pupil was dilated and fixed ml of csf was removed from the proximal evd and her pupils were then equal and reactive she was brought emergently to the ct scanner her image revealed that she had increased cerebral edema surrounding the left iph she then was brought emergently to the or for a left hemicraniectomy on she tolerated this procedure well a subgaleal drain was placed she was brought back to the icu to recover her postoperative exam was stable and her pupils were briskly reactive her postoperative images were as expected she then returned to the angio suite that same day for diagnostic cerebral angiogram and the thrombus was not visualized the dome of the aneurysm does not have flow but the base still has some blood flow within it her evd was functioning well and kept at cm of h on cardiac enzymes trended down her subgaleal drain was discontined ct head done after removal showed mild relief of the mass effect echo showed regional lv systolic dysfunction suggestive of stress cardiomyopathy with an ef of no significant valvular abnormality seen mild to moderate pulmonary artery hypertension or av mass tcd were without signs of vasospasm her corrected dilantin level was and no blus was given she needed fentanyl and a paralytic blous around pm as she was overbreathing the ventilator and had respiratolry alkalosis her low poc was putting her as risk for vasoconstriction and vasospasm her peep was brought up to a levophed drip was started for hypotension all paralytics and fentanyl were held for a neuro assessment at pm at this time she had bilateral corneal reflexes and mild pupillary reaction there was flexion in her ue to noxious stimuli right greater than left she withdrew her le to noxious eeg monitoring was in place her evd was functioning well she required a distal flush due to blood in the line and her output slowed down in the evening as her icp was not exceeding often and her evd level was cm h o her status remained critical on events of the day included weaning of the levophed maintained on neo sedation was changed to fentanyl and midazolam to control her neurogenic respiratory rate and respiratory alkolosis tcds were within normal limits the cerebral angiogram was discontinued given her cardiopulmonary instability broad spectrum antibiotics were started for gnr in her bal lower extremity dopplers were obtained to rule out dvts which was negative a cta was performed on which showed increasing cerebral edema surrounding the left temporal hematoma and diffuse sah she also was febrile we intiated agressive cooling to degrees celcius for cerebral protection she required sedation and neruo checks were limited to pupillary exams the evd was functioning well eeg showed diffuse encephalopathy she required multiple agents for hypotension an attempt was made at removing the arctic sun pads but the pts temperature began to climb it was re initiated after icp s began to rise as well she recieved a single dose of ns on a mini bal was done which resulted in staph and patient was started on ceftriaxone on patient was started on a pentobarb coma for increase in icp diamox was given x and artic sun reinitiated on cta revealed vasospasm pentobarb was weaned to rewarm to degrees and sbp greater than patient was taken to angiogram where angioplasty of the r mca and aca as well as l mca was done she recieved verapamil in each of the arteries and the size of aneurysm was seen to be larger in size patient was transported to icu with sheath in place on repeat head cta showed basilar artery vasospasm and ct showed new l aca infarct she was taken for angiogram where the basilar artery was angioplasty and the l ica aneurysm was stented and coiled l aca was seen to be in vasospasm as well but was unable to administer verapamil she was taken back to the icu where she was placed on plavix cooling and pentobarb were discontinued blood pressure goal was to be around liberalized evd was stable at sheath was taken out post angio on she remained stable except for persistant fevers persumably from vap and she remained on a cooling blanket to maintain normothermia bedside tcds revealed moderate spasm of bilateral vertebrals and basilar a cta was performed that showed diffuse vasospasm of the anterior and posterior circulation with the m segment of the l mca a bronch was done for a fever of on patient had eo to noxious rue attempts to localize lue flexion to nox ble w d to noxious stimuli perrl lower extremity dopplers were obtained for survailance with no evidence of dvts mri head with dwi was done on for prognostic evaluation evd was raised to cm h o she was no longer being cooled the mri showed extensive left sided infarcts and bifrontal infarcts a family meeting was held with dr and the stroke team to discuss prognosis and determine goals of care the patient s husband was told that there would be extensive deficit but maybe with extensive rehab she may regain some function that allows some ability for self care he was also told that she would not go to rehab from this hospitalization given her cognitive status as she is unable to participate in rehab so a would be needed the husband wanted to consult with other family members before making any decision on overnight she became febrile and her icps elevated to the s she was placed on the cooling blanket to cool her to normothermia and her evd was dropped to cm on the husband consented to go ahead with further care and consented to a trach peg placement her trach was placed on the plan as of is to stop plavix on place peg on and vps on she remained on the cooling blanket and her evd remained at cm there was no further icp issues through the day and her exam remained unchanged on patient continues to spike temperatures csf was sent for culture and cooling was discontinued id was also consulted for increase in wbc and fevers trach was placed on icp are stable and evd was replaced overnight for leaking around drain site and remained at cmh patient had eo to voice and stimuli weak flexion in bue triple flexion in rle and weak w d in lle she continues to be on two pressors to maintain her sbp on patient was placed on trach collar and able to tolerate that for a brief period of time pressors were stopped and patient was able to maintain a blood pressure above on patient was tolerating trach mask and stable from a pulmonary status had low grade temps but no fever spikes and completed a day course of nimodipine a low hematacrit was noted on am cbc at a repeat was performed that confirmed the initial finding but no blood transfusion was performed since the patient remained hemodynamically stable two c diff cultures came back negative from to patient remained afebrile off antibiotics she was started on a course of oral diflucan for vaginal candidiasis she underwent a ventricular perotineal shunt placement on with the help of general surgery for the laproscopic aproach to the abdomen on the patient s craniectomy site was noted to be more sunken compared to the prior day her shunt setting was changed to from she was also noted to have increased tone especially in her lower extremties so she was started on baclofen neurologically she was stable and tolerating a trach mask on her craniectomy site appeared full and her shunt was dialed down to she was started on eeg to r o seizure activity as she was noted to have increased tone on she remained stable eeg reports indicated some spikes but no active seizure activity we increased keppra to on medications on admission relpax for migraines tramodol for pain savella discharge medications clopidogrel mg tablet sig one tablet po daily daily for weeks please discontinue on aspirin mg tablet sig one tablet po daily daily please discontinue after dosing docusate sodium mg ml liquid sig one po bid times a day insulin regular human unit ml solution sig one injection asdir as directed glucagon human recombinant mg recon soln sig one recon soln injection q min as needed for hypoglycemia protocol heparin porcine unit ml solution sig one injection tid times a day bisacodyl mg suppository sig one suppository rectal times a day as needed for constipation ibuprofen mg ml suspension sig one po q h every hours as needed for fevers acetaminophen mg tablet sig tablets po q h every hours thiamine hcl mg tablet sig one tablet po daily daily potassium chloride meq packet sig one packet po prn as needed baclofen mg tablet sig tablet po tid times a day hydromorphone mg tablet sig one tablet po q h every hours as needed for pain agitation levetiracetam mg tablet sig two tablet po bid times a day metoprolol tartrate mg tablet sig one tablet po bid times a day ondansetron mg iv q h prn n v dextrose gm iv prn hypoglycemia protocol metoprolol tartrate mg iv q h prn hr potassium phosphate dibasic millimole ml parenteral solution sig one intravenous prn as needed magnesium sulfate solution sig one injection prn as needed potassium chloride meq ml piggyback sig one intravenous prn as needed calcium gluconate in d w gram ml solution sig one intravenous asdir as directed discharge disposition extended care facility hospital for continuing medical care discharge diagnosis left ica aneurysm left intraparenchymal hemorrhage intraventricular hemorrhage cerebral edema hydrocephalus post operative anemia requiring transfusion fever tachycardia internal carotid artery thrombus hypotension respiratory alkalosis stress cardiomyopathy with ef coma protien calorie malnutrition electrolyte imbalance pneumonia pulmonary edema x cm l adnexal cystic lesion aortic mass dysphagia respiratory failure spasticity discharge condition mental status confused always level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair discharge instructions general instructions you are going to be scheduled for replacement of your bone flap for wednesday a head ct is scheduled for am and surgery at pm please find detailed surgical instructions with your d c paperwork you will need to stop your aspirin week prior to surgery last dose to be on please discontinue plavix on you do not need an office visit before your surgery please draw pre op labs while in rehab and fax to our office at a lab requistion has been sent along you have a programmable vp shunt it is set at you will need to have this reprogrammed after any mri have a friend family member check your incision daily for signs of infection take your pain medicine as prescribed exercise should be limited to walking no lifting straining or excessive bending you may wash your hair only after sutures have been removed if your wound closure uses dissolvable sutures you must keep that area dry for days you may shower before this time using a shower cap to cover your head increase your intake of fluids and fiber as narcotic pain medicine can cause constipation we generally recommend taking an over the counter stool softener such as docusate colace while taking narcotic pain medication followup instructions please return on wed for your cranioplasty and pre op ct head the surgical letter has been sent along with your d c paperwork please call with any questions or concerns during your hospital stay it was noted that you have l adnexal cystic lesion postmenopausal recommend outpt pelvic us please call your primary care physician for this this should be done wihtin weeks completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending addendum patient s discharge on was delayed secondary to insurance approval she will be leaving on for no changes took place over night in her clinical status discharge disposition extended care facility hospital for continuing medical care md completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-12"",
""date_of_birth"" : ""2009-1-15"",
""sex"" : ""Female"",
""service"" : ""Neurosurgery"",
""allergies"" : [
""No Known Allergies""
],
""adverse_drug_reactions"" : [
""Attending Chief Complaint (CC) 1""
],
""chief_complaint"" : ""Major Surgical or Invasive Procedure 1"",
""history_of_present_illness"" : ""This is a year old female with history of migranes who at am experienced headache and speech difficulties the headache had been grad"
72909,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint serial hct monitoring status post mechanical fall major surgical or invasive procedure none history of present illness the patient is an year old male with history of metastatic prostate cancer followed by dr on docetaxel dvt on coumadin ckd baseline cr presenting with left flank pain epigastric pain and worsening fatigue after sliding down stairs at home yesterday the patient reports that he was walking up a flight of stairs in his home on the day prior to admission when he suddenly slipped falling on his left side denies loc or head strike he denies any preceding symptoms including sob cp dizziness lightheadedness unilateral weakness or numbness he remained on the ground for approximately one hour until his tenant helped him to his feet he was able to climb the stairs with the assistance of his tenant in an effort to reach his bedroom the following morning the patient reports increased pain in his epigastrum left flank and lle he states that he has had ongoing pain in these regions for months however he notes an exacerbation in the pain since the fall of note the patient initiated chemo with docetaxel on the patient notes worsening fatigue since initiation of the chemotherapy he was transfused u prbc on for wrosening anemia in the ed inital vitals were unable to get an o sat the patient underwent ct torso which showed hemorrhage in large left renal cyst abdominal free fluid not evidence of hemoperitoneum and fractures of left th th ribs plain films of femur knee elbow and shoulder did not reveal any acute fractures surgery evaluated patient and felt that there was no acute surgical issue hemorrhage into renal cyst appeared contained per their report he received albuterol ipratropium acetaminophen and mg of morphine the patient was given u prbcs and an additional unit was hanging at the time of transfer vitals at the time of transfer were ra on arrival to the icu the patient reports continued pain in his left leg and left flank past medical history past medical history ckd baseline htn lle dvt avascular necrosis of the left hip oncology history metastatic prostate cancer diagnosed in after developing bladder obstruction he underwent turp and was started on lupron he presented to clinic with metastatic disease and a psa he started ketoconazole hydrocortisone and finasteride on mr completed radiation therapy for bulky right inguinal lymphadenopathy in he received pamidronate on he has since been on several different regimens social history born in moved to us in lives in with his wife is independent at home has daughter smoked ppw from very rare etoh use no illicit drug use family history no fh of malignancy clotting or bleeding that he knows of physical exam on admission vitals t bp p r o ra general alert oriented no acute distress heent mmm swelling of left lower lip in region of trauma neck supple jvp not elevated lungs good air movement scattered expiratory wheezing b l cv regular rate and rhythm normal s s systolic murmur abdomen soft mildly tender in epigastrum non distended bowel sounds present no rebound tenderness or guarding ext edema in lle left leg right on discharge vitals t ra general nad skin warm and well perfused no excoriations or lesions no rashes heent at nc eomi perrla anicteric sclera pink conjunctiva patent nares mmm poor dentition nontender supple neck no lad no jvd lower lip is swollen but no bleeding cardiac rrr s s holosystolic murmur lung ctab abdomen nondistended bs nontender in all quadrants no rebound guarding no hepatosplenomegaly m s moving all extremities well no cyanosis significant pitting edmea in the lle grossly swollen compared to right pulses dp pulses bilaterally neuro cn ii xii intact pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso atyps metas myelos pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg am urine blood mod nitrite neg protein glucose neg ketone bilirub neg urobiln neg ph leuks neg discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood calcium phos mg ct abd pelvis hemorrhage in large left renal cyst abdominal free fluid not evidence of hemoperitoneum fractures of left th th ribs innumerable pulmonary nodules and diffuse hypodensities in liver concerning for metastates diffuse osseous metastatic disease and lymphadenopathy unchanged x ray l femur l knee diffuse sclerotic metastatic dz in l hemi pelvis unchanged sclerosis of l femoral head c w avascular necrosis no acute fx or dislocations x ray shoulder elbow no acute fracture or dislocation no joint effusion ct head no acute intracranial abnormality ct c spine no acute fracture or dislocation severe degenerative changes of cervical spine sclerotic changes in left rd rib consistent with metastatic disease brief hospital course brief hospital course the patient is an year old male with history of prostate cancer followed by dr on docetaxel dvt on coumadin ckd baseline cr presenting with left flank pain epigastric pain and worsening fatigue after sliding down stairs at home found to have hemorrhage of a large left renal cyst requiring brief icu admission for hemodynamic monitoring patient s course was complicated by chemotherapy induced neutropenia he was ultimately discharged to rehab for continued treatment active issues status post fall strictly mechanical per patient report evidence of trauma includes hemorrhage in large left renal cyst abdominal free fluid no evidence of hemoperitoneum and fractures of left th th ribs was seen by trauma surgery who felt there were no acute surgical issues no other fractures or dislocations based on imaging low suspicion for syncopal event leading to fall though patient does endorse intermittent dizziness with standing suggestive of orthostasis his coumadin was initially held but restarted after stable hematocrits physical therapy consult felt paitient would benefit from ongoing inpatient rehab post discharge anemia no evidence of acute blood loss hemorrhagic renal cyst contained within capsule based on imaging suspect worsening anemia may be related to taxotere nadir days hct trending down prior to presentation and received unit prbcs as outpatient on now s p units prbcs in emergency department acs was consulted and recommended consultation of urology urology commented that if no hematuria and hct is stable there is nothing to do but let the hemorrhage resolve on its own difficult to tell if the free fluid is a urinoma or not the only imaging that could potentially tell the difference is a ct with contrast with delayed phase to look for extravasation would only be indicated if he develops a fever uti or hematuria as he was stable with no hematuria evidence of uti or hematuria this was not done his coumadin was initially held and his hematocrit was trended q hrs his coumadin was restarted on hd bacteremia patient had one set of positive blood cultures from day of admission growing coagulase negative staphylococcus in the setting of persistent fevers and neutropenia he was started on vancomycin this was discontinued once anc had recovered patient deferevesed and did not require additional antibiosis no additional cultures were positive although cultures from and were pending at the time of discharge neutropenia likely secondary to taxotere as around nadir period of days patient was treated supportively until counts recovered suspect pre renal etiology in setting of poor po intake over last few days patient s creatinine clearence improved with iv fluids dvt on coumadin inr was subtherapeutic at on admission coumadin was initially held due to renal hemorrhage but restarted at home dose of mg qd prior to discharge inr was patinet will need weekly inr checks at rehab and will continue weekly checks with his pcp l flank leg pain leg pain likely secondary to diffuse osseus disease in setting of metastatic pancreatic cancer rib pain secondary to fractures he was continued on his home pain regimen oxycontin and oxycodone he was gicen incentive spirometry and pulmonary toilet metastatic prostate cancer recently initiated on taxotere on followed by dr has follow up on when he was supposed to recieve next cycle of chemo will likely be delayed weeks per dr transitional issues code full code pt will need weekly inr checks done by pcp final blood culture results were pending at the time of discharge medications on admission amlodipine mg tablet tablet s by mouth daily des prescribed by other provider dosage uncertain finasteride mg tablet tablet s by mouth daily hydrochlorothiazide mg tablet tablet s by mouth once a day oxycodone mg tablet or tablet s by mouth every three to four hours for pain oxycodone oxycontin mg tablet extended release hr tablet s by mouth twice a day prochlorperazine maleate mg tablet tablet s by mouth as needed every hours for nausa warfarin jantoven mg tablet tablet s by mouth daily cholecalciferol vitamin d vitamin d prescribed by other provider dosage uncertain discharge medications amlodipine mg tablet sig two tablet po daily daily finasteride mg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po bid times a day as needed for constipation oxycodone mg tablet extended release hr sig one tablet extended release hr po q h every hours warfarin mg tablet sig three tablet po once daily at pm oxycodone mg tablet sig tablets po q h every hours as needed for pain lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily disp adhesive patch medicated s refills acetaminophen mg tablet sig tablets po q h every hours as needed for fever discharge disposition extended care facility nursing care center discharge diagnosis primary mechanical fall hemorrhagic renal cyst neutropenic fever metastatic prostate cancer secondary chronic kidney disease baseline hypertension left lower extremity deep vein thrombosis avascular necrosis of the left hip discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions it was a pleasure taking care of you while you were in the hospital you were admitted for evaultion after falling at home you had a ct scan and x rays that did not show any fractures you were noted to have a small bleed in your kidney and were therefore observed overnight in the intensive care unit your bleeding was not significant and you continued to recieve your coumadin you also had very low white blood cell levels as a result of your reccent chemotherapy and were given antibiotics while you were having fevers this was stopped once your fevers stopped you were also seen by our physical therapists who felt you would benefit from rehab before being safe to be at home once you are discharged from rehab you will need to see dr your primary care doctor to have your coumadin levels inr checked the following changes were made to your medications start lidocaine patch applied to the left chest daily until pain resolves followup instructions department hematology oncology when thursday at am with md building sc clinical ctr campus east best parking garage department hematology oncology when thursday at pm with rn building sc clinical ctr campus east best parking garage,"{
""name"": ""John Doe"",
""DOB"": ""2012-1-1"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Penicillins""
],
""adverse_drug_reactions"": [
""Anemia""
],
""attending_chief_complaint"": ""Left flank pain, epigastric pain, worsening fatigue after sliding down stairs at home yesterday"",
""history_of_present_illness"": ""The patient is an year old male with history of metastatic prostate cancer followed by dr [**Last Name (STitle) 105**] on docetaxel, DVT on coumadin, CKD, baseline CR, presenting with left flank pain, epigastric pain and wors"
92057,admission date discharge date date of birth sex m service neurology allergies bactrim attending chief complaint right arm weakness and numbness major surgical or invasive procedure endotracheal intubation plus stent based angioplasty of external carotid artery history of present illness is a year old man with hiv on haart htn hl and pmh notable for l pca and l mca aca watershed strokes in and small patchy watershed strokes in similar pattern in secondary to an now chronically occluded left carotid with fetal pca on the left chronically occluded as well as a stenotic left verteberal artery he says he was in his usoh until this morning around am when he developed sudden onset numb and weak sensation in his right arm he awoke and traveled to a friend s house with his partner with no deficits or new symptoms then around while they were gathering small pieces of wood outside he felt abruptly unwell and developed numb and subjective weak sensation in his right hand arm he cannot give any example of arm hand weakness he could still move it without difficulty and did not drop anything but it felt weak to him there was no change in his speech or language per his partner and per him his partner thinks the right lower face may be slightly assymetric which is new initially he said this was a new symptom but on further questioning and reminding him that we have documentation from that he experienced tias from time to time with right arm and or leg numbness he recalled that he does experience the same symptom rue numb weak sensation for several seconds at a time roughly once per two weeks those typical episodes are typically followed by shaking of the arm hand which are though tto represent limb shaking tias related to transient hypoperfusion of the left anterior circulation via the right carotid and pcom the thing that is new today then seems to be the duration of the episode he thinks it has not changed in any way since its abrupt onset around this morning his partner says they just got back from vacation in yesterday he thinks the the patient has been more fatigued and less active sleeping more often for at least a week the patient says he has felt fine he denies recent illness he thinks he may be bumping into things more recently he has a chronic r hemianopsia since the stroke in his only medication changes recently are he started taking ibuprofen at or mg up to q hrs for teeth jaw pain s p recent dental work and his pcp stopped his statin medication a few months ago due to myalgias patient says symptoms were knee pain and numbness in just the right le review of systems negative except as above on neuro ros the pt denies headache change in vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies change in speech partner agrees denies change in baseline and word finding deficits denies weakness numbness parasthesiae outside the right hand arm no bowel or bladder incontinence or retention denies difficulty with gait besides related to chronic right knee pain on general review of systems the pt denies recent fever or chills no night sweats or recent weight loss or gain denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria denies arthralgias or myalgias denies rash teeth pain treating with ibuprofen past medical history strokes as above left carotid occlusion left vert stenosis left pca occlusion with residual baseline of dense right hemianopsia subtle right sensory loss language impairments and visuospatial difficulties hiv positive on haart no h o opportunistics historically good control with last cd and nd vl in atrius hypertension on acei hyperlipidemia on statin h o right shoulder injury per atrius epic records tobacco user shoulder pain cervical radiculopathy screening for colon cancer cva cerebral infarction lbbb left bundle branch block rotator cuff disorder hypercholesteremia hiv infection htn hypertension condyloma acuminata social history lives with partner they just returned yesterday from a vacation to south beach fl etoh occasional tobacco still smokes occasionally pk yr history ppd x yrs drugs no use family history per omr no history of strokes seizures clotting bleeding mi less than age physical exam on admission general physical examination vital signs ed triage f reg ra general lying in ed stretcher awake cooperative nad extremely tan says he just returned from south beach heent normocephalic and atraumatic shaved head balding eyeglasses no scleral icterus mucous membranes are moist no lesions noted in oropharynx but noticeably poor dentition neck neck is supple w full range of motion no lad or goiter loud bruit over left carotid soft bruit over right carotid pulmonary lungs cta bilateral bases non labored breathing cardiac distant regular heart sounds i had to tilt him to the left to hear normal s s no loud m r g abdomen soft non tender and non distended nbs extremities warm and well perfused no clubbing cyanosis or edema radial dp pulses bilaterally skin no gross rashes or lesions noted neurologic examination mental status aaox able to relate history with moderate difficulty his partner seems to remember several details faster than him and a few he did not remember at all grossly attentive speech was not dysarthric language is fluent with intact repetition and comprehension normal prosody and normal affect answers are frequently delayed with gaps between toughts phrases words he made no paraphasic errors with normal conversation but several when word substitution follows commands reliably there was no evidence of apraxia or neglect or extinction no visual extinction w in limits of his hemianopsia or sensory no l r confusion naming moderately impaired feather was hair and hammock was lawnchair he has great difficulty limited to words at a time he reports basline difficulty with finding the right words and with matching words to symbols he thinks this is unchanged since his stroke in writing paucity of written language sentence about the weather warm all caps memory registers at min at min with one substitution capital for apple and forgot a different word than before complex figure d copying excellent performance cranial nerves i olfaction not tested ii perrl to mm and brisk visual fields testing reveals total right homonymous hemianopsia does not spare any of the superior or inferior right visual field acuity grossly intact iii iv vi eoms full and conjugate no nystagmus no saccadic intrusion during smooth pursuits normal saccades v facial sensation intact and subjectively symmetric to light touch and pin and cold v v v vii possible very slight r nlf flattening at rest pt s partner agrees but no weakness or assymetry with volitional smile no ptosis brow elevation is symmetric eye closure is strong and symmetric viii hearing intact and subjectively equal to finger rub bilaterally ix x palate elevates symmetrically with phonation equal strength in trapezii bilaterally xii tongue protrusion is midline motor no drift no asterixis no tremor normal muscle bulk and tone delt bic tri we ff fe io ip q ham ta gastroc l r none of the rue groups were breakable by standard examination techniques but with added force they were slightly weaker relative to the left sensory ues patchy mild pinprick deficit in the right hand and forearm fingers extensor surface symmetric and normal sharp thenar eminence and ulnar surface and patchy forearm less sharp vs corresponding site on lue pinprick intact elsewhere no assymetry or deficit to propioceptive testing jps in thumbs or to cold sensation eyes closed finger to testing revealed no gross proprioceptive deficit did not miss les no deficits to light touch pinprick cold sensation or vibratory sensation in either distal lower extremity joint position sense is excellent in the left great toe and slightly reduced in the right great toe cortical sensory testing no agraphesthesia or astereoagnosia no extinction to dss reflexes left right biceps brisker on the right triceps brachioradialis quadriceps patellar gastroc soleus achilles plantar response was equivocal bilaterally great toe down other toes up with tickle responses coordination fine finger movements slightly clumsy r hand not left finger finger testing and heel knee shin testing with no dysmetria or intention tremor very slight dysdiadochokinesia noted on rapid alternating movements in the rue relative to the left gait stands without difficulty good initiation narrow based normal stride slightly decreased arm swing turns normally able to walk on heels slightly off balance toes side of feet able to tandem walk with occasional side step for balance romberg absent slight wobble does not look about to fall and says he does not feel unsteady pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood alt ast alkphos totbili pm blood lipase am blood ctropnt am blood albumin calcium phos mg cholest am blood hba c eag am blood triglyc hdl chol hd ldlcalc pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood glucose na k cl calhco pm urine blood tr nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg pm urine rbc wbc bacteri none yeast none epi pm urine color straw appear clear sp discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood calcium phos mg reports nchct no evidence of acute intracranial process in the setting of high clinical suspicion for ischemic event mr may be considered for further assessment if not contra indicated encephalomalacia in the left pca distribution signifies prior infarction cta head neck overall little change since the most recent cta of with possible relatively acute infarcts in the left centrum semiovale extensive atherosclerotic disease involving the left common and internal carotid artery with occlusion of the left ica at its origin through its distal cervical and petrous segments with reconstitution at the level of its supraclinoid segment via cross filling from the circle of evidence of previous left pca territorial infarction with established encephalomalacia and chronic occlusion of this vessel at its origin less severe atherosclerotic disease involving the distal right common and proximal internal carotid arteries with focal ulceration and or short segmental dissection involving its proximal most portion unchanged on studies dating to severe tandem stenoses involving the origin and more distal v segments of the congenitally hypoplastic left vertebral artery likely related to atherosclerotic disease mri head neck late acute early subacute infarcts predominantly in the high left frontal lobe including both the pre and post central gyri likely accounting for the patient s presentation these are in a distinctive linear array highly suggestive of watershed infarction likely related to the known severe steno occlusive disease of the ipsilateral internal carotid artery so called stump emboli originating from the known occlusive disease is another consideration extensive cystic encephalomalacia with porencephalic change gliosis and volume loss related to remote left pca territorial infarction chronic inflammatory disease involving the paranasal sinuses ekg normal sinus rhythm left bundle branch block no significant change from tracing of rate pr qrs qt qtc p qrs t cerebral angiogram with nsg right common carotid artery arteriogram shows that there is atheromatous disease of the right internal carotid artery close to the bifurcation however there is no significant stenosis the right internal carotid artery fills well along the cervical petrous cavernous and supraclinoid portion there is cross fill into the left anterior cerebral artery and into the middle cerebral artery and also into the supraclinoid carotid artery there is a prominent posterior communicating artery on the right side left common carotid artery arteriogram demonstrates a stenosis at the junction of the common carotid with the external carotid artery left common carotid artery arteriogram also demonstrates reconstitution of the left internal carotid artery in the supraclinoid segment through a large ophthalmic artery left common carotid artery arteriogram status post angioplasty and stenting demonstrates a robust flow into the left external carotid artery in addition the intracranial circulation is also seen to fill robustly through the ophthalmic artery and the supraclinoid carotid artery the common femoral artery arteriogram shows widely patent right common femoral artery brief hospital course mr was admitted to the neurology service for the investigation of a transient right sided numbness and weakness of the arm the patient had recently suffered a diarrheal illness and had recently returned from vacation in he was on ct angiography to have evidence of left eca stenosis in the setting of known prior almost complete left ica stenosis of note he had recently stopped his hmgcoa reductase inhibitor due to some concerning side effects that he had heard about in the news he received a routine mri of his head which showed the presence of watershed infarcts between the aca and mca distributions which were thought to have occurred in the setting of hypotension hypoperfusion he was restarted on a statin medication and he was upgraded to a full aspirin mg daily neurosurgery and neurovascular intervention was consulted for the possibility of an intervention on the day prior to his discharge he underwent cerebral angiography and stenting of left common carotid artery and external carotid artery with spider mm distal embolism protection device with pre and post angioplasty and a mm x mm protege stent the procedure was uneventful the following day he was doing well and had no residual localizing symptoms on the right arm he had a stable alexia agraphia with a right visual field cut he was given strict ed warnings educated about important medication changes and instructed on when to follow up with his neurologist neurosurgeon and primary care physician asked mr to stay well hydrated and to check his blood pressure on a daily basis at least for the first week following discharge medications on admission aspirin mg tab stopped simvastatin mos ago lisinopril metoprolol succ daily omeprazole ec daily truvada emtricitabine tenofovir mg daily nevirapine mg daily recent ibuprofen mg q hrs for dental pain s p recent dental work discharge medications emtricitabine tenofovir mg tablet sig one tablet po daily daily nevirapine mg tablet sig two tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet chewable sig one tablet chewable po daily daily disp tablet chewable s refills metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po daily daily lisinopril mg tablet sig one tablet po daily daily zantac mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home discharge diagnosis main diagnosis external carotid artery stenosis with left sided watershed stroke history of left posterior cerebral artery stroke history of left internal carotid artery stenosis hiv hypertension hyperlipidemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you during this hospitalization you were admitted to the neurology wards and neuro intensive care of the for symptoms of right sided weakness and numbness that you experienced through a series of physical examinations laboratory studies and neuroimaging studies we determined that you sustained a series of small strokes in your left brain that controls your right arm these occurred because of a critical blockage in an artery that supplies blood to that area of the brain you briefly received a heparin drip blood thinning medications and in consultation with the neurosurgical team you received a stent placement angioplasty in the affected artery external carotid artery we ask that you take or clopidogrel at a dose of mg daily for one month after one month you can stop taking this medication we ask that you take a daily aspirin at mg daily to reduce the risk of future strokes this can be purchased over the counter please be sure to measure your blood pressure daily can be done at your local pharmacy try to keep the higher number systolic blood pressure between and stay well hydrated on days that you are particularly dehydrated we ask that you consider skipping your blood pressure medications to avoid unsafe drops in your blood pressure we restarted you on a medication called atorvastatin at mg daily so as to reduce your blood cholesterol levels do not take omeprazole from now on as it can have a problem interaction with you can consider restarting this medication after has been discontinued in the meantime you can use zantac or ranitidine to treat acid reflux disease we have arranged follow up appointments for you to see dr pcp dr neurosurgery and dr vascular neurology please be sure to keep these appointments please be sure to contact us at the numbers listed below if you have any questions or concerns for now these are your daily medications aspirin mg daily mg daily for one month atorvastatin mg daily lisinopril mg daily metoprolol succinate mg daily ranitidine mg twice daily truvada emtricitabine tenofovir mg daily nevirapine mg daily followup instructions primary care physician md monday pm location address phone fax neurosurgery provider md phone date time vascular neurology provider md phone date time md completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Neurology"",
""allergies"": ""Bactrim"",
""attendingChiefComplaint"": ""Right arm weakness and numbness"",
""chiefComplaint"": ""Right arm weakness and numbness"",
""historyOfPresentIllness"": ""admission date discharge date date of birth sex m service neurology allergies bactrim attending chief complaint right arm weakness and numbness major surgical or invasive procedure endotracheal intubation plus stent based angioplasty of external carotid artery history of present illness is a year old man with hiv on haart htn hl and pmh notable for l pca and l"
6773,admission date discharge date date of birth sex m service int m history of present illness mr is a year old male with a history of coronary artery disease ischemic cardiomyopathy and atrial fibrillation who presented to hospital on complaining of five days of melena and diffuse abdominal discomfort his initial hematocrit was and on upper endoscopy he was found to have barrett s grade i erosion there were plans to do colonoscopy for further evaluation of sources for gastrointestinal bleeding and the patient was given a golytely bowel prep at hospital however the patient developed emesis and ten out of ten abdominal pain during this time with an episode bradycardia to to s range and decrease in blood pressure to systolic blood pressure in the s in the setting of having had a bowel movement and getting up from the commode an arterial blood gas was done after this event and the patient was found to have a serum ph of pco of and pao of on two liters nasal cannula there was initial concern for a possible colonic acute mesenteric ischemia given the abdominal pain and hypotension and history of melena but abdominal ct scan done at the outside hospital did not show any evidence of such a temporary pacer was placed secondary to the bradycardic event the patient was started on intravenous heparin given concern for acute mesenteric ischemia with a history of atrial fibrillation the patient was transferred from the outside hospital for further gi work up and evaluation past medical history duodenal ulcer treated with pepcid history of h pylori treated history of colonic polyps avms history of atrial fibrillation on coumadin history of coronary artery disease with a history of myocardial infarction in status post coronary artery bypass graft left ventricular ejection fraction of moderate mitral regurgitation and severe pulmonary hypertension spinal degenerative joint disease with right shoulder contraction type diabetes mellitus diet controlled peripheral vascular disease question of chronic obstructive pulmonary disease allergies no known drug allergies medications on transfer protonix mg p o q day heparin units per hour zocor mg p o q day levofloxacin mg p o q day flagyl mg intravenous q six regular insulin sliding scale isordil mg p o three times a day avapro mg p o q day neurontin mg p o three times a day outpatient medications zocor mg p o q day isordil neurontin mg p o three times a day lasix mg p o q a m avapro atenolol mg p o twice a day social history former smoker quit since former alcohol quit lives in facility daughter is in open care physical examination in general a pleasant male in no acute distress vital signs with temperature f heart rate blood pressure respiratory rate saturation o heent normocephalic atraumatic dry mucous membranes pupils are equal round and reactive to light extraocular movements intact neck left cordis in place cardiac examination regular rate and rhythm no murmurs rubs or gallops lung examination clear to auscultation bilaterally abdomen soft with suprapubic and bilateral lower quadrant tenderness but no rebound extremities with no cyanosis clubbing or edema chronic venous stasis changes neurological alert and oriented times three cranial nerves intact grossly non focal laboratory from in the morning white blood cell count hematocrit platelets down from mcv to chemistry panel with sodium potasium chloride bicarbonate bun creatinine glucose pt ptt fibrin negative d dimer and negative fibrin degradation products ck mb fraction troponin chest x ray showed cardiomegaly no infiltrates no effusion ct scan of the abdomen showed gallstones but no evidence of cholecystitis right intestinal opacity adhesions open celiac supra mesenteric and common iliac arteries summary of hospital course the patient was initially admitted to the medical intensive care unit for close monitoring given history of bradycardia placement of temporary pacemaker and history of recent gastrointestinal bleeding hospital course was notable for the following gastrointestinal bleeding the patient had a known history of arteriovenous malformations and polyps with gastrointestinal bleeding in egd done at the outside hospital showed grade i esophagitis and ct scan of the abdomen had already patent mesenteric vessels no valve thickening or obstruction the patient had had hematocrits checked after blood transfusion at the outside hospital at least one unit of packed red blood cells and two units of fresh frozen plasma the gi consultation service was consulted for help in managing the patient s history of gastrointestinal bleeding the patient was placed on intravenous protonix fluids and initially n p o with serial abdominal examinations after review of the data history and ct scan it was felt that acute mesenteric ischemia was unlikely to have been responsible and heparin was discontinued on the patient underwent a colonoscopy and esophagogastroduodenoscopy the egd showed medium hiatal hernia otherwise a normal egd to second part of duodenum erosions were seen inside the hernia these erosions were thought to have been the cause for patient s melena and the gi consult service advised keeping patient on protonix mg p o twice a day times one week then mg p o q day for days the patient s colonoscopy on showed polyps in the transverse colon otherwise normal colonoscopy to the cecum polypectomy was recommended at a future date and follow up when gastrointestinal bleeding and cardiac issues resolved the patient was subsequently monitored with serial checks with hematocrit which were stable with an initial trend downward he did have hematocrit of around to when transferred from the medical intensive care unit to the regular medical and given his history of coronary artery disease it was felt that he would benefit from blood transfusion he received one unit of packed red blood cells and his subsequent hematocrits rose from to range and have remained stable there since cardiovascular the patient has a known history of coronary artery disease and atrial fibrillation his serial cardiac enzymes were sent to rule out myocardial infarction given recent episode of hypotension and bradycardia these returned negative he did have a temporary pacer placed at the outside hospital for symptomatic bradycardia and cardiology consulted on this matter as well after review of the patient s history and hematocrit it was felt that his bradycardia was likely due to a combination of vasovagal episode in the setting of bowel movement during bowel preparation for colonoscopy and beta blockade with atenolol with the possibility of enhanced effects in the setting of acute renal insufficiency his beta blockers were initially held and the patient had no further episodes of bradycardia his blood pressure remained stable and his temporary pacemaker was discontinued because he did have a history of atrial fibrillation and did need rate control low dose beta blockers were restarted with metoprolol and have been titrated up with good rate control and no further episodes of bradycardia or hypotension his history of atrial fibrillation had prompted use of anti coagulants in the past but given the acute episodes of gastrointestinal bleeding his coumadin was initially held but when his hematocrit stabilized his coumadin was restarted and should be continued with goal inr of to also his anti hypertensive medications were held in the setting of hypotensive event however when his blood pressure stabilized and his renal function improved his angiotensin receptor blocker and lasix were restarted hypoxia the patient developed an o requirement during the course of his hospital stay this was in the setting of transfusion and intravenous fluid and holding of his lasix his physical examination and chest x ray findings were consistent with congestive heart failure and the patient has been restarted on his lasix and his angiotensin receptor blocker for treatment of this with subsequent improvement in his hypoxia it is anticipated that with further therapy his o requirements will resolve he will need continued monitoring of his daily weights and intakes and outputs until his hypoxia resolved and his cardiovascular status becomes stable diabetes mellitus the patient has a known history of type diabetes mellitus that was formerly controlled on diet he was started on regular insulin sliding scale and was on fingersticks while in the hospital and may benefit from started an oral if he continues to have periodic elevated blood sugars deconditioning after a prolonged hospital stay the patient was deconditioned and after physical therapy evaluation was felt to be someone who could benefit from physical therapy in a rehabilitation setting disposition the patient was subsequently stable fro discharge and is awaiting transfer to rehabilitation facility discharge diagnoses gastrointestinal bleeding likely secondary to esophageal erosions barrett s type i esophagus bradycardic event question vasovagal question secondary to enhanced effects of beta blocker in the setting of acute renal insufficiency acute renal insufficiency prerenal etiology with creatinine of on presentation to and improvement to baseline creatinine of after intravenous fluid hydration anemia secondary to gastrointestinal bleed history of coronary artery disease history of type diabetes mellitus history of atrial fibrillation colon polyps needs gi follow up for polypectomy once gastrointestinal bleeding issues and cardiovascular status stabilize peripheral vascular disease history of spinal degenerative joint disease questionable history of chronic obstructive pulmonary disease discharge medications protonix mg p o twice a day times two weeks then change to mg p o q day times days metoprolol mg p o twice a day continue to monitor heart rate and blood pressure and adjust for rate control ibesartan mg p o q day atorvastatin mg p o q day warfarin mg p o q day adjust to goal inr of to lasix mg p o q a m potassium chloride meq p o q day neurontin mg p o three times a day isordil mg p o three times a day discharge instructions the patient will be discharged to rehabilitation he will need follow up with his primary care physician on an ongoing basis he will inr checked two days following discharge and adjust coumadin to goal inr of to the patient will also need to follow up monitoring of his hematocrit to insure stability given history of gastrointestinal bleeding the patient will also need follow up colonoscopy for polypectomy given findings of transverse colon polyps during hospital stay discharge diet cardiac two gram salt condition on discharge stable m d dictated by medquist d t job,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Medicine"",
""admissionDate"": ""2017-01-05"",
""dischargeDate"": ""2017-01-07"",
""dateOfDeath"": ""2017-01-07"",
""serviceOfAdmission"": ""Medicine"",
""historyOfPresentIllness"": ""Mr. [**Known lastname 1081**] is a year old male with a history of coronary artery disease, ischemic cardiomyopathy, and atrial fibrillation who presented to hospital on complaining of five days of melena and diffuse abdominal discomfort.  His initial hemat"
13825,admission date discharge date date of birth sex m service neurosurgery history of present illness the patient is a year old gentleman who presented to an outside hospital with a headache and lightheadedness not relieved by medication or rest the headache started on the evening of and the patient was transferred to and then to for further management of intercerebral hemorrhage and subarachnoid hemorrhage the patient has no trouble walking or with diplopia or visual changes no nausea or vomiting no shortness of breath or chest pain past medical history the patient has a past medical history of bipolar past surgical history undescended testicle repair in the medications on admission depakote mg by mouth once per day social history the patient is married with children he is a nonsmoker physical examination on presentation neurologically awake and alert and oriented times four cranial nerves ii through xii were intact strength was in the deltoids biceps triceps wrist extension and interossea bilaterally his sensation was grossly intact to light touch his naming was his problem solving was logical his reflexes were in the upper extremities and in the knees and ankles the toes were downgoing pertinent laboratory values on presentation white blood cell count was his hematocrit was and his platelets were sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and blood glucose was brief summary of hospital course the patient was admitted to the neurosurgery service a head computed tomography showed a left frontal contusion with intraparenchymal hemorrhage and subarachnoid hemorrhage with no hydrocephalus the patient was admitted to the intensive care unit for closer management the patient underwent a magnetic resonance imaging magnetic resonance angiography which showed a left frontal arteriovenous malformation the patient then had an angiogram on which showed evidence of a left frontal arteriovenous malformation the patient had no complications from the angiogram and was transferred back to the intensive care unit for closer monitoring he was awake and alert extraocular movements were full pupils were equal round and reactive to light no diplopia the face was symmetric strength was in all muscle groups status post angiogram on he was taken back to angiogram and underwent embolization of the arteriovenous malformation without complications post procedure he was again monitored in the intensive care unit and remained neurologically stable he was taken to the operating room on monday for a craniotomy and excision of the arteriovenous malformation there were no complications the patient tolerated the procedure well and again was back in the intensive care unit for close neurosurgical observation he was alert awake and oriented times three his strength was in the left upper extremity his grasp was on the right antigravity in the deltoid and biceps was triceps were iliopsoas were full bilaterally his frontalis was intact his face was symmetric extraocular movements were full no nystagmus his incision was clean dry and intact his naming was repetition was intact his diet was advanced he was out of bed to chair he had a magnetic resonance imaging with magnetic resonance angiography which showed good excision of the arteriovenous malformation he did have an episode of paranoia on postoperative day on the patient was seen by the psychiatry service who felt that this was delirium and recommended holding benzodiazepines and narcotics he was seen by physical therapy and occupational therapy he remained neurologically stable he was awake alert and oriented times three with improved right sided strength speech was clear psychiatry felt that this episode was not a manic episode it was delirium secondary to surgery and steroid use the patient continued to be stable he was afebrile alert awake and oriented times three he was ambulatory his wound was clean dry and intact discharge disposition he was discharged to home on condition at discharge condition on discharge was stable discharge instructions followup followup in one week for staple removal and was to follow up dr in one month medications on discharge his medications at the time of discharge included labetalol mg by mouth twice per day famotidine mg by mouth twice per day depakote mg by mouth twice per day colace mg by mouth twice per day percocet one to two tablets by mouth q h as needed decadron weaned off over one week s time m d dictated by medquist d t job,"[
""date"": ""2019-1-29"",
""type"": ""SICU NPN 7a-7p""
]"
59135,admission date discharge date date of birth sex m service surgery allergies protonix cortisone motrin attending chief complaint referral for paraesophageal hernia repair contributing to gi bleed major surgical or invasive procedure laparoscopic repair of paraesophageal hernia laparoscopic gastroplasty fundoplication and flexible gastroscopy history of present illness year old man who was referred from pcp to dr for surgical evaluation of a large hiatal hernia with ulcer and significant blood loss microcytic anemia patient c o of fatigue from blood loss he obtained a barium swallow and a motility study to evaluate the anatomy and propulsive force and the decision to proceed to surgery was made with patient past medical history his past medical history is notable for a history of cardiomyopathy and some mild congestive heart failure he has had atrial fibrillation in the past and been cardioverted twice he has been on coumadin and amiodarone in the past but has now been in sinus rhythm and is off both medications there is some question history of a septal defect of the heart but has not had any surgery his past surgeries include an appendectomy several knee surgeries including five arthroscopic surgeries on the left knee social history the patient drinks socially he lives alone he smoked three packs of cigarettes a day for approximately years but quit years ago he works as a social worker in a psychiatric family history family history is notable for diabetes in his mother and lung disease in his father physical exam at time of discharge afebrile vss alert oriented x nad rrr ctab abdomen soft steri strips in place over surgical incisions le warm some edema of l knee pulses pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt inr pt am blood plt ct am blood glucose urean creat na k cl hco angap am blood tsh am blood t t pm blood crp pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirub sm urobiln ph leuks neg pm joint fluid wbc rbc polys lymphs monos pm joint fluid crystal few shape needle locatio intrac birefri neg comment c w monoso brief hospital course mr was admitted post op to the surgical after undergoing a laproscopic paraesophageal hernia repair for details of the operation please see dr operative report initially he did well postoperatively on hospital day pod he began to feel short of breath cxr found bilateral effusions and o sats decreased to on ra sats successfully increased with l nc he was found to be in atrial fibrillation and was sent to the icu d t need of diltiazem gtt he had a temperature of and increased to from so blood cultures were sent and came back negative cardiology was consulted on the patient and he was successfuly weaned off dilt and rate controlled on lopressor tid patient was able to be transferred out of the sicu to the floor with telemetry where his rate controlled afib was monitored cardiology recommended coumadin for anticoagulation before cardioversion while awaiting cardioversion he converted to normal sinus rhythm he had an episode of bradycardia pod he also experienced knee pain on pod his knee was swollen and warm an xray showed no fractures a joint fluid evaluation revealed high wbc and crystals consistent with gout at time of discharge his temperature and wbc were normal x d he was in normal sinus rhythm he was sent home on coumadin to be followed up with by his pcp dr for cardioversion in month with dr if he returned to atrial fibrillation he was given a prescription for toprol mg to be taken daily with plans to follow this up with dr his knee pain was improving physical therapy was set up to assist him at home and he received a colchicine prescription to be discharged by dr on monday if he is improving he was given dilaudid mg po for pain from surgery colace for constipation and acetaminopen this discharge information and his ekgs will be sent to dr office medications on admission bupropion hcl wellbutrin xl dosage uncertain prescribed by other provider recorded only delorie nr enalapril maleate dosage uncertain prescribed by other provider recorded only delorie nr esomeprazole magnesium nexium dosage uncertain prescribed by other provider recorded only delorie allergy alert nr furosemide lasix dosage uncertain prescribed by other provider recorded only delorie nr iron b if fa mv min dss hemax nr metoprolol succinate toprol xl nr modafinil provigil nr sucralfate carafate dosage uncertain nr chlorpheniramine acetaminophen coricidin dosage uncertain nr vitamin e dosage uncertain discharge medications hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever disp tablet s refills colchicine mg tablet sig one tablet po prn as needed as needed for pain please take for knee pain only as needed disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation disp capsule s refills warfarin mg tablet sig one tablet po once a day please adjust with dr on disp tablet s refills metoprolol succinate mg tablet sustained release hr sig two tablet sustained release hr po daily daily disp tablet sustained release hr s refills discharge disposition home with service facility discharge diagnosis paraesophageal hernia chronic blood loss anemia atrial fibrillation chronic congestive heart failure acute gouty arthritis discharge condition stable discharge instructions please call your doctor or return to the emergency department for any of the following increasing rednessswelling around your incision increasing discharge from your incision fevers chills vomiting abdominal pain shortness of breath chest pain or any other symptoms which may concern you followup instructions follow up with dr in weeks please call to make appointment phone you have an appointment with dr on monday it is important that you make this appointment to have your blood drawn for an inr check please call dr if there is any reason you cannot make this appointment please follow up with dr at or another electrophysiologist of dr choice regarding cardioversion one month from now completed by,"[
""admission_date"" : ""2019-1-29"",
""discharge_date"" : ""2019-2-1"",
""date_of_birth"" : ""2010-10-15"",
""sex"" : ""Male"",
""service"" : ""Surgery"",
""allergies"" : ""Protonix, Cortisone, Motrin"",
""attending_chief_complaint"" : ""Contributing to GI bleed"",
""chief_complaint"" : ""Major surgical or invasive procedure (LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA, LAPAROSCOPIC GASTROPEXY, FUNDOPLASTY AND FLEXIBLE GASTROSCO"
4833,admission date discharge date date of birth sex m service medicine allergies nsaids attending chief complaint stridor major surgical or invasive procedure endotracheal intubation fiberoptic bronchoscopy central venous line l subclavian placement transesophageal echocardiography picc line placed history of present illness yo spanish speaking m hx dm htn pulm htn af transferred from hospital for further evaluation management of worsening stridor patient was initially admitted to osh on he presented complaining of back pain and dysuria and was found to have a klebsiella urinary tract infection with urosepsis as well as arf cr from baseline he was initially admitted to the icu during his stay he developed worsening stridor per report he was started on solumedrol empirically he evaluated first with a chest neck ct which showed bronchomalacia but no obvious parenchymal disease a laryngoscopy performed by ent was negative by report he had bronchoscopy on the day of transfer which demonstrated moderate tracheal occlusion and significant edema in the proximal of the trachea extrinisc compression vs malacia rmsb with circumferential extrinsic occlusion at the orfice and lmsb narrowing there was moderate mucous but no endobronchial lesion or foreign body he had been treated with solumedrol and nebulizers but did not tolerate heliox by facemask he was transferred to for further management by interventional pulmonary past medical history cri baseline cr unknown etiology paroxysmal a fib htn pulm htn hypercholesterolemia dm hepatic steatosis osteroarthritis social history no significant tob use no drugs married family history non contributory physical exam pe vs fm gen obses man sitting upright slight resp distress audible stridor able to speak words skin slightly diaphoretic warm heent no jvd perrl op dry cor rrr no m r g pulm diffuse inspiratory stridor no audible rales abd obsese soft nt nd extr wwp no edema neuro grossly intact mae x pertinent results bronchoscopy at osh external compression of left main bronchus external compression of right main bronchus ct chest no evidence of external compression of the bronchi evidence of tracheobronchomalacia transthoracic echo conclusions the left atrium is dilated left ventricular wall thickness cavity size and systolic function are normal lvef regional left ventricular wall motion is normal the ascending aorta is mildly dilated there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen no evidence for endocarditis seen ct scan chest abdomen pelvis with contrast impression multilobulated right pleural based mass without significant enhancement local invasion or associated thoracic lymphadenopathy no primary neoplasm identified elsewhere within the torso this may represent post infectious sequelae mesothelioma nerve sheath tumor or metastatic disease from unknown primary if clinically indicated biopsy could be performed no significant change in distal sigmoid colonic wall thickening cholelithiasis without evidence of cholecystitis labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso atyps metas myelos nrbc am blood pt ptt inr pt pm blood pt ptt inr pt am blood fdp am blood fibrino am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood lipase am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood calcium phos mg am blood hapto am blood caltibc ferritn trf am blood ammonia am blood pth am blood type art po pco ph calhco base xs pm blood lactate pm blood freeca brief hospital course m initially transferred from osh for interventional pulmonary evaluation of worsening inspiratory stridor which was later identified as tracheobronchomalacia other issues included renal failure and metabolic derangement resolving mssa bacteremia his current issues include a pleural based lung mass anemia with occult positive stool infections hepatitis and paroxismal afib a pleural based mass please see attached ct reports this pleural based mass on the right was stable on his various ct scans radiology was concerned about it being a multilobulated right pleural based mass without significant enhancement local invasion or associated thoracic lymphadenopathy no primary neoplasm identified elsewhere within the torso this may represent post infectious sequelae mesothelioma nerve sheath tumor or metastatic disease from unknown primary if clinically indicated biopsy could be performed question as whether this is an old finding or a more recent one of note his respiratory status is stable on room air at time of transfer b tracheobronchomalacia copd on initial arrival patient had severe stridor concerning for urgent requirement of intubation however continuous bronchodilator treatment overnight induced near complete resolution of the stridor and urgent intubation was not required on hospital day two however pt was intubated for airway protection given continued poor mental status and underwent bronchoscopy at that time which revealed no airway stenosis or external compression without significant tracheobronchomalacia following stabilization pt was extubated and again required continuous bronchodilator therapy including racemic epinephrine as well as corticosteroids as empiric therapy for restrictive airway disease with ultimate resolution of stridor therefore it was felt that pt most likely had bronchospasm as a result of his metabolic derangement and renal insufficiency uremia he has been stable on room air for several days now with nebulizer treatments written prn the steroids are being tapered by mg of prednisone per day as his respiratory status has been stable and there is a concern for multiple infections including sigmoid colitis he is currently on mg c infections his wbc had trended down to about but has risen back up slowly to this can partly be attributed to the steroid treatment but also is concerning for infection ct scan showed sigmoid colitis please see attached reports we do not think this is ischemic colitis as he was ruled out with a normal lactate and bicarb of note he was occult blood positive and complained of abdominal pain especially when defecating he is being treated empirically for c diff antigen negative x thus far and for gram negative coverage with levoquin started today given his recent high doses of steroids and his colitis would have a low threshold for examining for free air if his abdominal pain worsens mssa bacteremia per report bottles at osh and started on nafcillin on though no positive surveillance cultures here remained hemodynamically stable no septic physiology and afebrile both tte and tee performed while intubated were negative for endocarditis no evidence for septic emboli on complete ct chest abdomen pelvis pt had initially complained of back pain on admission to osh however denied this when he arrived here so no search for epidural or paraspinal abscesses was made therefore the source remains unknown for this infection would continue the nafcillin for weeks concern about the right pleural based mass is does it represent an infectious source or malignancy see discussion above d acute on chronic renal failure creatinine fena no eos on smear and bland sediment from chronic renal insufficiency cr but was thought to have developed acute tubular necrosis though the etiology was unclear nevertheless uremia was felt to be the primary etiology of patient s poor mental status as well as partial contributor to bronchospasm patient did require phos binders his renal function has returned to it s original state with a cr of he was started in epoetin units sc qmwf e heptatitis no known hx liver disease hep serologies show hbsag hbsab hbcab hav ab igm hav negative positive positive positive hepatitis c serology hcv ab negative hep b e antigen antibodies were not evaluated during inpatient admission but should be followed his liver enzymes are remaining high at alt ast ld ldh alkphos totbili f anemia mild thrombocytopenia on coumadin though held throughout osh stay given ffp for central line placement no evidence of dic his warfarin is still being held but he has been continued on aspirin he had occult blood positive stool and gi was consulted and suggested follow up after infection in colon calms down his hct dropped to a low of and he was transfused two units of packed rbc would stop the asa if his bleeding continues warfarin is still being held g uti klebsiella uti at osh however negative ua ucx here felt to be resolved on arrival h coronary artery disease not active during this admission however continued asa lipitor but held beta blocker for concern of bronchospasm i paroxysmal atrial fibrillation remained in sinus for most of micu course with rbbb and lafb on the floor he was placed on telemetry and had multiple episodes a day of short lasting afib with tachycardia his diltiazem was increased to mg daily to help rate control him his warfarin is being held secondary to his bleeding and his occult positive stool gi consult here suggeted that he will need gi follow up when the infection clears will need to find out when to restart warfarin if origin of bleed remains unknown j dm glyburide discontinued given renal failure his sugars were quite high given the steroids and infections he is currently controlled to blood sugars in the s with nph at units am and pm and humalog units before meals in addition he had a sliding scale of humalog if needed the patient insisted on transfer back to hospital for the remainder of his acute hospitalization and ongoing care this request was discussed with his primary care physician at hospital who agreed to the transfer although a number of issues remain unresolved at the time of transfer they were communicated directly with dr to optimize continuity of care although the patient was stable at the time of transfer sitting in a chair without complaints eating conversing and feeling subjectively improved a number of diagnostic and therapeutic interventions remain pending in his clinical care medications on admission nafcillin g q h x weeks start solumedrol tid atrovent albuterol nebs heliox dilt po tid lopressor q morphine colace senna asa lipitor qd tylenol prn meds at home include coumadin mg qd glyburide mg discharge medications albuterol sulfate solution sig one inhalation q h every hours as needed docusate sodium mg capsule sig one capsule po bid times a day atorvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h every to hours as needed sevelamer mg tablet sig one tablet po tid times a day b complex vitamin c folic acid mg capsule sig one cap po daily daily albuterol mcg actuation aerosol sig puffs inhalation q h every to hours as needed ipratropium bromide mcg actuation aerosol sig six puff inhalation q h every to hours as needed racepinephrine solution for nebulization sig one ml inhalation q h every hours as needed epoetin alfa unit ml solution sig one injection qmowefr monday wednesday friday senna mg tablet sig tablets po bid times a day as needed for constipation magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed lactulose g ml syrup sig thirty ml po q h every hours as needed diltiazem hcl mg tablet sig two tablet po tid times a day insulin nph human recomb unit ml suspension sig five units subcutaneous twice a day metronidazole mg tablet sig one tablet po tid times a day prednisone mg tablet sig two tablet po daily daily levofloxacin mg tablet sig one tablet po q h every hours nafcillin in d w g ml piggyback sig two intravenous q h every hours pantoprazole mg recon soln sig one recon soln intravenous q h every hours discharge disposition extended care discharge diagnosis acute on chronic renal failure uremia with mental status changes acute bronchospasm reactive airways staphylococcus aureus bacteremia with unknown source sigmoid colitis pleural based mass on right mild thrombocytopenia discharge condition stable respiratory status stable on room air discharge instructions transfer to hospital under the care of dr please see discharge summary for specific instructions patient has foley cath in place followup instructions he will need follow up with nephrology for his chronic renal failure he will need follow up with gastroenterology for the occult blood in his stool and for resolution of his colitis completed by [NEW_RECORD] admission date discharge date date of birth sex m service orthopaedics allergies nsaids attending chief complaint transfered from hospital to evaluate bilateral leg weakness by spinal mri major surgical or invasive procedure epidural abscess debridement history of present illness yo spanish speaking male with a h o dm htn pulm htn af cri was transfered from hospital for an mri of his spine to evaluate for epidural abscess secondary to bilateral lower extremity weakness the physicians at hospital were concerned about cord compression or cauda equina syndrome and wanted him transfered to a hospital with a neurosurgical service backup he is also here for an mri despite the bullet logged in his buttocks to evaluate for these conditions he was recently discharged from back to hospital after evaluation for trachealmalacia which he did not seem to have his problem list includes recent bacteremia with an unknown source tee was negative and multiple ct scans of his abdomen and plevis were negative for abscess or mass pleural based mass and now complaining of bilateral lower extremity weakness of note one ct scan showed sigmoid colitis for which he is being treated with flagyl and ceftriaxone with his transfer paper work his wbc was noted to be with neutrophils currently he says he has pain in both legs right more than left he says that he can not stand up and walk and he feels weak he denies currently sob cp abdominal pain ha or change in vision past medical history bacteremia on nafcillin since cri baseline cr unknown etiology paroxysmal a fib htn pulm htn hypercholesterolemia dm hepatic steatosis osteroarthritis bilateral knee replacement bullet in buttocks social history no significant tob use no drugs married family history non contributory physical exam vs t bp p r o sat on l wt kg gen obese man lying in bed with sunglasses on in nad foley cath in place heent eomi perrl tachy mm clear op no lad cv heart sounds distant secondary to body habitus rrr normal s s no murmur heard lungs distant breath sounds but lungs sound ctab abdomen bs soft ntnd extremities edema in bilateral lower extremities neuro he can only just slightly move his legs left more than right against gravity patellar reflexes can not be elicited secondary to his bilateral knee replacements achilles tendons showed no reflexes but of note he is quite edematous and has a long history of dm no babinski reflex bilaterally unsure about sensation in his feet bilaterally given probably neuropathy but he does have sensation in his thighs bilaterally pertinent results mra brain findings multiple bilateral periventricular hyperintensities are noted on the flair images but there is no evidence of acute stroke on the diffusion weighted images on the mr angiography there is hypoplastic t segment on the right side with fetal pca which is a normal variant no evidence of stenosis or occlusion of vessels of circle of impression no acute infarct chronic microvascular disease mri t spine findings the study is extremely limited due to the extensive motion artifacts however there appears to be epidural abscess in the mid thoracic region which is however not clearly visualized due to the artifacts cord compression cannot be assessed due to the motion artifacts on the axial images there also appear to be pre and paraspinal soft tissue signal intensity abnormalities on the right and right paraspinal pleural based mass impression epidural abscess in the mid thoracic region cord compression not adequately assessed due to the motion artifacts right paraspinal pleural based soft tissue swelling recommend to repeat mri if possible for better evaluation findings were discussed with dr by dr on noon please note that the preliminary report is discrepant from the final report and the final report findings were conveyed to dr mri l spine findings there is evidence of degenerative disc disease with spinal canal stenosis at l l level and l level degenerative changes are also noted in the vertebral bodies there is linear enhancing tissue noted in the epidural region at t l level likely due to epidural abscess however the upper extent of this is not visualized on the l spine mri cord compression cannot be adequately assessed no pre or para vertebral soft tissue abnormality impression degenerative disc disease with associated lumbar spinal canal stenosis epidural abscess at t l level with superior extent not demarcated on the l spine mri please also see the thoracic spine mri report performed on the same day and dictated separately brief hospital course mr is a yo spanish speaking male with a history of bactermia with unknown etiology dmii afib chronic renal failure who was transfered to from hospital to evalute his bilateral le weakness with an mri of the spine on admission his nafcillin was continued for this first noted on at hospital the metronidazole and ceftriaxone were discontinued he was noted to have an extremely elevated ck rising to in the presence of acute on chronic renal failure he was given ivf with bicarb flush his kidneys through this he continued to make sufficient uop with foley cath in place the reason for this rhabdo is unknown at this time nephrology is following mri of the spine on showed possible epidural and paraspinal abscesses with questionable cord compression he was noted on physical exam to have no rectal tone orthopedics spine was consulted neurology is also consulted after coding in the or pt was transferred to the micu where he was maintained on pressors cvvh and ventilated on the decision was made to convert the patient to cmo and patient expired on at medications on admission docusate sodium mg capsule sig one capsule po bid times a day atorvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily sevelamer mg tablet sig one tablet po tid times a day b complex vitamin c folic acid mg capsule sig one cap po daily daily epoetin alfa unit ml solution sig one injection qmowefr monday wednesday friday diltiazem hcl mg tablet sig tablet po tid times a day insulin nph human recomb unit ml suspension sig five units subcutaneous twice a day metronidazole mg tablet sig one tablet po tid times a day prednisone mg tablet sig two tablet po daily daily ceftriaxone g iv q hrs nafcillin in d w g ml piggyback sig two intravenous q h every hours pantoprazole mg recon soln sig one recon soln intravenous q h every hours discharge medications n a discharge disposition extended care discharge diagnosis bacteremia paroxysmal afib acute on chronic renal failure cad htn dmii discharge condition expired discharge instructions n a followup instructions n a md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies nsaids attending addendum regarding prior discharge disposition pt was erroneously entered as going to an extended care facility however pt expired during this admission please make appropriate change to disposition discharge disposition extended care md completed by,"{
""date"": ""2019-12-10"",
""discharge_date"": ""2019-12-11"",
""service"": ""Medicine"",
""allergies"": ""NSAIDs"",
""attending_chief_complaint"": ""stridor"",
""chief_complaint"": ""stridor"",
""history_of_present_illness"": ""yo spanish speaking m hx dm htn pulm htn af transferred from hospital for further evaluation management of worsening stridor patient was initially admitted to osh on he presented complaining of back pain and dysuria and was found to have a klebsiella urinary tract infection with urosepsis as well as arf cr from baseline he was initially admitted to the icu during his stay he developed worsening stridor per report he was started on"
56985,admission date discharge date date of birth sex m service medicine allergies penicillins ciprofloxacin attending chief complaint fever major surgical or invasive procedure mechanical ventilation icu monitoring picc line placement x central line placement history of present illness mr is a year old male with a history of apml s p induction and consolidation chemotherapy who has been on a maintenance program with mp then methotrexate and atra who was found to have recurrent disease and was recently admitted for midam chemotherapy and discharged two days prior to admission the patient reports having really bad diarrhea two days prior to admission in the evening he had two more episodes of diarrhea on the evening prior to admission he has had some mild abdominal cramping discomfort but no abdominal pain he has had some intermittant nausea but no vomiting there is no blood in his stool he has also had pain near his anus for the past days which disappeared after he received his first antibiotic infusion in clinic today the patient came to clinic for routine labs today he was noted to be thrombocytopenic and received a platelet transfusion afterward his temperature rose to despite receiving acetaminophen prior he had blood cultures drawn both peripherally and from his picc line he received l normal saline and aztreonam mg iv infusion on arrival to the floor he was febrile to and vancomycin and flagyl were hung ros as above additionally notable for poor appetite and low energy which are stable since his chemo and some intermittant lightheadedness negative for headache recent vision or hearing changes runny nose sore throat cough shortness of breath chest pain palpitations brbpr dysuria rashes myalgias or arthralgias past medical history acute promyelocytic leukemia s p cholecystectomy irritable bowel syndrome history of hypercholesterolemia history of anal fissures social history negative for tobacco rarely drinks etoh he lives with his wife and yr old son owns a seafood company and is a former stock broker he has no known chemical exposures his only foreign travel is to he has a dog family history his father died of prostate cancer and also had dm and heart disease he has a cousin with cancer no known family with leukemia or lymphoma physical exam vs t bp hr rr on ra general middle aged caucasian male appears tired but comfortable heent sclerae anicteric perrl eomi oropharynx is clear no exudates or erythema no oral lesions mmm neck no cervical supraclavicular or axillary lymphadenopathy heart tachycardic regular rhythm normal s s no m r g lungs ctab no crackles wheezes or rhonchi abd soft obese ntnd no hsm appreciated rectal peri anal tissue with mild erythema near the anus but no obvious swelling bleeding or exudate no tenderness to palpation of the peri anal tissues extremities no edema dp pulses bilaterally right picc line with small amount of dried blood under dressing but no tenderness to palpation skin no rashes neuro alert and oriented x cnii xii grossly intact language appropriate moves all extremities symmetrically pertinent results course labs labs on admission to am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso atyps metas myelos pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili dirbili indbili pm blood type art po pco ph caltco base xs microbiology data blood blood culture routine final proteus vulgaris final sensitivities escherichia coli final sensitivities proteus vulgaris escherichia coli ampicillin r ampicillin sulbactam s cefazolin s cefepime s s ceftazidime s s ceftriaxone s s cefuroxime s ciprofloxacin s s gentamicin s s levofloxacin s meropenem s s piperacillin s piperacillin tazo s s tobramycin s s trimethoprim sulfa s r remaining blood cultures negative or no growth to date sputum mini bal no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final no growth gram stain final pmns and epithelial cells x field per x field gram negative rod s all other sputum cultures negative immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii urine all urine cultures negative peritoneal fluid pm peritoneal fluid gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture preliminary no growth anaerobic culture preliminary pending acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary pending fungal culture preliminary pending misc cmv viral load final cmv dna not detected imaging serial ct scans ct w contrast inflammation associated with the duodenum extending along the retroperitoneum findings most likely represent duodenitis perforated duodenal cannot be excluded although no extraluminal air is identified pancreatitis with secondary duodenal inflammation is less likely ct abd pelvis w o contrast study date of pm progressed appearance of inflammation with increased ascites stranding is seen around the duodenum right perinephric area and pancreas regarding pancreatitis or renal pathology recommend correlation with labs since this may be a secondary inflammatory process no conclusive evidence for perforation but given the inflammatory changes around the duodenum the appropriate clinical setting could consider a repeat scan in hours to evaluate for extravasation and perforation ct abdomen pelvis w o contrast study date of pm extensive inflammatory change in the peritoneum and retroperitoneum with free fluid and stranding as previously though no evidence of extraluminal leak of oral contrast increase of right pleural effusion ct abdomen pelvis w o contrast study date of progression of intra abdominal free fluid and minimal change in the overall degree of intra peritoneal stranding there is no evidence of extraluminal leak of contrast or obstruction progression of right lung effusion and tree in opacities which may be secondary to the diffuse process involving the abdomen though should be clinically correlated for possible infection in the setting of neutropenia ct torso w o contrast interval worsening of the consolidation of the bilateral lower lobes this finding may represent atelectasis however superimposed infection cannot be excluded there are small bilateral pleural effusions interval increase in the amount of ascites since the prior exam with a moderate amount now present ct abdomen pelvis w o contrast study date of persistent basilar left greater than right pulmonary consolidations this may represent atelectasis however superimposed pneumonia cannot be excluded small bilateral pleural effusions are improved mild jejunal wall thickening is non specific but could reflect opportunistic infection persistent moderate intra abdominal ascites with no evidence of loculated abscess formation unilat up ext veins us port left study date of thrombosis of the left basilic vein with no upstream extension hypoechoic well defined mass of the right forearm measuring cm differentials include thrmbosed superficial vein and soft tissue tumor most recent portable cxr there are low lung volumes which slightly limits assessment particularly in the lower lungs which have some associated volume loss ng tube is in the stomach right upper quadrant clips are present there is right ij line with tip in the svc there is no pneumothorax ct head new right frontal hemorrhagic contusion with probable small regions of adjacent subarachnoid hemorrhage known external soft tissue swelling no skull fractures close follow up as clinically indicated findings were discussed with dr on date of exam at a m this study done on at am is available for review on at am and wet rea dwas given to the physician as mentioned above small amount of fluid in the mastoid and petrous apices on both sides new since prior ct head no interval change to right frontal partially hemorrhagic contusion with small regions of adjacent subarachnoid hemorrhage f u a sindicated clinically other details above labs on discharge wbc hbg hct platelets coags pt ptt inr chem gluc bun crn na k cl hco brief hospital course in brief mr is a year old male with a history of apml s p multiple rounds of chemotherapy who recently underwent midam chemotherapy being treated with atra and was admitted with febrile neutropenia and diarrhea and found to have gnr sepsis and duodenitis febrile neutropenia gnr sepsis the patient was initially covered empirically with vancomycin aztreonam and flagyl with concern for a gi source given his recent diarrhea and history of anal fissures he had no respiratory or urinary symptoms on presentation and initial chest x ray was negative for pneumonia initial ct scan on was concerning for duodenitis and the patient s antibiotic regimen was broadened to include ciprofloxacin and micafungin and blood cultures from the previous day were positive for gram negative rods overnight the patient s lfts rose and he had multiple electrolyte abnormalities that were corrected intravenously surgery was consulted early on the morning of given continued fevers and worsening abdominal pain an abdominal ultrasound was obtained and showed no evidence of occlusive disease or intrahepatic duct dilatation the patient s lfts continued to rise during the day his inr and ptt also rose and additional labs were concerning for dic the patient was transfused with multiple units of platelets and also received prbcs ffp and vitamin k to try to correct his coagulopathy the patient had an episode of diarrhea on that consisted of black colored liquid he was placed on pantoprazole iv bid for gi bleeding a repeat ct scan in the evening with gastrograffin demonstrated increased inflammation but negative for duodenal perforation as his lactate was rising and his platelets remained very low despite several transfusions in the context of a neutrophil count of he was then taken to the for further management in route to the a ct abd was done which showed extensive inflammatory changes in the peritoneum and retroperitoneum the cause was unclear but thought perhaps to be related to his atra which was held surgery followed him and thought that there was no indication for surgical management repeat ct the following day showed progression of intra abdominal free fluid and minimal change in the overall degree of intra peritoneal stranding his abdomen continued to be distended and tender and he was increasingly short of breath and hypoxic he was eventually intubated for airway protection blood cultures grew proteus and e coli from he underwent meropenem desensitization followed by meropenem treatment empiric acyclovir at treatment doses was also started filgrastim was also started for neutropenia patient was followed by id and started had the following courses of antibiotics vanco linezolid metronidazole voriconazole neutropenia resolved as of patient was treated for a total of two weeks of vancomycin and meropenum following recovery of his counts on consequently last day of therapy was patient continued to have low grade fevers while on meropenum and vancomycin infectious work up involved mini bal negative gram stain multiple negative blood cultures and urine cultures negative b glucan and aspergillus c diff negative x diagnostic para negative gram stain and cultures negative lue dvt during the workup for the patient s fever on meropenem and vancomycin the patient was found to have dvt in the left upper extremity at the site of a picc patient was started on heparin drip and was initially started on coumadin but changed to lovenox low grade fevers felt to be secondary to clot and eventually resolved on the night of the patient fell standing up from the bed while on lovenox see below lovenox was discontinued the decision was made not to restart lovenox as the dvt was likely induced by the picc placement and small enough not to require long term anticoagulation respiratory distress the patient was intubated in the setting of abdominal distension and pain no obvious primary pulmonary process the patient was successfully extubated on using precedex thrombocytopenia initially related to the patient s recent chemotherapy he was initially transfused to keep his platelets k subsequently however he did not bump his platelets appropriately to transfusion likely as a result of dic and his acute illness and given his gi bleeding his transfusion threshold was increased once his acute illness resolved his platelet count was maintained over the next week without transfusions acute promyelocytic leukemia the patient was initially continued on atra per his home regimen however his dose was reduced to mg po bid on the morning of given the worsening of his acute illness in the atra was discontinued the patient was instructed to discuss restarting this medication with his primary oncologist dr on discharge subarachnoid hemorrhage in the setting of anticoagulation with lovenox the patient was given protamine and vitamin k head ct showed small subarachnoid hemorrhage and neurosurgery was consulted repeat head ct the following day did not show change in the hemorrhage neurosurgery recommended maintaining platelet count and if should repeat head imaging the patient should follow up with dr in weeks with repeat head ct at that time history of anal fissures the patient was continued on analpram dysuria no evidence of uti on ua or urine cultures started following discontinuation of foley catheter most likely traumatic in nature used lidojet and pyridium for symptomatic relief medications on admission docusate sodium mg hydrocortisone pramoxine analpram hc cream apply prn anal fissure lorazepam mg q h prn anxiety nausea nystatin unit ml suspension ml qid prn thrush oxycodone mg po q h prn pain caphosol cc po qid prn mouth sores sennosides mg prn constipation atra mg po qam mg po qpm discharge medications colace mg capsule sig one capsule po twice a day as needed for constipation analpram hc cream sig one rectal once a day as needed for pain nystatin unit ml suspension sig five ml po qid times a day as needed for mouth pain thrush ativan mg tablet sig tablets po every four hours as needed for anxiety oxycodone mg tablet sig one tablet po q h every hours as needed for pain saliva substitution combo no solution sig one ml mucous membrane qid times a day as needed for mouth sores senna mg capsule sig one capsule po twice a day as needed for constipation heparin flush units ml ml iv prn line flush picc heparin dependent flush with ml normal saline followed by heparin as above daily and prn per lumen ursodiol mg capsule sig one capsule po tid times a day disp capsule s refills acyclovir mg capsule sig two capsule po q h every hours disp capsule s refills fluconazole mg tablet sig two tablet po q h every hours disp tablet s refills phenazopyridine mg tablet sig one tablet po tid times a day for days disp tablet s refills famotidine mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home with service facility discharge diagnosis primary diagnoses gram negative rod bacteremia acute hepatitis from drug toxicity duodenitis colitis acute promyelocytic leukemia subarachnoid hemorrhage deep vein thrombosis of the upper extremity secondary diagnoses hypercholesterolemia s p cholecystetomy discharge condition the patient was afebrile and hemodynamically stable prior to discharge discharge instructions you were admitted to for evaluation of abdominal distension you were found to have an infection in your bowel that infected your blood stream you had a complicated hospital course where you were treated with iv antibiotics for many days you had to be intubated and maintained on a mechanical ventilator for a period of time because of your illness you were weaned off the ventilator and worked with physical therapy to regain your strength your antibiotics were discontinued and you will only need to continue on antibiotics for prophylaxis as an outpatient you will need to follow up closely with your primary oncologist medication changes start ursodiol mg times a day start acyclovir mg capsule two capsules every hours start fluconazole mg tablet two tablet every day start famotidine mg twice a day start phenazopyridine mg tablet times a day as needed for pain with urination for days stop atra please discuss with dr when to restart this medication if you experience chest pain fevers shortness of breath abdominal pain diarrhea constipation worsening pain with urination or any other concerning symptoms please seek medical attention completed by,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Medicine"",
""allergies"": [
""Penicillins"",
""Ciprofloxacin""
],
""attendingChiefComplaint"": ""Fever"",
""chiefComplaintHistory"": [
""Fever""
],
""chiefComplaintDetails"": [
""Fever""
],
""historyOfPresentIllness"": [
""Mr. [**Known lastname 1081**] is a year old male with a history of apml s p induction and consolidation chemotherapy who has been on a maintenance program with mp then methotrexate and atra who was found to have recurrent disease and was recently"
11597,admission date discharge date date of birth sex f service history of present illness the patient is a year old woman with a history of diabetes hypertension elevated cholesterol chronic renal insufficiency and known three vessel coronary artery disease not amenable to percutaneous intervention who is transferred from an outside hospital with transfer from an outside hospital with elevated finger stick blood sugars and diabetic ketoacidosis with an evolving non st elevation myocardial infarction with elevated troponin in cks the patient s symptoms began three days prior with nausea and vomiting no associated chest pain shortness of breath lightheadedness dysuria urinary frequency bright red blood per rectum no sick contacts dietary indiscretion the patient s symptoms persisted until she presented to hospital on and was found to have finger stick blood sugars in the s with an anion gap of and ketones in her urine and small acetone in her blood the patient was treated with dka with intravenous fluids and an insulin drip routine check of her ck and troponin noted elevation in troponin the patient was transferred here for cardiac evaluation past medical history coronary artery disease status post left circumflex stent in cardiac catheterization on revealed left anterior descending coronary artery with diffuse disease left circumflex with diffuse disease right coronary artery with occlusion with left to right collaterals pulmonary capillary wedge pressure of left ventricular and diastolic pressure cardiac output ejection fraction with mitral regurgitation and anterolateral apical inferior and posterior basal hypokinesis diabetes times forty years complicated by gastroparesis hypertension elevated cholesterol cholelithiasis chronic renal insufficiency with recent baseline creatinine of to allergies codeine medications at home lopressor mg po b i d cardizem cd mg po q d univasc mg po b i d nph insulin units in the morning and units in the evening regular insulin sliding scale enteric coated aspirin mg po q day family history notable for coronary artery disease and diabetes social history the patient denies alcohol and tobacco she lives with her son and daughter physical examination on admission temperature pulse blood pressure respiratory rate o sat on room air general appearance the patient is awake alert and in no acute distress heent no jvd cardiovascular regular rate and rhythm normal s and s no murmurs lungs clear to auscultation bilaterally abdomen soft nontender obese with decreased bowel sounds extremities no edema distal pulses neurological examination was nonfocal admission laboratory studies on at the outside hospital white blood cell count hematocrit platelets sodium potassium chloride bicarbonate bun creatinine glucose ck troponin liver function tests notable for ast alt alkaline phosphatase amylase lipase urinalysis revealed ketones greater then glucose to white blood cells to red blood cells electrocardiogram from the outside hospital showed sinus tachycardic at beats per minute normal axis and normal intervals elevations in leads f v through v with a q wave in lead and avf st depressions in leads and avl also with st depressions in v through v with a t wave inversions in v and v this was not significantly changed from electrocardiogram on hospital course cardiovascular the patient with known coronary artery disease with three vessel disease with recent cardiac catheterization to define anatomy considered not amenable to cutaneous intervention or coronary artery bypass graft currently the patient was medically managed for a non st elevation myocardial infarction likely the precipitant for or the result of her diabetic ketoacidosis during this hospitalization the patient was continued on aspirin and plavix was added for greater antiplatelet activity she was continued on lopressor and was started on isordil zocor and continued on her univasc her cardiac regimen was maximized during her hospital stay patient with known ejection fraction of to with diastolic dysfunction the patient had no clinical evidence of congestive heart failure although she did have som e mild lower extremity edema on the day prior to discharge the patient received mg of intravenous lasix in the setting of her blood transfusions and diuresed approximately cc and was approximately cc negative for the day she was not discharged home on lasix as she has never been on standing lasix in the past following the patient s acute presentation with a non st elevation myocardial infarction and known disease not amenable to intervention the patient received hours of heparin and integrilin her hematocrit remained stable during that time and it was discontinued on as noted a cardiac catheterization was not repeated during this hospitalization given recently defined anatomy the patient had no episodes of chest pain or shortness of breath during this hospital stay renal patient with a chronic renal insufficiency with a prior baseline creatinine of approximately however over the last several months including her most recent hospitalization the patient s creatinine has been higher in the to range the patient s creatinine remained relatively stable at about during this hospitalization she has already been seen in follow up by dr in the nephrology department at the and she has a follow up appointment scheduled with him in several weeks given her likely diabetic nephropathy she was continued her univasc she would likely benefit from erythropoietin given probably anemia of chronic disease endocrine the patient presented with diabetic ketoacidosis it is unclear what the trigger was whether it preceded or was secondary to myocardial infarction the patient was started on an insulin drip and given aggressive intravenous fluids at the outside hospital the patient was continued on that regimen here at the on and on the patient s anion gap had closed and she was starting to take po with finger stick blood sugars in the s to s on the patient s insulin drip was turned off the patient was restarted on her prior dose of nph her nph dose was increased slightly from and at the time of discharge to account for required regular insulin over the prior day the patient should follow up with dr at the diabetes center gastrointestinal patient with a history of gastroparesis as documented by recent gastric emptying study she had no nausea or vomiting she was started on reglan and will be discharged on this medication she has gastrointestinal follow up scheduled later this month patient also with a history of cholelithiasis with no acute symptoms during this hospitalization hematologic the patient was noted to have a drop in her hematocrit after initial presentation from approximately to without any evidence of acute bleed she had no hemodynamic instability hematocrit remained stable at approximately to throughout her hospital stay her initial anemia workup was suggestive of anemia of chronic disease she was transfused one unit of packed red blood cells on the day prior to discharge and her hematocrit bumped appropriately to the patient had a normal reticulocyte count b and folate studies were pending at the time of discharge infectious disease the patient was noted to hve a superficial infection of a right antecubital intravenous site following its removal she received daily betadine dressings and application of by gauze pads the patient should continue this care at home and should return should she develop fevers or chills or worsening erythema or pain at this site prophylaxis the patient was out of bed and maintained on protonix during this hospitalization she was cleared by physical therapy prior to discharge and will be seeking cardiac rehab at hospital discharge condition stable discharge diagnoses non st elevation myocardial infarction chronic renal insufficiency type diabetes diabetic ketoacidosis gastroparesis anemia hypertension hypercholesterolemia medications on discharge univasc mg po b i d lopresor mg po t i d nph insulin units subq q a m units subq q p m regular insulin sliding scale plavix mg po q day welchol mg three tabs po b i d zocor mg po q day isordil mg po t i d protonix mg po q d cardizem cd mg po q day enteric coated aspirin mg po q d reglan mg po q i d follow up the patient should follow up with her primary care physician in warim the patient has a follow up scheduled with dr in nephrology later this month the patient should follow up with dr at the diabetes center the patient should follow up with cardiologist dr in two weeks the patient will pursue cardiac rehab at hospital with patient to call to arrange m d dictated by medquist d t job,"{
""name"": ""Patient 1211"",
""date"": ""2019-10-10"",
""sex"": ""Female"",
""service"": ""MICU"",
""admission_date"": ""2019-10-10"",
""discharge_date"": ""2019-10-13"",
""date_of_birth"": ""2019-10-10"",
""service_history"": [
""History of Present Illness:  The patient is a year old woman with a history of diabetes, hypertension, elevated cholesterol, chronic renal insufficiency, and known three vessel coronary artery disease not amenable to percutaneous intervention who is transferred from an outside hospital with elevated finger stick blood sugars and diabetic keto"
6912,admission date discharge date date of birth sex f service medicine allergies pitocin attending chief complaint cardiac arrest major surgical or invasive procedure placement of intracranial pressure monitor history of present illness y o f months post partum who was in her usual state of health this am when she laid down on the couch per husband pt had been up all night with their new baby and told him she was going to lay down no complaints at that time she was watching television and then he saw her roll off the couch to the floor she was unresponsive and gasping for breath he could not feel a pulse he called but didn t do cpr because she was breathing on her own he says that seconds before the paramedics arrived she stopped breathing when they arrived she was in vf arrest she was defibrillated x and then was in asystole given epi x and was then in sinus tach she was intubated and per the osh report they suctioned cc of gastric contents from her ett she was taken to where a head ct was negative and she was begun on a lidocaine gtt her tox screen was negative there she was then transferred here for further maanagement in the ed at patient had a cta chest negative for pe a second ct head that was negative due to fever to vanc levo flagyl was given patient had copious respiratory secretions a right ij was placed she also received about l ivf past medical history h o palpitations unclear history first noted about years ago was seen by cardiologist in now resolved depression ptsd months post partum social history lives with husband was previously in care smokes ppd no etoh denies any drugs h o care and abuse family history brother has htn physical exam pe t tm bp hr rr o gen intubated obese caucasian female not responsive to pain heent perrl no corneal reflex no gag neck supple cv tachy s s lungs sound junky bilateral abd obese nt nd bs ext no edema pertinent results wbc pmns bands lymphs monos hct plt na k cl co bun cr glu ca mg phos ck mb trop mri head impression diffuse cerebral edema with slow diffusion along the cerebral cortices bilaterally and in the basal ganglial region indicative of diffuse anoxic injury mra of the head impression somewhat prominent vascular structures could be related to increased intracranial pressure no evidence of vascular occlusion or stenosis is seen echocardiogram the left ventricular cavity size is normal there is severe global left ventricular hypokinesis with some preservation of basal lateral and basal posterior wall motion overall left ventricular systolic function is severely depressed ct head impression no intracranial hemorrhage or mass effect opacified paranasal sinuses which could be exacerbated by endotracheal tube brief hospital course a p y o f months post partum with h o palpitations futher history unknown admitted following a vf arrest at home of unknown etiology developed severe anoxic brain injury cardiac arrest the was admitted to the micu with stable bp in sinus tachycardia the event was judged to be likely resulting from post partum cardiomyopathy echocardiogram confirmed depressed cardiac function the pt remained in sinus tachycardia without further events neuro the pt remained unresponsive following since hospitalization there was concern for brain injury from cardiac arrest the pt s neurological exam deteriorated on hd and hd she developed extensor posturing she was unable to demonstate any signs of awareness off of sedation ct scan showed evidence of increased intracranial pressure a cranial bolt was placed by neurosurgery for icp monitoring icp remained elevated to s with elevations to s when the pt seized she was treated with ativan for seizures dilantin prophylaxis was started neurology consultants and primary team agreed that prognosis was severe irreversible brain injury with no prospect for recovery of awareness discussions with the health care proxy were held discussions with the family included involvement of the organ donation protocol which it was felt that the pt would have clearly wanted by it was felt that the pt s icp had stabilized without further expected progression to brain death the decision was reached with the health care proxy that the pt would not have wanted to be kept artificially on mechanical repiration she was taken off of the ventilator on and passed away within hours respiratory failure the pt was intubated during the vf arrest there were patchy infiltrates bilaterally on the cxr c w aspiration the pt was treated with levo flagyl medications on admission none discharge disposition expired discharge diagnosis cardiac arrest anoxic brain injury discharge condition deceased discharge instructions none followup instructions none,"{
""name"": ""Ms. [**Known lastname 1051**]"",
""date of birth"": ""2014-10-28"",
""sex"": ""Female"",
""service"": ""Medicine"",
""allergies"": [
""Pitocin""
],
""admission date"": ""2015-02-28"",
""discharge date"": ""2015-03-01"",
""date of death"": ""2015-03-01"",
""history of present illness"": ""admission date discharge date date of birth sex f service medicine allergies pitocin attending chief complaint cardiac arrest major surgical or invasive procedure placement of intracranial pressure monitor history of present illness y o f months post partum who was in her usual"
18113,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint hcc with vascular invasion transferred from icu major surgical or invasive procedure multiple paracenteses history of present illness year old man with pmh of hcv cirrhosis and hcc with vascular involvement with several admissions recently for hyponatremia and ams he presented to the ed at gsh with presyncope and hypotension while at commode and was given l ns and g ceftriaxone he had a recent discharge on at which time he had been admitted for presyncope sbp pleurex catheter infection and encephalopathy the patient has been known to not take his lactulose as prescribed in the ed here he was given levo and vanco peritoneal fluid was sent and gram stain came back with gram cocci in clusters pairs chains and yeast he was admitted to the icu in the icu he was given l of fluids and required a levophed drip and vasopressin he also received units of prbcs the pleurex catheter was removed and the site sutured oncology saw the patient and he is considered terminal he was deemed a poor prognosis and thus not a candidate for liver transplant and also not candidate for chemo or radiation he was also hypothermic on arrival to the icu past medical history hepatocellular carcinoma diagnosed in after f u labs for cirrhosis revealed an elevated afp and imaging studies revealed infiltrative hcc with portal vein thrombosis not amenable to transplant given size of lesion not a candidate for chemoembolization given portal vein thrombus not a candidate for systemic chemotherapy given hepatic decompensation and refractory ascites followed by dr in oncology who has had multiple discussions with patient regarding his limited treatment options has met with from palliative care hepatitis c per pt hepc from experimentation with ivdu x as a teen cirrhosis approximatly years s p palliative pleurex catheter drain drains l ascitic fluid q h s p cholecystectomy social history lives in with wife children and grandchildren works as ortho tech prior heavy etoh use nips and beers day last drink years ago cigarette day family history significant for maternal uncle who died of an unknown cancer his mother and father are both alive and well his mother does have asthma and cad she is status post a four vessel cabg his father s medical history is unknown he has a brother with heart disease and another brother who died of cirrhosis there is no other liver cancer that he knows of in the family physical exam vs t bp hr rr glucose weight kg general intensely jaundiced having liquid stools hostile and verbally agressive refused to talk until his wife was present heent marked scleral icterus somewhat disheveled chest crackles at bases cv rrr sem abdomen very distended positive fluid wave pleurez site c d i with stitches extremities trace edema mental status hostile verbally agressive pertinent results am lactate am type comments not specif am pt ptt inr pt am anisocyt macrocyt am neuts lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am albumin calcium phosphate magnesium am lipase am alt sgpt ast sgot alk phos amylase am estgfr using this am glucose urea n creat sodium potassium chloride total co anion gap am ascites wbc rbc polys lymphs monos plasma mesotheli macrophag other am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am cortisol am albumin calcium phosphate magnesium am alt sgpt ast sgot ld ldh alk phos tot bili am glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm type art temp po pco ph total co base xs intubated not intuba pm lactate pm urine amorph few pm urine rbc wbc bacteria few yeast none epi pm urine blood neg nitrite neg protein neg glucose neg ketone tr bilirubin mod urobilngn neg ph leuk tr pm type art temp po pco ph total co base xs intubated not intuba pm lactate pm o sat pm hct pm type mix comments collected pm o sat pm cortisol pm hct pm pt ptt inr pt pm type art temp po pco ph total co base xs intubated not intuba pm type art temp po pco ph total co base xs intubated not intuba pm cortisol at discharge complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct am renal glucose glucose urean creat na k cl hco angap am enzymes bilirubin alt ast ld ldh ck cpk alkphos amylase totbili dirbili indbili am ruq u s no intra or extra hepatic biliary ductal dilatation cirrhotic liver with poorly defined hypoechoic lesion better seen on prior exam thrombus is again seen within the main portal vein large amount of ascites micro peritoneal fluid gram stain no pmns gpc in pairs chains and clusters budding yeast w pseudohyphae culture grew cns oxacillin r albicans vanco sensitive enterococcus blood cx ngtd urine cx ngtd blood cx ngtd blood cx ngtd stool cx neg for cdiff stool cx neg for cdiff peritoneal fluid gram stain pmns no microorgs peritoneal fluid cultures pending imaging cxr evidence of prior granulomatous insult as previously noted no focal acute pulmonary process v q scan low prob for pe ct head no evidence of acute intracranial hemorrhage brief hospital course yo m with hcv cirrhosis and infiltrative hcc with portal vein thrombosis admitted with ams and hypotension syncope sbp diagnosed w sbp on originally treated w ctx vanco and caspo in the icu then changed caspo to fluconazole changed back to caspo on sensitivities on cns and enterococcus returned on and both are sensitive to vanco so the patient was continued on vancomycin and caspofungin for d course but ctx was d c repeat parecentesis showed an improvement in sbp hcc given invasion into portal vein not a candidate for radiation or chemotherapy his prognosis is extremely poor and his life expectancy one month or less oncology followed the patient in the micu and on the floor the family was not open to a palliative care consult or hospice arf concerning for hrs and or prerenal etiology he received l in the unit and urine na was so he likely he has hepatorrenal syndrome he was tried on midodrine and octreotide w improvement in cr to so meds were d c on however cr up to on so we restarted midodrine and octerotide cr continuing to rise up to on in spite of treatment this is likely a trminal stage of his hepatorrenal disease in spite of medication and optimum fluid management non anion gap metabolic acidosis ag of normal is mostly due to his low bicarbonate bicarb ranged most likely related to his renal failure fluid resuscitation with normal saline as his diarrhea had improved altered mental status pt had no asterixis on exam but ams was most likely due to hepatic encephalopathy his mood remained very labile and on one occasion the patient almost hit his wife pruritus worsened and the patient was requiring almost around the clock hydroxyzine which might have contributed to his sleepiness and mood changes the patient was continued on lactulose and rifaximin he never required restraints or sitters anemia hct remained in the high s and his labs were consistent with anemia of chronic disease esld hcv not transplant candidate hcc with vascular involvement his tbilirubin remained very elevated and his coagulation profile worsened albumin and platelets remained stable meld he was continued on ursodiol and started on cholestyramine for improvement of pruritus fen regular diet no ivf checked lytes daily repleted prn access pac ppx pneumoboots ppi bowel regimen lactulose code full dispo home with services medications on admission medications on transfer nystatin oral suspension ml po qid prn swish and swallow ceftriaxone gm iv q h octreotide acetate mcg sc q h diphenhydramine mg po q h prn itching pantoprazole mg iv q h fluconazole mg iv q h rifaximin mg po tid heparin flush port units ml ml iv daily prn ml ns followed by ml of units ml heparin units heparin each lumen daily and prn sarna lotion appl tp prn ipratropium bromide neb neb ih q h prn wheezing ursodiol mg po tid lactulose ml po tid vancomycin hcl mg iv q h midodrine mg po tid discharge medications rifaximin mg tablet sig one tablet po tid times a day lactulose g ml syrup sig forty five ml po tid times a day cholestyramine sucrose g packet sig one packet po bid times a day disp packet s refills ursodiol mg capsule sig two capsule po bid times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours camphor menthol lotion sig one appl topical times a day as needed hydroxyzine hcl mg tablet sig tablets po q h every hours as needed for pruritus disp tablet s refills simethicone mg tablet chewable sig one tablet chewable po tid times a day as needed for abdominal bloating disp tablet chewable s refills hospital bed hospital bed with air mattress commode commode port a cath please provide port a cath care as per neht protocol caspofungin mg recon soln sig thirty five mg intravenous once a day disp doses refills morphine concentrate mg ml solution sig mg po q min prn as needed for shortness of breath or wheezing disp ml refills ativan mg tablet sig tablets po q h as needed for agitation disp tablet s refills discharge disposition home with service facility vna discharge diagnosis primary diagnosis polymicrobial sbp acute renal failure hrs hemoptysis secondary diagnosis hep c cirrhosis hcc esld discharge condition fair waxing and mental status but bp and hr stable discharge instructions you were admitted after an episode of fainting and hypotension you were found to have spontaneous bacterial peritonitis with multiple different organisms and were in the icu you also had problems with hepatorenal syndrome causing renal failure hypotension requiring pressors and hemoptysis requiring multiple blood transfusions you were transferred out to the floor once you were hemodynamically stable on the floor you continued to have worsening renal failure your creatinine improved initially and treatment of hrs was stopped however your creatinine worsened and you were restarted on octreotide and midodrine you underwent several more paracenteses on the floor the decision was made to try to bring you home and have you bridge to hospice care when needed please take all medications as prescribed please call dr or go to the er if you develop any of the following symptoms fever chills shortness of breath difficulty breathing worsening mental status chest pain swelling increased abdominial distensions or any other worrisome symptoms p followup instructions please call your vna or hospice nurse with any questions or concerns you can also call dr in the liver center with any questions [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint hypothermia major surgical or invasive procedure none history of present illness this is a yom with hepatitis c cirrhosis and hepatocellular carcinoma with a recent admission for hypotension in the setting of polymicrobial sbp discharged home with bridge to hospice returns days following discharge with worsening abdominal distention he underwent multiple therapeutic paracenteses during his last hospitalization and his ascites began progressively worsening since discharge there was plan for therapeutic paracentesis as an outpatient on monday but he wife became increasingly concerned and brought him to the ed during his last hospitalization he was found to have polymicrobial sbp with heavy growth of enterococcus coag negative staph and sparse candidal growth he completed a course of vancomycin and was discharged home on caspofungin to be continued indefinitely his creatinine also rose to a max of and was attributed to hepatorenal syndrome he was placed on midodrine and octreotide without improvement in his renal function thus it was decided to discontinue these medications prior to discharge in discussion with family it was decided to send the patient home with bridge to hospice he was discharged off diuretics on medications to control his pruritis caspofungin and morphine and ativan for comfort in the ed the pts vitals were t c p bp s s r sat ra he was found to be hypothermic to f with sbp of he was given vanc ctx and transferred to the micu past medical history hepatocellular carcinoma diagnosed in after f u labs for cirrhosis revealed an elevated afp and imaging studies revealed infiltrative hcc with portal vein thrombosis not amenable to transplant given size of lesion not a candidate for chemoembolization given portal vein thrombus not a candidate for systemic chemotherapy given hepatic decompensation and refractory ascites followed by dr in oncology who has had multiple discussions with patient regarding his limited treatment options has met with from palliative care hepatitis c per pt hepc from experimentation with ivdu x as a teen cirrhosis approximatly years s p palliative pleurex catheter drain drains l ascitic fluid q h s p cholecystectomy social history lives in with wife children and grandchildren works as ortho tech prior heavy etoh use nips and beers day last drink years ago cigarette day family history significant for maternal uncle who died of an unknown cancer his mother and father are both alive and well his mother does have asthma and cad she is status post a four vessel cabg his father s medical history is unknown he has a brother with heart disease and another brother who died of cirrhosis there is no other liver cancer that he knows of in the family physical exam vitals t bp p r sat ra gen chronically ill appearing aam lying in bed with bear hugger somnolent opens eyes to loud voice slurred speech heent conjunctivae jaundiced neck supple no lad no thyromegaly chest ctab no wheezes or rhonchi cv rrr normal s s no m g r abd distended soft fluid wave mild ttp diffusely ext pitting edema bl le skin diffuse maculopapular rash over legs and abdomen neuro somnolent pertinent results pm k pm pt ptt inr pt pm lactate pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos amylase tot bili pm lipase pm neuts lymphs monos eos basos pm plt count brief hospital course the pt was admitted to the icu with hypothermia to f and hypotension with sbp in the s upon further discussion with the family the pt was made cmo and decision for comfort measures was made it was discussed that further aggressive measures such as dialysis central line placement and central line placement would not result in any benefit to his care it was agreed that he should be made comfortable as had already been discussed with the palliative care team following his last admission he was given iv morphine boluses prn received mg total for comfort in the setting of abdominal pain pressure his o sats dropped to the s and respirations ceased he passed within hrs of admission into the icu likely due to sepsis pts wife and family were at the bedside at the time of death medications on admission rifaximin mg tid lactulose ml tid cholestyramine sucrose g ursodiol mg pantoprazole mg camphor menthol lotion prn hydroxyzine hcl mg po q h prn simethicone mg tid prn caspofungin mg iv qdaily morphine concentrate mg ml solution mg po q min prn as needed for shortness of breath or wheezing ativan mg po q h as needed for agitation discharge medications none discharge disposition expired discharge diagnosis death discharge condition expired discharge instructions none followup instructions none,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-13"",
""date_of_birth"" : ""2048-10-10"",
""sex"" : ""Male"",
""service"" : ""Medicine"",
""allergies"" : ""Penicillins"",
""attending_chief_complaint"" : ""HCC with vascular invasion"",
""chief_complaint"" : ""Presyncope"",
""history_of_present_illness"" : ""Year old man with PMH of HCV cirrhosis and HCC with vascular involvement with several admissions recently for hyponatremia and ams he presented to the ED at GSH with presyncope and hypotension"
95770,admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint shortness of breath x weeks major surgical or invasive procedure cardiac catheterization with bare metal stent to the right coronary artery history of present illness patient is a year old female with a past medical history of diabetes who presented to her pcp s office earlier today with worsening doe x weeks an ecg done at the pcp s office showed old inferior q waves with new st elevations in ii iii avf she was taken to bidn where labs at notable for ck and trop at noon today on arrival to the ed there her initial vitals were o sat r a bp hr and she was becoming increasingly dyspneic she was started on a heparin and integrillin gtt given plavix mg aspirin metoprolol iv and transferred to for urgent catheterization in the cath lab patient was increasingly tacypneic and was thus intubated prior to the procedure there was a occlusion of the rca and a bms was placed over this lesion she also had a diag mid lad mid lcx right heart cath notable for a pcwp pa oressures she was given mg iv lasix and transferred to the ccu intubated on review of systems she denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools she denies recent fevers chills or rigors she denies exertional buttock or calf pain all of the other review of systems were negative cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history psoriatic arthritis depression niddm macular degeneration past surgical history appendectomy bilateral vein ligation and right knee surgery s p right breast partial masectomy social history social history pt lives alone has daughter in was previously independent no history of smoking alcohol drugs as per osh documentation patient intubated here family history family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam admission pe vs intubated on fio general nad intubated heent ncat neck supple cardiac rr normal s s no m r g lungs anterior lung fields clear to ausculation b l abdomen soft nondistended bs extremities no le edema warm well perfused with soft cast on r leg skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt general yo f in no acute distress heent no lymphadenopathy jvp non elevated chest crackles bibasilar from prior cv s s normal in quality and intensity rrr abd soft non tender non distended bs normoactive ext wwp no edema dps pts neuro cns ii xii intact strength in u l extremities gait wnl skin no rash psych alert oriented fair understanding of medical condition pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt am blood pt inr pt pm blood glucose urean creat na k cl hco angap pm blood na k cl am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood ck mb ctropnt pm blood ck mb am blood ck mb ctropnt pm blood calcium phos mg am blood calcium phos mg cholest pm blood calcium phos mg pm blood calcium phos mg am blood hba c eag am blood triglyc hdl chol hd ldlcalc pm blood type art temp rates tidal v peep fio po pco ph caltco base xs aado req o assist con intubat intubated pm blood type art temp rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated d c labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood ck cpk am blood calcium phos mg pm blood calcium phos mg am blood calcium phos mg studies echo left ventricular wall thicknesses are normal the left ventricular cavity is dilated overall left ventricular systolic function is severely depressed lvef secondary to extensive apical akinesis inferior posterior akinesis and septal akinesis with focal dyskinesis the right ventricular free wall thickness is normal right ventricular chamber size is normal with borderline normal free wall function intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation there are focal calcifications in the aortic arch the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate to severe tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion cath final diagnosis three vessel coronary artery disease severe diastolic ventricular dysfunction inferior wall stemi acute occlusion at the level of mid rca successfully treated with a bare metal vision stent x mm brief hospital course assessment plan year old female with a past medical history of diabetes who presented to her pcp s office with worsening doe x weeks found to have st elevations in inferior leads and now s p bms to mid rca vessel disease on cath acute systolic chf a post cath echo showed that the patient had an ef of with apical septal poterior ak and focal dk also has tr and mr than being an acute change her poor heart function was though to be a more chronic progression over thelast few months this is consistent with the patient s description of nhya class symptoms at home the patient initially had crackles on exam that improved during the hospitalization as well as no peripheral edema initially the patient was very tachypneic during the cath and was intubated she also received mg iv lasix at the time and made good urine her respiratory status continued to improve as fluid was taken off the patient did no have an oxygen requirment on discharge and was sent home on torsemide mg daily the patient was also medically optimized for her chf and started on metoprolol atorvastatin and her home lisinopril dose was increased she was also started on spironolactone the patient should have a repeat echo in about one month to assess for any changes in her heart failure now that she has been started on a heart failure medication regimen inf mi the patient was found to have old q waves in the inferior leads as well as new st elevations in ii iii and avf the patient did not make troponins with peak being she was taken to the cath lab and found to have a occlusion of the rca and a bms was placed over this lesion she also had a diag mid lad mid lcx other vessels not stented because of distal nature of occlusions the patient was started on asa mg as well as plavix mg for at least one month post procedure the patient was continued on integrillin drip for hours the patient was found to have an a c of her lipid panel showed tc tg hdl and ldl of the patient was started on atorvastatin mg daily elevated wedge respiratory status pt was increasingly tachypneic prior to cath and was intubated on assist control with tv cc resp rate peep on fio also found to have right heart cath notable for a pcwp pa oressures she was given mg iv lasix and transferred to the ccu intubated right heart cath notable for a pcwp pa oressures she was given mg iv lasix and transferred to the ccu intubated the patient was extubated the next morning and diuresis was continued and her respiratory status continued to improve the patient was discharged on torsemide and was instructed to follow up labs as an outpatient htn the patient s home dose of lisinopril was increased from mg daily to mg daily and she was started on metoprolol mg that was later transitioned to mg of metoprolol succinate daily the patient was also started on spironlactone daily diabetes type the patient was taken metformin at home it was held during the hospitalization and she was kept on humalog sliding scale while in patient she required minimal amounts of insulin and a c was found to be she was discharged on her home dose of metformin psoriatic arthritis the patient was continued on her home dose of methotrexate she has a rheumatologist at nwh who follows her depression mood disorder the patient is followed by outpatient psychiatrist her lithium and effexor were initially held but then restarted after she was extubated the patient had a lithium level that was checked which was normal transitional issues the patient will need to have her lytes checked on and have her results faxed to her primary care doctor s office the patient will need to have a repeat echo done as she has been started on medications for her heart failure medications on admission lisinopril mg po daily metformin mg po bid methotrexate mg tabs tabs by mouth once weekly folic acid mg po daily effexor mg po tid lithium mg tabs tabs by mouth mg total managed by dr discharge medications clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills folic acid mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet sig one tablet po daily daily disp tablet s refills spironolactone mg tablet sig tablet po daily daily disp tablet s refills venlafaxine mg tablet sig one tablet po tid times a day lithium carbonate mg capsule sig two capsule po bid times a day metformin mg tablet sig one tablet po bid times a day lisinopril mg tablet sig one tablet po daily daily disp tablet s refills metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day disp tablet extended release hr s refills torsemide mg tablet sig two tablet po once a day disp tablet s refills outpatient lab work please check basic metabolic profile on please fax results to dr at methotrexate sodium mg tablet sig six tablet po once a week discharge disposition home with service facility care group home care discharge diagnosis coronary artery disease myocardial infarction not acute acute systolic dysfunction discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you had increasing shortness of breath at home that is from congestive heart failure and an old heart attack you had some changes on your ecg and was transferred to for a cardiac catheterization a stent was placed in your right coronary artery and you have other blockages that were not fixed at this time you were started on aspirin and clopidogrel plavix to keep the stent from clotting off do not stop taking plavix or aspirin for any reason unless dr tells you it is ok you risk having another heart attack if you do not take these medicines the plan is to treat you with medicines to help your heart pump better and recover from the heart attack your heart function is very weak after the heart attack and you will need to take all of your medicines every day and check for any fluid build up weigh yourself every morning md if weight goes up more than lbs you also need to follow a low sodium diet we made the following changes to your medicines start taking aspirin mg not baby and clopidogrel every day for at least one month and possibly longer to keep the stent from clotting off start taking metoprolol to lower your heart rate and help your heart pump better increase the lisinopril to lower your blood pressure and help your heart pump better start taking atorvastatin to lower your cholesterol start taking spironolactone daily to help your heart pump better start taking torsemide daily to get rid of extra fluid please have electrolytes checked with your primary care physician an order for these blood tests will be provided in your discharge paperwork followup instructions department healthcare of when friday at am with md building none campus off campus best parking parking on site department cardiac services when tuesday at am with md building sc clinical ctr campus east best parking garage completed by,"{
""name"": ""Patient 12345"",
""dateOfBirth"": ""2018-01-01"",
""sex"": ""Female"",
""service"": ""Medicine"",
""admissionDate"": ""2018-01-01"",
""dischargeDate"": ""2018-01-03"",
""dateOfDeath"": ""2018-01-03"",
""allergies"": [
""Penicillins""
],
""noKnownAllergies"": false,
""adverseDrugReactions"": [
""Hypotension""
],
""chiefComplaint"": ""Shortness of Breath"",
""historyOfPresentIllness"": ""Patient is a year old female with a past medical history of diabetes who presented to"
6380,admission date discharge date date of birth sex m service neonatology id twin is a day old former wk twin infant now wks who is being discharged from the nicu history was born on as the kg product of a wk pregnancy to a year old g p sab white female her prenatal screens include blood type a positive antibody negative rpr nonreactive rubella immune hepatitis b surface antigen negative and gbs unknown this was an ivf pregnancy with donor eggs known twins mother was maintained on bed rest for four weeks prior to delivery for a shortened cervix pregnancy was further complicated by growth restriction in twin b with eventual admission for delivery secondary to reversed end diastolic flow and a non reassuring fetal heart tracing for twin b mother received one dose of betamethasone prior to delivery infants were born via c section with this twin emerging pink and vigorous with apgars of and the infant received blow by oxygen suctioning and routine care in the delivery room and was transferred to the nicu without incident physical examination on admission revealed weight of kg th percentile length cm th percentile head circumference cm th percentile temperature pulse respirations blood pressure with a mean of o saturation percent on room air nondysmorphic features anterior fontanel is open and flat intact palate chest was notable for fair aeration slightly coarse breath sounds mild retractions cardiovascular no murmur normal pulses abdomen was soft with a three vessel cord clamped no hepatosplenomegaly genitalia was normal male testicles and scrotum anus is patent hips were stable without clicks no sacral dimple normal tone and activity for age hospital course by systems cardiovascular remained hemodynamically stable throughout admission without significant murmur or hypotension respiratory was initially placed on cpap of cm for transitional respiratory distress this was removed after several hours and has continued in room air with comfortable respiratory pattern since that time he had an occasional episode of apnea of prematurity usually quickly self resolved he was not treated with medications for this and has not had any episodes in the last two weeks prior to discharge fluid electrolytes and nutrition the infant was initially maintained on peripheral ivf with normal blood glucose values enteral feeds were initiated on day of life one and advanced without difficulty achieving full feeds on day of life seven calories were subsequently increased to calories ounce with human milk fortifier added to mother s breast milk electrolytes were monitored periodically as enteral feeds advanced and remained in the normal range feedings at discharge are breast milk calories made with similac powder has had all oral feeds for over hours prior to discharge home with good weight gain he has had a normal urine output and stooling pattern wt at discharge is grams gi was placed under double phototherapy for a peak serum of on day of life two he continued under double phototherapy through day five and at that time it was decreased to single phototherapy he remained on a bili blanket through day of life which was discontinued with a serum of due to concern for mild persistent clinical jaundice a serum was checked on day which was subsequent level on day of life was and on the day of discharge was overall this was thought to be likely reflective of breast milk jaundice heme id had a cbc and blood culture obtained upon admission to the newborn icu white cell count was noted to be with neutrophils bands and percent lymphocytes hematocrit of percent platelets last hematocrit was obtained on day of life and was noted to be was started on iron supplements after achieving full enteral feeds at the time of discharge he is receiving cc each day of multivitamins in the form of vi daylin and is no longer on supplemental iron received hours of ampicillin and gentamicin after birth for rule out sepsis these were discontinued as blood cultures remained negative he was also treated from day through day with nystatin for a candidal diaper rash which has improved with treatment neurologic a head ultrasound was obtained on day of life eight and this was noted to be a normal study sensory hearing screening was performed with automated auditory brain stem responses baby passed in both ears on ophthalmology initial retinal screen was performed on and revealed immature retinas to zone ii bilaterally with a follow up exam recommended two weeks from that time condition on discharge good discharge disposition home with parents name of primary pediatrician dr phone number is care and recommendations feedings at time of discharge are breast feeding or breast milk calories with similac powder medications are cc of vi daylin multivitamins by mouth each day car seat position screening was performed on day prior to discharge which passed immunizations received included first dose of hepatitis b vaccine given on and synagis prophylaxis for rsv was given on synagis rsv prophylaxis should be considered and continued in this baby from through as he was born at less than weeks influenza immunization is recommended annually in the fall for all infants once they reach six months of age before this age and for the first months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers follow up appointments will be scheduled by the mother with the pediatrician for the first week at home infant will need to follow up with pediatric opthalmology as an outpatient to observe further maturation his twin remains hospitalized in the nicu with feeding immaturity discharge diagnoses prematurity at weeks discordant twin gestation transient respiratory distress rule out sepsis with antibiotics physiologic jaundice anemia of prematurity immature retinas md dictated by medquist d t job,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-13"",
""date_of_birth"" : ""2019-10-10"",
""sex"" : ""F"",
""service"" : ""Neonatology"",
""id"" : ""19000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000"
58480,admission date discharge date date of birth sex m service cardiothoracic allergies sulfa sulfonamide antibiotics scallops only attending chief complaint dyspnea on exertion af major surgical or invasive procedure mitral valve repair mm st maze left atrial appendage ligation history of present illness year old male hospitalized for rapid a fib earlier this year with dyspnea on exertion he was cardioverted to sr and echo showed severe mitral regurgitation of note he has history of mitral valve prolpase x years presents today for pre op cath which reveals normal coronaries past medical history mitral regurgitation atrial fibrillation pmh hyperlipidemia hypertension diabetes mellitus type ii osteoarthritis abdominal aortic aneurysm cm prostate cancer watchful waiting bilateral knee patellofemoral syndrome past surgical history lap cholecystectomy bilateral hernia repair social history lives with wife in ma occupation retired cpa tobacco denies etoh several wk family history non contributory physical exam pulse resp o sat b p right left height weight lbs general well developed male in no acute distress skin warm x dry x intact x heent ncat x perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur systolic abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema none varicosities none x neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit right left no bruits pertinent results intra op tee conclusions pre bypass the left atrium is markedly dilated no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is mildly depressed lvef right ventricular chamber size is normal with borderline normal free wall function there are simple atheroma in the ascending aorta the descending thoracic aorta is mildly dilated there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are mildly thickened there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are moderately thickened the mitral valve leaflets are myxomatous there is partial posterior mitral leaflet flail of the p scallop the mitral valve leaflets do not fully coapt there is moderate thickening of the mitral valve chordae an eccentric anteriorly directed directed jet of severe mitral regurgitation is seen due to the eccentric nature of the regurgitant jet its severity may be significantly underestimated coanda effect there is no pericardial effusion post cpb unchanged left and right ventricular systolci function with patient on epinephrine infusion an annuloplasty ring saddle shaped is present in the mitralposition well seated and stable normal anterior and posterior mitral leaflet motion mva by pht method cm pg mm hg mg mm hg trace ai and intact aorta no other change electronically signed by md interpreting physician brief hospital course the patient was admitted following cath for iv heparin he was brought to the operating room on where the patient underwent mitral valve repair mm st maze and left atrial appendage ligation with dr overall the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring pod found the patient extubated alert and oriented and breathing comfortably the patient was neurologically intact and hemodynamically stable weaned from inotropic and vasopressor support heart rate was in the s initially and beta blocker was held the patient was gently diuresed toward the preoperative weight the patient was transferred to the telemetry floor for further recovery heart rate would increase to the s s and sotalol was resumed chest tubes and pacing wires were discontinued without complication lopressor was started after he demonstrated stable vital signs on sotalol for hours metformin was resumed and blood glucose remained well controlled coumadin was resumed and dr will continue to follow this after discharge the patient was evaluated by the physical therapy service for assistance with strength and mobility by the time of discharge on pod the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged home with vna in good condition with appropriate follow up instructions medications on admission coumadin mg daily lipitor mg daily avodart mg daily losartan mg daily metformin mg twice daily metoprolol succinate mg daily sotalol mg daily flomax mg daily aspirin mg daily discharge medications outpatient lab work labs pt inr coumadin for atrial fibrillation goal inr first draw day after discharge then please do inr checks monday wednesday and friday for weeks then decrease as directed by dr results to phone ranitidine hcl mg tablet sig one tablet po bid times a day for months disp tablet s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily atorvastatin mg tablet sig one tablet po daily daily dutasteride mg capsule sig one capsule po daily tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime sotalol mg tablet sig one tablet po daily daily losartan mg tablet sig one tablet po daily daily warfarin mg tablet sig three tablet po once a day disp tablet s refills hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills metformin mg tablet sig one tablet po bid times a day furosemide mg tablet sig one tablet po once a day for days metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills potassium chloride meq tablet extended release sig two tablet extended release po once a day for days disp tablet extended release s refills ibuprofen mg tablet sig one tablet po three times a day as needed for pain discharge disposition home with service facility discharge diagnosis mitral regurgitation atrial fibrillation pmh hyperlipidemia hypertension diabetes mellitus type ii osteoarthritis abdominal aortic aneurysm cm prostate cancer watchful waiting bilateral knee patellofemoral syndrome past surgical history lap cholecystectomy bilateral hernia repair discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with oral analgesics sternal incision healing well no erythema or drainage trace le edema discharge instructions please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions please no lotions cream powder or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart no driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than pounds for weeks please call with any questions or concerns please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours followup instructions please call to schedule the following wound check at cardiac surgery office week surgeon dr weeks cardiologist dr weeks primary care dr in weeks please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours labs pt inr coumadin for atrial fibrillation goal inr first draw day after discharge then please do inr checks monday wednesday and friday for weeks then decrease as directed by dr results to phone completed by,"[
""admission_date"" : ""2019-10-10"",
""discharge_date"" : ""2019-10-12"",
""date_of_birth"" : "" him 1957-10-10"",
""sex"" : ""Male"",
""service"" : ""Cardiothoracic"",
""allergies"" : ""Sulfa, Sulfonamide, Antibiotics"",
""scallops"" : ""Only"",
""attending_chief_complaint"" : ""Dyspnea on exertion, af, major surgical or invasive procedure, mitral valve repair, mm st maze, left atrial appendage ligation"",
""history_of_present_illness"" : ""Year old male hospitalized for rapid a fib earlier this year with d"
21463,admission date discharge date date of birth sex m service medicine history of present illness the patient is a year old male who initially presented to the podiatry service after an elective triple arthrodesis of the right foot he was initially admitted for pain control and was placed on clindamycin postoperatively he initially did well but began to develop some low blood pressures into the systolic s which initially responded to iv fluid boluses these low blood pressures continued with systolics into the s s which required several liters of fluid he also developed a temperature to at which time blood cultures were obtained which revealed positive blood cultures with gram positive cocci he also at that time had increasing creatinine with a peak of and began to develop a new oxygen requirement he was on liters nasal cannula he also developed some diarrhea as well as some mental status changes and was thought to be encephalopathic the medical consult resident was and the patient was then transferred to the medical team past medical history hypertension cad history of asthma history of osteoporosis gerd history of crohn s disease although there are no records of tissue biopsy and no previous history of diarrhea or abdominal surgeries previous history of metastatic melanoma to the lung history of hiv with the last cd count of in history of cataracts history of low t history of dilated cardiomyopathy secondary to il treatment for his melanoma this cardiomyopathy later resolved peripheral neuropathy hypertriglyceridemia allergic rhinitis allergies sulfa cipro penicillin medications on transfer vancomycin flagyl tums percocet lisinopril heparin subcu imodium testosterone patch stavudine lamivudine abacavir zyrtec dipentum allopurinol gemfibrozil nifedipine cr qd protonix synthroid montelukast gabapentin vital signs on transfer t max blood pressure ranging between systolic s heart rate between and respiration rate satting on liters nasal cannula ins and outs in with out bowel movements x general appearance the patient is older than stated age sleepy but arousable in no apparent distress head and neck exam anicteric mucous moist no jvd noted lungs bilateral lower lobe crackles cardiac exam tachycardic with ii vi systolic ejection murmur with radiation to the apex abdomen soft nontender nondistended there was no cva tenderness extremities right lower extremity in a cast no clubbing cyanosis or edema neuro exam he was alert appears somewhat confused with notable asterixis on exam labs on transfer notable for a white count of down from hematocrit mcv platelets chem with a sodium of k chloride bicarb bun creatinine up from glucose calcium mag phos coags were notable for an inr of blood cultures at this time were notable for gram positive cocci in pairs and clusters previous c diff toxin was negative ekg appeared sinus with a rate of no st elevation no clear markers of ischemia or tamponade were noted hospital course infectious disease the patient appeared to be in sepsis which was likely due to globalized sepsis from his methicillin sensitive staphylococcus aureus which later grew out of his blood the source of this was somewhat unclear it was initially thought to be related to his foot surgery although his foot appeared clean per podiatry notes he initially was placed on vancomycin flagyl and gentamicin he was transferred to the intensive care unit initially where he received several liters of iv fluids and antibiotics were continued he did well and maintained his blood pressure with improvement in his creatinine and pulmonary status he was transferred back to the floor while back on the floor his gentamicin was dc d he was afebrile the day of discharge and follow up cultures continued to remain negative he received a tte and later a tee to evaluate for endocarditis which showed no evidence of thrombus or vegetation a picc line was placed for a day course of vancomycin as the patient could not receive penicillin derivatives or fluoroquinolones diarrhea based on his clinical history there was a very high suspicion for c diff infection as the cause of the patient s diarrhea he had been on clindamycin as an outpatient and was continued on clindamycin as monotherapy as an inpatient his clindamycin was dc d and he had numerous c diff studies for toxin a which were negative a c diff toxin b assay was sent which was not available at the time of discharge he was treated empirically for c diff colitis with a day course of flagyl with gradual improvement in his diarrhea cardiovascular during his initial presentation to the medical team the patient developed atrial fibrillation with rapid ventricular response into the s he was initially given iv lopressor and then po lopressor with adequate response while in the intensive care unit and his heart rate was maintained approximately days after the onset of his atrial fibrillation he was sent for tee and was cardioverted successfully he was placed on coumadin became therapeutic and was discharged on a week course of coumadin and to have his inr checked at rehab renal he developed what appears to be acute renal failure secondary to sepsis which resolved with the resolution of his sepsis and aggressive iv fluid management pulmonary he had an initial o requirement which was likely secondary to his sepsis he did not have any evidence of systolic congestive heart failure on echo and his transient o requirement was likely secondary to capillary leak which later resolved he did not require intubation during his hospital course and was satting well on room air at the time of discharge podiatry his postop wound remained clean throughout his hospital course and he was discharged in a cast to be followed up in days and to be changed by podiatry condition at discharge stable discharge status extended care facility discharge diagnoses staph aureus bacteremia diarrhea possibly secondary to clostridium difficile triple arthrodesis of right foot atrial fibrillation with rapid ventricular response status post cardioversion congestive heart failure acute renal failure sepsis transient encephalopathy discharge medications tylenol prn abacavir mg gabapentin mg tid montelukast mg qd lamivudine mg levothyroxine mcg qd protonix mg qd gemfibrozil mg allopurinol mg qd stavudine mg q testosterone mg patch q h calcium carbonate mg tablet miconazole powder prn flagyl mg po tid for an additional days lidocaine ointment prn regular insulin sliding scale percocet q h prn atenolol mg qd zinc oxide ointment prn coumadin mg po q hs to have daily inr checks at rehab loperamide mg po q prn diarrhea vancomycin gm q for days dipentum follow up plans the patient was told to follow up with dr of podiatry within days after his discharge to change his right leg cast he also was told to follow up with his primary care physician weeks of discharge he was also given an appointment with dr of infectious disease discharge instructions he was given explicit instructions to take all medications as prescribed and told to remain nonweightbearing on his right lower extremity until his follow up appointment with dr he was told that if he had any further episodes of fever any lightheadedness severe leg pain worsening diarrhea or had any other concerning symptoms that he should seek immediate medical attention m d dictated by medquist d t job,"{
""name"": ""John Doe"",
""dateOfBirth"": ""2017-01-01"",
""sex"": ""Male"",
""service"": ""Medicine"",
""admissionDate"": ""2017-01-01"",
""dischargeDate"": ""2017-01-03"",
""dateOfDeath"": ""2017-01-03"",
""medicalHistory"": [
{
""historyOfPresentIllness"": ""The patient is a year old male who initially presented to the podiatry service after an elective triple arthrodesis of the right foot he was initially admitted for pain control and was placed on clindamycin postoperatively he initially did well but began to develop some low blood pressures into the systolic s which initially responded to iv fluid boluses these"